Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators

Does cessation of combustible cigarette and heated tobacco product smoking immediately following a fracture benefit fracture healing? In vivo and in vitro validation

Combustible cigarette and heated tobacco products (HTPs), the two most frequently used tobacco products, negatively affect bone healing. However, whether smoking cessation following fracture benefits bone healing is unclear. Therefore, this study investigated the effect of smoking cessation immediately after surgery on reduced fracture healing induced by smoking. Smoking combustible cigarettes and heated tobacco products generates cigarette smoking extracts (CSE) (extracts from combustible cigarettes [cCSE] and from HTPs [hCSE], respectively). In vivo, CSEs were injected intraperitoneally into rat models for 3 weeks before femoral midshaft osteotomy and fixation. The rats were then divided into CSE continuation and cessation groups postoperatively. Micro-computed tomography (μCT) and biomechanical analyses were performed 6 weeks postoperatively to assess bone union at the fracture site. In vivo study showed μCT assessment also revealed significantly higher cortical bone mineral density (p = 0.013) and content (p = 0.013), and a higher bone union score (p = 0.046) at the fracture site in the cCSE cessation group than in the cCSE continuation group. Biomechanical assessment revealed that elasticity at the fracture site was significantly higher in the cCSE cessation group than in the cCSE continuation group (p = 0.041). These findings provide that smoking cessation, particularly of combustible cigarette, immediately after a fracture accelerates bone fracture healing and increases mechanical strength at the fracture site.

Preventive effects of transcutaneous CO2 application on disuse osteoporosis and muscle atrophy in a rat hindlimb suspension model

We previously demonstrated that transcutaneous CO2 application promotes muscle fiber-type switching, fracture healing, and osteogenesis by increasing blood flow and angiogenesis. Here, we aimed to investigate the preventive effects of transcutaneous CO2 application on disuse osteoporosis and muscle atrophy in a rat hindlimb suspension model. Eleven-week-old male Sprague-Dawley rats were divided into hindlimb suspension (HS), HS with transcutaneous CO2 application (HSCO2), and control groups. HSCO2 rats were administered transcutaneous 100 % CO2 gas in their bilateral hindlimbs, five times a week for 20 min. After 3 weeks, we harvested the gastrocnemius, femur, and tibia for assessment. Histological analysis revealed a significant decrease in the gastrocnemius myofiber cross-sectional area in HS rats compared to the control rats, whereas HSCO2 rats exhibited a significant increase compared to HS rats. Micro-computed tomography showed significant bone atrophy in the trabecular and cortical bones of the femur in HS rats compared to those of the control rats, whereas significant improvement was noted in HSCO2 rats. Histological analysis of the proximal tibia revealed more marrow adipose tissue in the HS rats than in the control rats. However, in the HSCO2 rats, fewer marrow adipose tissue and osteoclasts were observed. Moreover, HSCO2 rats had more osteoblasts and higher expression of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) and vascular endothelial growth factor (VEGF) than the HS rats. The gastrocnemius and distal femur of HSCO2 rats also exhibited elevated PGC-1α and VEGF expression and upregulation of the myogenesis markers and osteogenesis markers compared to those of HS rats. This treatment effectively prevented disuse osteoporosis and muscle atrophy by promoting local angiogenesis and blood flow. PGC-1α is crucial for promoting this angiogenic pathway. Transcutaneous CO2 application may be a novel preventive procedure for disuse osteoporosis and muscle atrophy, complementing medication and rehabilitation.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BACKGROUND

The widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.

METHODS

A retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.

RESULTS

After adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).

CONCLUSIONS

Our findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

Early surgery within 48 hours of admission for hip fracture did not improve 1-year mortality in Japan: a single-institution cohort study

INTRODUCTION

Early surgery for hip fracture, within 48 hours of hospital admission, is effective in reducing mortality. However, the average preoperative waiting time for hip fractures in Japan is 4.5 days and the 1-year mortality rate after a hip fracture is 10% in Japan. This study aimed to investigate whether early surgery, within 48 hours, could reduce the 1-year mortality rate in patients with hip fractures in Japan.

METHODS

This cohort study involved 402 consecutive patients with hip fractures who underwent surgical treatment between January 2013 and September 2019. The exclusion criteria were an age of <60 years and in-hospital injury. A total of 389 patients were included in this study. The patients were divided into two groups: those who underwent early surgery within 48 hours of admission (early group) and those who di not undergo early surgery (delayed group). We compared patient characteristics and treatment outcomes between the 2 groups.

RESULTS

A comparison of patient characteristics revealed that the early group had lower hemoglobin levels (P=0.046), lower C-reactive protein levels (P = 0.031), lower numbers of patients with weekend hospitalization, lower numbers of patients with a history of using medications that may cause bleeding (P < 0.01), and who received general anaesthesia (P < 0.01). However, there were no significant differences with regard to the other variables between the 2 groups. A treatment outcome analysis showed that the early group had shorter waiting times for surgery (P < 0.01) and shorter stays in acute-care wards (P < 0.01). However there were no differences in the total hospital stay, Barthel index at discharge, home discharge rates, in-hospital mortality rates, and 1-year mortality.

CONCLUSION

Our findings indicate that early surgery did not reduce the 1-year mortality rate in older patients with hip fractures in Japan.

Delay to surgery beyond 12 hours is associated with increased hip fracture mortality

PURPOSE

Time to surgery from admission is one of the few variables known to influence outcome after a hip fracture. We reviewed our hip fracture database to determine correlation between delays to surgery and mortality in our elderly hip fracture population.

METHODS

Data on all hip fracture patients admitted to a large district hospital were prospectively collected between January 1989 and August 2021. Time of the injury, time of admission and time of surgery were recorded. Patients over 60 years old with a hip fracture requiring operative management were included. Patients with pathological fractures, those managed conservatively, and patients delayed for medical reasons were excluded. Surgical timing categories were divided into; under 12 h, 12-24 h, 24-72 h and over 72 h.

RESULTS

Time from admission to surgery was recorded for 10,659 patients, of these time of fall was available for 10,346 patients. Mean age was 82.2 years (sd 8.39) for the cohort and 30 day mortality was 6.20%. Odds of 30-day mortality was 1.43 (CI 1.057-1.988, p = 0.025) for delay to surgery from admission of over 12 h compared to under 12 h. Odds ratios for 30-day mortality were not significant at any other time threshold. The odds of 30-day mortality for delay to surgery from time of fall were 1.550 (CI 1.026-2.459, p = 0.048) at the 12 h threshold.

CONCLUSION

This is the largest prospective study to date in elderly patients with hip fractures demonstrating a statistically significant increase in 30-day mortality with a delay to surgery over 12 h.

Role of the Stress Index in Predicting Mortality among Patients with Traumatic Femoral Fractures

BACKGROUND

Traumatic femoral fractures, often resulting from high-energy impacts such as traffic accidents, necessitate immediate management to avoid severe complications. The Stress Index (SI), defined as the glucose-to-potassium ratio, serves as a predictor of mortality and adverse outcomes in various trauma contexts. This study aims to evaluate the prognostic value of the SI in patients with traumatic femoral fractures.

METHODS

This retrospective cohort study included adult trauma patients aged 20 or above with traumatic femoral fractures from the Trauma Registry System at a level 1 trauma center in southern Taiwan between 1 January 2009 and 31 December 2022. At the emergency room, serum electrolyte levels were assessed using baseline laboratory testing. By dividing blood glucose (mg/dL) by potassium (mEq/L), the SI was calculated. The best cut-off value of the SI for predicting mortality was determined using the Area Under the Curve (AUC) of Receiver Operating Characteristic (ROC).

RESULTS

A total of 3717 patients made up the final group, of which 3653 survived and 64 died. In comparison to survivors, deceased patients had substantially higher blood glucose levels (199.3 vs. 159.0 mg/dL, p < 0.001) and SIs (53.1 vs. 41.6, p < 0.001). The optimal SI cut-off value for predicting mortality was 49.7, with a sensitivity of 53.1% and a specificity of 78.7% (AUC = 0.609). High SI was associated with increased mortality (4.2% vs. 1.0%, p < 0.001) and longer hospital stays (12.8 vs. 9.5 days, p < 0.001). The adjusted odds ratios of mortality, controlled by comorbidities, the Glasgow Coma Scale, and the Injury Severity Score, were significantly higher in patients with a higher SI (AOR 2.05, p = 0.016) than those with a lower SI.

CONCLUSIONS

Elevated SI upon admission correlates with higher mortality and extended hospital stay in patients with traumatic femoral fractures. Although the SI has a moderate predictive value, it remains a useful early risk assessment tool, necessitating further prospective, multi-center studies for validation and standardization.

For Surgically Treated Geriatric Acetabular Fractures, Longer Duration between Admission and Surgery Is Associated with an Increase in Post-operative Complications: A Study Using the National Trauma Data Bank

INTRODUCTION

The purpose of this study was to determine whether time from hospital admission to surgery is associated with inpatient complications and mortality for geriatric patients undergoing surgical treatment of acetabular fractures.

METHODS

This was a retrospective cohort study using the National Trauma Data Bank from 2016 to 2018 of patients presenting to level I through IV trauma centers in the United States. All patients aged 60 years or older with acetabular fractures requiring surgical treatment were included. The main outcome measurements were inpatient mortality and complication rates.

RESULTS

There were 6,036 patients who met inclusion criteria. The median age was 69 years (interquartile range 64-76 years). The odds of a complication increased by 7% for each additional day between hospital admission and surgery (multivariable regression OR 1.07, 95% CI = 1.04 to 1.10; P < 0.001). Complications were also associated with patient age (OR 1.05, 95% CI = 1.03 to 1.06; P < 0.001) and mCCI ≥ 5 (OR 2.52, 95% CI = 1.4 to 4.2; P = 0.001). Inpatient mortality was not associated with time to surgery (OR 0.97, 95% CI = 0.92 to 1.02; P = 0.30), but was associated with patient age (OR 1.07, 95% CI = 1.05 to 1.10; P < 0.001; P < 0.001) and mCCI ≥ 5 (OR 4.62, 95% CI = 2.31 to 8.50; P < 0.001).

DISCUSSION

In this database study, time from hospital admission to surgery was associated with a notable increase in inpatient complications but not inpatient mortality after adjusting for potentially confounding variables while age and mCCI were associated with both mortality and complications. Additional research is needed to determine the relationship between time to surgery with longer term mortality and complications and to assess causality.

LEVEL OF EVIDENCE

Prognostic Level III.

Patients risk for mortality at 90 days after proximal femur fracture - a retrospective study in a tertiary care hospital

BACKGROUND

Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality.

METHODS

In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479).

RESULTS

We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years).

CONCLUSION

The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.

Challenges in Delivering Effective Care for Older Persons with Fragility Fractures

Fragility fractures occur because of low-impact trauma or even spontaneously in individuals with osteoporosis. Caring for older persons with fragility fractures can present several challenges due to the unique needs and vulnerabilities of this population. Older individuals commonly have multiple medical conditions, such as osteoporosis, arthritis, cardiovascular diseases, and diabetes. These comorbidities can complicate fracture management and increase the risk of complications. Fracture repair through surgery may be more complex in older patients due to poor bone quality, decreased tissue elasticity, and higher chances of anesthesia complications. In addition, mobility and functional limitations post-fracture are highly prevalent in this population, affecting their independence and increasing their risk of institutionalization. Addressing these challenges requires a multidisciplinary approach involving orthopedic surgeons, geriatricians, physical and rehabilitation physicians, physiotherapists, occupational therapists, dieticians, social workers, and caregivers. Preventive measures, such as fall prevention strategies and osteoporosis management, can also play a vital role in reducing the incidence of fragility fractures in older persons.

Early surgery within 48 h was associated with reduced perioperative blood loss and red blood cell transfusion requirements in older patients with hip fracture: a retrospective study

PURPOSE

The aim of this study was to analyze the relationship between the timing of surgery and perioperative blood loss, red blood cell (RBC) transfusion rate, and RBC transfusion volume in older patients with hip fracture.

METHODS

From January 2020 to August 2022, this retrospective study enrolled older patients with hip fracture who underwent surgery in our hospital. The demographics, fracture type, type of surgery, time from injury to hospital, timing of surgery, medical history (hypertension, diabetes), duration of surgery, intraoperative blood loss, laboratory tests, and preoperative, postoperative and perioperative RBC transfusion requirements were recorded and analyzed. According to the surgical treatment within 48 h or after 48 h after admission, the patients were divided into early surgery group (ES) and delayed surgery group (DS).

RESULTS

A total of 243 older patients with hip fracture were finally included in the study. Among these, 96 patients (39.51%) underwent surgery within 48 h of admission and 147 (60.49%) underwent surgery after this time. Total blood loss (TBL) in the ES group was lower than that in the DS group (576.03 ± 265.57 ml vs 699.26 ± 380.58 ml, P = 0.003). Preoperative RBC transfusion rate, and preoperative and perioperative RBC transfusion volume in the ES group were significantly lower than those in the DS group (15.63% vs 26.53%, P = 0.046; 50.00 ± 128.15 ml vs 117.01 ± 225.85 ml, P = 0.004; 80.21 ± 196.63 ml vs 144.90 ± 253.52 ml, P = 0.027).

CONCLUSION

Timing of surgery within 48 h of admission for older patients with hip fracture was associated with reduced the total blood loss and RBC transfusion requirements during the perioperative period.

Direct Anterior Approach Total Hip Arthroplasty Is Associated With Reduced 1-Year Mortality and Surgical Complications After Femoral Neck Fracture

BACKGROUND

In some studies, the direct anterior approach (DAA) for elective total hip arthroplasty (THA) is associated with decreased dislocation and greater functional gains compared to the posterior approach (PA), as well as higher functional outcomes compared to the direct lateral approach (LA) at 2 weeks postoperatively. Given the paucity of literature on femoral neck fracture (FNF), we aspired to determine the association between the surgical approach used in THA and outcomes.

METHODS

We conducted a retrospective review of patients undergoing THA for FNF at 9 institutions from 2010 to 2019. Patients who had high-energy injury mechanisms, were nonambulatory prior to injury, had concomitant femoral head or acetabular fractures, or did not reach minimum 1-year follow-up were excluded. The study included 622 THAs, of which 348 (56%) were performed through a DAA, 197 (32%) through a PA, and 77 (12%) through an LA. Postoperative complications and mortalities at 90 days and 1 year were compared between groups. Multivariable logistic regression models were constructed for each outcome of interest.

RESULTS

The DAA was associated with a decreased risk of 90-day dislocation (odds ratio [OR] 0.25; 95% confidence interval [CI] 0.10 to 0.62; P = .01), mechanical revision (OR 0.12; 95% CI 0.02 to 0.56; P = .01), and mortality (OR 0.38; 95% CI 0.16 to 0.91; P = .03) compared to the PA. The DAA was also associated with decreased risk of dislocation (OR 0.32; 95% CI 0.14 to 0.74; P = .01), mechanical revision (OR 0.22; 95% CI 0.08 to 0.65; P = .01), and mortality at 1 year compared to PA (OR 0.43; 95% CI 0.21 to 0.85; P = .02).

CONCLUSION

The DAA for THA after FNF is associated with higher in-hospital medical complications but lower risks of postoperative reoperation and mortality. Postdischarge care may impact this association and needs to be addressed in future studies. The DAA should be used among surgeons experienced with the approach for FNF to minimize complications.

LEVEL OF EVIDENCE

Retrospective cohort, Level III.

Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis

Background

A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients.

Methods

The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI.

Results

41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001).

Conclusions

Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.

Rate of Complications after Hip Fractures Caused by Prolonged Time-to-Surgery Depends on the Patient's Individual Type of Fracture and Its Treatment

INTRODUCTION

Hip fractures are common injuries in the elderly and are usually treated with timely surgery. While severe postoperative complications are reported for up to 10% of patients, many studies identified predictive factors for the occurrence of complications postoperatively. A controversially discussed factor is "time-to-surgery". The aim of the study was to examine if time-to-surgery was associated with the occurrence of complications and if the complication rate differed between the patient individual fracture types of intracapsular on the one hand and extracapsular hip fractures on the other hand. We hypothesized that time-to-surgery had less impact on complications in intracapsular hip fractures compared to extracapsular ones, and therefore, guidelines should pay attention to the patient individual case scenario.

MATERIALS AND METHODS

All patients who were admitted to the Department of Trauma and Orthopaedic Surgery of an academic teaching hospital for hip fracture surgery (n = 650) over a five-year period were included in the study. After the application of the exclusion criteria, such as periprosthetic or pathologic fractures, cases needed immediate surgical treatment, and after outlier adjustment, 629 cases remained in the study. Hip fractures were classified into intracapsular fractures (treated by hip arthroplasty) and extracapsular fractures (treated by intramedullary nailing osteosynthesis). The occurrence of severe complications in patients treated within 24 h was compared with patients treated later than 24 h after injury. For statistical evaluation, a multivariate logistic regression analysis was performed to investigate the impact of time-to-surgery interval on the occurrence of complications.

RESULTS

Patients with an extracapsular fracture, which was treated with intramedullary nailing (44.5%), rarely suffered a serious complication when surgery was performed within 24 h after injury. However, when the interval of the time-to-surgery was longer than 24 h, the complication rate increased significantly (8.63% vs. 25.0%, p = 0.002). In contrast to this finding in patients with intracapsular fractures (55.5%), which were treated with cemented arthroplasty, complication rates did not depend on the 24 h interval (26.17% vs. 20.83%, p = 0.567).

CONCLUSIONS

The occurrence of complications after surgical treatment of hip fractures is associated with the time interval between injury and surgery. A 24 h time interval between injury and surgical procedure seems to play a major role only in extracapsular fractures treated with osteosynthesis but not in intracapsular fractures treated with arthroplasty. Therefore, guidelines should take notice of the patient individual case scenario and, in particular, the individual hip fracture type.

Osteoporosis: Molecular Pathology, Diagnostics, and Therapeutics

Osteoporosis is a major public health concern affecting millions of people worldwide and resulting in significant economic costs. The condition is characterized by changes in bone homeostasis, which lead to reduced bone mass, impaired bone quality, and an increased risk of fractures. The pathophysiology of osteoporosis is complex and multifactorial, involving imbalances in hormones, cytokines, and growth factors. Understanding the cellular and molecular mechanisms underlying osteoporosis is essential for appropriate diagnosis and management of the condition. This paper provides a comprehensive review of the normal cellular and molecular mechanisms of bone homeostasis, followed by an in-depth discussion of the proposed pathophysiology of osteoporosis through the osteoimmunological, gut microbiome, and cellular senescence models. Furthermore, the diagnostic tools used to assess osteoporosis, including bone mineral density measurements, biochemical markers of bone turnover, and diagnostic imaging modalities, are also discussed. Finally, both the current pharmacological and non-pharmacological treatment algorithms and management options for osteoporosis, including an exploration of the management of osteoporotic fragility fractures, are highlighted. This review reveals the need for further research to fully elucidate the molecular mechanisms underlying the condition and to develop more effective therapeutic strategies.

Delay between admission and surgery as a potential risk factor for postoperative morbidity and mortality in elderly patients with hip fractures: A retrospective study

BACKGROUND

This study aimed to assess the impact of delay between admission and surgery on the postoperative outcomes such as mortality and related complications in elderly patients with acute hip fractures.

METHODS

840 patients aged ≥65 years from January 2009 to September 2015 were included in this retrospective study. According to the interval from admission to surgery, the patients were divided into four groups: group A (surgery within 24 h), group B (surgery within 24 h-48 h), group C (surgery within 48 h-72 h), and group D (surgery later than 72 h). Postoperative complications during hospitalization and mortality at different follow-up time points were compared.

RESULTS

A total of 763 cases were successfully followed up, with an average follow-up time of 30.4 ± 13.1 months. The mean age of the patients was 79.4 ± 6.8 years. The difference in gross postoperative complications among groups was statistically significant in terms of pressure sore (P = 0.02), respiratory complications (P = 0.001), and urological complications (P < 0.001). The multivariate logistic regression analysis identified 3 factors independently associated with the postoperative morbidity, including age (odds ratio [OR] = 1.040), postoperative drainage volume (OR = 1.002) and time from admission to surgery (OR = 1.108). The difference in postoperative mortality among groups was statistically significant at 1 year (P = 0.046) after operation. The multivariate logistic regression analysis identified that age, postoperative drainage volume and time from admission to surgery were independently associated with mortality at 1 year postsurgery.

CONCLUSION

The incidence of postoperative morbidity and mortality in elderly patients with hip fracture is usually the result of multiple factors, surgeons should pay attention to the patient's age, postoperative wound status and surgical delay time, which may significantly affect the outcome of the treatment.

The Impact of Surgical Timing of Hip Fracture on Mortality: Do the Cause and Duration of Delay Matter?

Purpose

Delay in performance of hip fracture surgery can be caused by medical and/or administrative reasons. Although early surgery is recommended, it is unclear what constitutes a delayed surgery and whether the impact of delayed surgery can differ depending on the reason for the delay.

Materials and Methods

A total of 269 consecutive hip fracture patients over 50 years of age who underwent surgery were prospectively enrolled. They were divided into two groups: early and delayed (time from reaching the hospital to surgery less than or more than 48 hours). Patients were also categorized as fit or unfit based on anesthetic fitness. One-year mortality was recorded, and regression analyses were performed to assess the impact of delay on mortality.

Results

A total of 153 patients (56.9%) had delayed surgery with a mean time to surgery of 87±70 hours. A total of 115 patients (42.8%) were considered medically fit to undergo surgery. No difference in one-year mortality was observed between patients with early surgery and those with delayed surgery (P=0.854). However, when assessment of the time to surgery was performed in a continuous manner, mortality increased with prolonged time to surgery, particularly in unfit patients, and higher mortality was observed when the delay exceeded six days (fit: P=0.117; unfit: P=0.035).

Conclusion

The effect of delay on mortality was predominantly observed in patients who were not considered medically fit, suggesting that surgical delays might have a greater impact on patients with medical reasons for delay.

[Impact of the COVID-19 pandemic and the strict population confinement on hip fracture incidence in Spain: A systematic review]

BACKGROUND AND OBJECTIVE

During the COVID-19 pandemic, a strict population confinement was decreed in Spain. In a situation of health crisis and health system saturation, knowledge of pathologies whose treatment cannot be delayed is of great importance for the correct management of resources and processes. The objective was to determine the influence of the COVID-19 pandemic and the strict population confinement on hip fracture incidence in Spain.

MATERIAL AND METHOD

Systematic review following the PRISMA guidelines. Search in Pubmed and Chocrane Library on 11/11/2022: hip fracture and COVID-19 and Spain.

RESULTS

Six studies met the inclusion criteria, 50% showed a decrease in the hip fractures incidence during strict population confinement (all in Comunidad de Madrid hospitals), and in the other 50% there were no differences (all in other region hospitals). It was constant that hip fractures, either did not decrease, or decreased much less than the rest of fractures during the period of strict population confinement, increasing their relative number with respect to the total admissions in orthopedic surgery and traumatology.

CONCLUSIONS

The behavior of the hip fractures number during the strict population confinement decreed by the COVID-19 pandemic has not been symmetrical in all regions. To design and implement contingency plans in the event of a pandemic situation, these data must be taken into account in order to properly plan material and human resources.

Enhanced Recovery After Surgery (ERAS) Protocol in Geriatric Hip Fractures: An Observational Study

INTRODUCTION

Geriatric hip fractures are the new global pandemic. It is predicted to reach 7.3-21.3 million cases worldwide by 2050. Even with optimal care, geriatric patients suffer a higher morbidity and mortality rate when compared with the general population and often demand expensive hospital aftercare. This study aims to assess the implications of the successful adoption of the enhanced recovery after surgery (ERAS) protocol in the management of geriatric hip fractures in an Indian facility.

METHODS

This is a retrospective study conducted in a tertiary care hospital in India and reported following REporting of studies Conducted using the Observational Routinely collected health Data (RECORD) guidelines. We included all geriatric patients over 60 years of age who were admitted with hip fractures for surgical management between January 2021 and January 2023. The individual perioperative components of the ERAS protocol focus on key areas such as preoperative nutritional support, effective multimodal analgesia with optimal pain control, fluid management, and early postoperative mobilization.

RESULTS

Thirty-eight geriatric patients with a mean age of 77.5 (± 9.6) years were included for analysis. Twenty-three patients sustained intertrochanteric fractures and underwent fixation with proximal femur nailing and the remaining had 15 sustained neck or femur fractures of which 11 underwent hemiarthroplasty surgery and the remaining four underwent a total hip replacement. The mean time to surgery was 2 (± 0.2) days. Eighty-two percent (n=31) of the patients were mobilized with a walking frame within a day after surgery and were followed up after discharge with home physiotherapy. The mean time to ambulation was 2 (± 0.62) days. The mean length of stay was 4 (± 1.6) days. We had a 30-day readmission rate of 5.2% (n=2) and a 30-day mortality rate of 5.2% (n=2). The one-year mortality rate was 13% (n=5).

CONCLUSION

Management of geriatric hip fractures requires exceptional interdisciplinary coordination and carefully planned strategies to optimize patient care. With the implementation of the ERAS protocol, we could perceive clinical benefits in terms of early recovery and short length of hospital stay in patients with hip fractures. Further comparative studies are required, which can determine the relative importance of individual measures in the ERAS protocol and understand their longer-term outcomes in hip fracture surgeries.

The use of skin traction in the adult patients with proximal femur fracture. What are the effects, advantages and disadvantages? A scoping review

BACKGROUND

Hip surgery is normally the chosen therapy for proximal femur fractures. Surgery within 24-48 h after hip fracture is recommended, but surgery may not always be performed promptly. Consequently, skin-traction is applied to reduce complications. The purpose of this review is to assess both advantages and disadvantages of skin traction.

METHODS

A scoping review was conducted. The research question was: which are the effects of skin traction, its advantages and disadvantages in adult patients with proximal femur fractures hospitalised in orthopaedic wards? The search was done in the databases PubMed, CINAHL, Cochrane, Embase, DOAJ, ClinicalTrials.gov and OpenDissertation.

RESULTS

9 records were included, skin traction effects were summarised in 7 categories: pain, pressure sores, comfort and relaxation, thromboembolism, damage from adhesive, complications and quality of care. The possible advantage is pain reduction between 24 and 60 h, the possible disadvantage is skin damage.

DISCUSSION AND CONCLUSION

The routine use of skin traction does not appear recommended, but more consistent evidence is necessary to make clinic decisions. Future RCTs could focus on the effects of skin traction 24-60 h after hospitalisation and before surgery.

Risk factors for postoperative medical morbidity and 3-month mortality in elderly patients with hip fracture following hip arthroplasty during COVID-19 pandemic

BACKGROUND

The purpose of the current study was to investigate the incidence of postoperative medical complications and 3-month mortality in patients  ≥ 70 years old with hip fracture following hip arthroplasty (HA) and independent risk factors associated with postoperative medical complications and 3-month mortality during the Coronavirus Disease 2019 (COVID-19) pandemic.

METHODS

A multicenter retrospective study was conducted, patients  ≥ 70 years old with HA for hip fracture under general anesthesia were included during COVID-19 and before COVID-19 pandemic. The outcome was defined as postoperative medical complications and 3-month mortality. The baseline characteristics and risk factors were collected, multivariable logistic regression was used to identify independent risk factors for postoperative medical complications and 3-month mortality.

RESULTS

A total of 1096 patients were included during COVID-19 pandemic and 1149 were included before COVID-19 pandemic in the study. Patients  ≥ 70 years with hip fracture for HA had longer fracture to operation duration (7.10 ± 3.52 vs. 5.31 ± 1.29, P < 0.001), and the incidence of postoperative medical complications (21.90% vs. 12.53%, P < 0.001) and 3-month mortality (5.20% vs. 3.22%, P = 0.025) was higher during COVID-2019 pandemic. Multivariate logistic regression analysis showed that dementia (OR 2.73; 95% CI 1.37-5.44; P = 0.004), chronic obstructive pulmonary disease (COPD) (OR 3.00; 95% CI 1.92-4.71; P < 0.001), longer fracture to operation duration (OR 1.24; 95% CI 1.19-1.30; P < 0.001) were associated with increased risk for postoperative medical complications. COPD (OR 2.10; 95% CI 1.05-4.17; P = 0.035), dementia (OR 3.00; 95% CI 1.11-7.94; P = 0.031), postoperative medical complications (OR 4.99; 95% CI 2.68-9.28; P < 0.001), longer fracture to operation duration (OR 1.11; 95% CI 1.04-1.19; P = 0.002) were associated with increased risk for 3-month mortality.

CONCLUSIONS

In conclusion, we found that postoperative medical morbidity and 3-month mortality in patients with hip fracture underwent HA were 21.90% and 5.20%, respectively, during the COVID-19. COPD, dementia and longer fracture to operation duration were associated with negative outcome in patients with hip fracture underwent HA during the COVID-19.

Predictive analysis of lower limb fractures in the orthopedic complex operative unit using artificial intelligence: the case study of AOU Ruggi

The length of stay (LOS) in hospital is one of the main parameters for evaluating the management of a health facility, of its departments in relation to the different specializations. Healthcare costs are in fact closely linked to this parameter as well as the profit margin. In the orthopedic field, the provision of this parameter is increasingly complex and of fundamental importance in order to be able to evaluate the planning of resources, the waiting times for any scheduled interventions and the management of the department and related surgical interventions. The purpose of this work is to predict and evaluate the LOS value using machine learning methods and applying multiple linear regression, starting from clinical data of patients hospitalized with lower limb fractures. The data were collected at the "San Giovanni di Dio e Ruggi d'Aragona" hospital in Salerno (Italy).

Influence of time to surgery on clinical outcomes in elderly hip fracture patients : an assessment of surgical postponement due to non-medical reasons

AIMS

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

METHODS

This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission.

RESULTS

Prolonged total length of stay was found when surgery was performed ≥ 24 hours (median 6 days (interquartile range (IQR) 4 to 9) vs 7 days (IQR 5 to 10); p = 0.001) after admission. No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of 12 hours each, pressure sores and urinary tract infections were diagnosed more frequently when time to surgery increased.

CONCLUSION

Longer time to surgery due to non-medical reasons was associated with a higher incidence of postoperative pressure sores and urinary tract infections when time to surgery was more than 48 hours after admission. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay.Cite this article: Bone Joint J 2022;104-B(12):1369-1378.

Incidence and risk factors associated with postoperative surgical site infection in younger adults with hip fractures: a case-control study

PURPOSE

Hip fracture is associated with high morbidity and mortality. The most common complication after hip fracture is surgical site infection (SSI). The goal was to investigate risks associated with SSI in young adults who underwent surgery for hip fractures.

METHODS

We conducted a case-control study enrolling 1243 patients from Jan 2015 to Dec 2019. This study investigated the multifaceted factors including demographics, lifestyles, comorbidities, surgical variables, and laboratory test results. Patients were divided into the case group (developed SSI) and control group (not developed SSI). Univariate analyses and multivariate logistic regression analyses were used to identify the risk factors independently associated with SSI.

RESULTS

A total of 25 patients including 16 (1.8%) in femoral neck fracture and nine (2.5%) in intertrochanteric fracture developed SSI post-operatively, with an accumulated incidence rate of 2.0%. Among them, four cases (1.6%) were deep SSI and 21 cases (98.4%) were superficial SSI. In most cases, Staphylococcus aureus caused the infections. Diabetes mellitus (OR 4.05, 95%CI: 1.08-15.23, P = 0.038), cerebrovascular disease (OR 3.71, 95%CI: 1.14-12.03, P = 0.029), heart disease (OR 6.23, 95%CI: 1.81-21.48, P = 0.004), and operative time (OR 1.01, 95%CI: 1.01-1.02, P = 0.002) in femoral neck fractures while ALP (> upper limit) (OR 33.39, 95%CI: 2.21-504.89, P = 0.011) and CK (> upper limit) (OR 40.97, 95%CI: 1.70-989.31, P = 0.022) in intertrochanteric fractures were found to be significantly associated with SSI.

CONCLUSION

Targeted pre-operative management, depending on the patients' fracture type and risk factors, should be developed to reduce post-operative SSI rates of younger adults with hip fracture.

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on hip and femur fracture care.

DESIGN

A retrospective cohort study. Setting: Level 1 trauma center. Patients: 2928 patients with femoral neck, pertrochanteric, and femoral shaft and distal femur (FSDF) fractures.

INTERVENTION

Implementation of a DOTR.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), emergency department (ED) LOS, intensive care unit (ICU) LOS, and time to operating room (TTOR).

RESULTS

Implementation of a DOTR resulted in significant improvement in TTOR for all patient groups ( P < 0.05). We found shorter TTOR for pertrochanteric ( P < 0.001), femoral neck ( P = 0.039), and FSDF groups ( P = 0.046). Total hospital LOS was shorter for patients with pertrochanteric ( P < 0.001) and femoral neck fractures ( P = 0.044). Patients with pertrochanteric hip fractures demonstrated shorter ICU LOS ( P < 0.001). No LOS improvements were observed among patients in the FSDF group. ED LOS was significantly longer in all patient groups ( P < 0.001).

CONCLUSIONS

Implementation of a DOTR was associated with shorter TTOR, shorter hospital and ICU LOS, and longer ED LOS. There was a greater number of patients transferred into the investigating institution and fewer patients transferred out. These data support the utility of a DOTR as it relates to an improvement in hospital stay-related outcomes in patients with fractures of the hip and femur. Our results suggest that a DOTR in a Level I trauma hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

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

Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review

Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.

Alliance for the development of the Argentinian Hip Fracture Registry

Age expectancy has significantly increased over the last 50 years, as well as some age-related health conditions such as hip fractures. The development of hip fracture registries has shown enhanced patient outcomes through quality improvement strategies. The development of the Argentinian Hip Fracture Registry is going in the same direction.

INTRODUCTION

Age expectancy has increased worldwide in the last 50 years, with the population over 64 growing from 4.9 to 9.1%. As fractures are an important problem in this age group, specific approaches such as hip fracture registries (HFR) are needed. Our aim is to communicate the Argentinian HFR (AHFR) development resulting from an alliance between Fundación Trauma, Fundación Navarro Viola, and the Argentinian Network of Hip Fracture in the elderly.

METHODS

Between October 2020 and May 2021, an iterative consensus process involving 5 specialty-focused meetings and 8 general meetings with more than 20 specialists was conducted. This process comprised inclusion criteria definitions, dataset proposals, website deployment with data protection and user validation, the definition of hospital-adjusted registry levels, implementation planning, and sustainability strategies.

RESULTS

By June 2021, we were able to (1) outline data fields, including epidemiological, clinical, and functional dimensions for the pre-admission, hospitalization, discharge, and follow-up stages; (2) define three levels: basic (53 fields), intermediate (85), and advanced (99); (3) identify 21 benchmarking indicators; and (4) make a correlation scheme among fracture classifications. Simultaneously, we launched a fundraising campaign to implement the AHFR in 30 centers, having completed 18.

CONCLUSION

AHFR development was based on four pillars: (1) representativeness and support, (2) solid definitions from onset, (3) committed teams, and (4) stable funding. This tool may contribute to the design of evidence-based health policies to improve patient outcomes, and we hope this experience will help other LMICs to develop their own tailored-to-their-needs registries.

Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis

Background

In older adults, the recovery after hip fracture surgery is not always to be well expected due to high risks of adverse outcomes including perioperative complications and mortality. We aimed to evaluate the intertrochanteric fracture (IF) patients with diabetes mellitus (DM) and receiving surgical fixation with intramedullary nail on the perioperative complications, total hospital costs (THC), length of hospital stay (LOS), and mortality.

Methods

In this retrospective cohort study, among 487 consecutive intertrochanteric fracture patients with age over 65 years and treated surgically by using intramedullary nail between Jan. 2015 and Mar. 2020, 353 patients were included, including 81 with DM and 272 without DM. After using propensity-score matched (PSM) analysis, 80 patients remained in each group. The perioperative complications, 30-day, 90-day, 1-year, and 2-year survival rates, THC, and LOS were observed and compared between two groups. Overall survival was compared by Kaplan–Meier method.

Results

No significant between-group differences were found in 30-day, 90-day, 1-year, and 2-year mortality rates, THC, LOS, and other perioperative complications after PSM and McNemar’s tests (all p>0.05), except for neurological complications (p<0.004) and endocrine/metabolic complications (p<0.001). At a mean follow-up time of 36.2 months, there were no statistically significant differences between the groups based on the Kaplan–Meier survival curve (p=0.171, log-rank).

Conclusion

IF surgery patients with DM are more prone to suffer perioperative neurological and endocrine/metabolic complications and they should be managed individually while being aware of these risks henceforth. Further high evidence clinical trials are needed to expand in DM patients with IF.

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

INTRODUCTION

The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient's admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors.

MATERIALS AND METHODS

The first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients.

RESULTS

ReSPECT form completion rates rose from 23% in cycle 1-32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention.

CONCLUSION

This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.

Severity of Illness Impacts Outcomes More than Admitting Service for Isolated Hip Fracture Patients

INTRODUCTION

Isolated hip fractures (IHF) are common injuries in the elderly. Controversy exists about which hospital service is best suited to manage these patients. We hypothesize that baseline patient severity of illness (SOI) score drives patient outcomes, not the hospital service managing these patients.

METHODS

Retrospective review of all IHF patients from 2014 to 2018 at our Level 1 trauma center. Basic demographics were obtained. Patients were divided into service line they were admitted; surgical vs non-surgical. Primary outcomes included hospital length of stay (HLOS), time to OR, time to VTE prophylaxis, complication rate (defined by the Trauma Quality Improvement Program), 30-day mortality, and readmissions. SOI score (which is DRG-based) was controlled to see if any differences in primary outcomes occurred between cohorts. Chi-square was used for categorical variables and regression analysis for continuous variables. Significance was p < 0.05.

RESULTS

A total of 366 total patients were analyzed with the same ISS. A total of 102 were admitted to a surgical service and 264 to a non-surgical service. Average overall age was 80 year, 66.9% were female, and 86% were Caucasian. There was no statistical difference between outcomes when comparing admitting services. Controlling for SOI score, there was no difference between admitting service for outcomes as well. SOI score was a significant predictor for increased HLOS and complication occurrence (p < 0.001) via regression analysis, with a 6.06-fold increase in complication rate from mild to moderate SOI score (p = 0.001).

CONCLUSION

There is no difference in outcomes based on admitting service and process measures. However, the SOI score is perhaps a better predictor of outcomes for isolated hip fracture patients.

Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends

Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.

The Impact of COVID-19 on SARSCoV-2-Negative Elderly Patients with Hip Fractures: A Single-Center Retrospective Study from Shanghai, China

Purpose

Coronavirus disease 2019 (COVID-19) has brought an unprecedented change in wellbeing globally. The spread of the pandemic reportedly reduced the incidence of activity-related trauma, while that of fragility fractures remained stable. Here, we aimed to identify the risk factors associated with the prognosis of SARS-CoV-2 negative elderly patients with hip fractures.

Patients and Methods

This retrospective study included elderly patients with hip fractures between 1st January and 9th May during the COVID-19 pandemic (Experiment group) and the same period from 2017 to 2019 (Control group). Perioperative mortality, complications, and functional recovery were compared between two groups of different time frame in the total cohort and patients who received surgical treatment. Multiple linear regression was carried out to identify the risk factors influencing the prognosis of COVID-negative elderly patients with hip fractures.

Results

The proportion of patients with admission time less than 24 hours and the 6-month postoperative Parker score were significantly decreased during COVID-19 compared with the pre-COVID-19 period (p < 0.001). Multiple linear regression demonstrated that TTA (defined as time from injury to admission), rehabilitation after discharge and outpatient follow-up were associated with the 6-month Parker score in the total population (p < 0.001) and in patients who received surgical treatment (p < 0.001).

Conclusion

Elderly patients with hip fractures had a poorer prognosis in epidemic period despite being COVID-19 negative. Factors including timely admission, postoperative follow-up, and rehabilitation could optimize safety and significantly improve the prognosis of elderly COVID-19 negative patients with hip fractures, even during a pandemic.

Single vs Dual-site service reconfiguration during Covid-19 pandemic - A tertiary care centre experience in hip fractures and a Scoping review

Aims and objectives

The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on "Dual site" reconfigurations in response to Covid-19 pandemic.

Methods

We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign.

Results

In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways.

Conclusion

It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.

Incidence and risk factors associated with surgical site infection after surgically treated hip fractures in older adults: a retrospective cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common complications in the traumatic orthopedics field, but remains not adequately studied after hip fractures.

AIMS

This study aims to investigate the incidence and risk factors associated with SSI after surgically treated hip fractures in older adults.

METHODS

A retrospective cohort study including 2932 older adult patients (1416 with femoral neck fracture and 1516 with intertrochanteric fracture) surgically treated from Jan 2015 to Dec 2019 due to hip fractures was performed. Their data on demographics, injury-related data, surgery-related data, and preoperative laboratory test results were collected from hospitalization medical records. Univariate analyses were used to compare between the patients with and without SSI, and multivariate logistic regression analyses were used to identify the risk factors.

RESULTS

A total of 89 patients developed SSI, with an accumulated incidence rate of 3.04% (95%CI 2.41-3.66). Staphylococcus aureus was the most common source of infection. In univariate analysis, 11 items were found to be significant in femoral neck fractures and 5 items were found to be significant in intertrochanteric fracture. In the multivariable logistic regression model, cerebrovascular disease (OR 2.17, 95%CI 1.14-4.15) and hematocrit (HCT) (< Lower limit) (OR 3.46, 95%CI 1.13-10.56) were independent risk factors for SSI in femoral neck fracture. Heart disease (OR 2.13, 95%CI 1.18-3.85) was a risk factor for SSI, while LDH (> 250 U/L) (OR 0.44, 95%CI 0.20-0.95) was a protective factor for SSI in intertrochanteric fracture.

DISCUSSION

We observed 89 cases (3.04%) of SSI in 2932 older adult patients with hip fractures in this study. Cerebrovascular disease and lower HCT were two independent risk factors for SSI in femoral neck fracture, whereas heart disease was a risk factor and LDH was a protective factor for SSI in intertrochanteric fracture.

CONCLUSIONS

Targeted preoperative management, such as predicting the probability of SSI and taking appropriate measures accordingly is essential and highly regarded. Future multicentric studies with more patients evaluated are expected to better address the risk factors for SSI in older hip fracture patients.

Machine Learning and Regression Analysis to Model the Length of Hospital Stay in Patients with Femur Fracture

Fractures of the femur are a frequent problem in elderly people, and it has been demonstrated that treating them with a diagnostic–therapeutic–assistance path within 48 h of admission to the hospital reduces complications and shortens the length of the hospital stay (LOS). In this paper, the preoperative data of 1082 patients were used to further extend the previous research and to generate several models that are capable of predicting the overall LOS: First, the LOS, measured in days, was predicted through a regression analysis; then, it was grouped by weeks and was predicted with a classification analysis. The KNIME analytics platform was applied to divide the dataset for a hold-out cross-validation, perform a multiple linear regression and implement machine learning algorithms. The best coefficient of determination (R²) was achieved by the support vector machine (R² = 0.617), while the mean absolute error was similar for all the algorithms, ranging between 2.00 and 2.11 days. With regard to the classification analysis, all the algorithms surpassed 80% accuracy, and the most accurate algorithm was the radial basis function network, at 83.5%. The use of these techniques could be a valuable support tool for doctors to better manage orthopaedic departments and all their resources, which would reduce both waste and costs in the context of healthcare.

Lockdown imposition due to COVID-19 and its effect on orthopedic emergency department in level 1 trauma center in South Asia

BACKGROUND

The coronavirus pandemic brought the entire world to a standstill. One of the most stringent lockdowns in the world was implemented in India. With the entire healthcare system being stretched, emergency orthopaedic services also take a hit. We studied the trends in patient presentation, testing, management, and restructuring of doctors at a tertiary care orthopaedic centre and compared them with the data from the same time period the previous year (2019).

METHOD

Data was collected separately for all the 5 different phases of lockdown and unlock, as well as for the same duration of months in 2019, and was analysed for epidemiological trends.

RESULTS

A rapid fall in the total number of cases was seen during the lockdown, followed by a skewed rise during the unlock. Forearm, wrist, and hip fractures were the most common fractures. Once nucleic acid testing of all patients intended to be admitted was started, a steep rise in coronavirus positivity was seen. There was a reduction in the total number of cases compared to 2019, but it was not as significant as would have been expected due to the complete standstill of activity during the lockdown.

CONCLUSION

During a pandemic, with the healthcare system under a crisis of workforce and infrastructure, there needs to be a separate task force for catering to orthopaedic emergencies since all fractures cannot be managed conservatively and the numbers of trauma-related patients did not show a stark fall as compared to normal months of last year.

LEVEL OF EVIDENCE

Level 3 Retrospective Case Series.

The Efficacy of Multidisciplinary Team Co-Management Program for Elderly Patients With Intertrochanteric Fractures: A Retrospective Study

Background

Intertrochanteric fractures increased quickly in past decades owing to the increasing number of aging population. Recently, geriatric co-management was rapidly emerging as a favored clinical care model for older patients with hip fractures. The purpose of this study was to assess the efficacy of a multidisciplinary team (MDT) co-management program in elderly patients with intertrochanteric fractures.

Methods

In this retrospective study, patients were divided into MDT group and traditional orthopedic care (TOC) group according to the healthcare model applied. 249 patients were included in the TOC group from January 2014 to December 2016 and 241 patients were included in the MDT group from January 2017 to December 2019. Baseline data, peri-operative data, and postoperative complications were collected and analyzed using SPSS 21.0.

Results

No significant differences were observed between the two groups in terms of patient baseline characteristics. Patients in the MDT group had significantly lower time from admission to surgery and length-of-stay (LOS) compared with those in the TOC group. Furthermore, the proportion of patients receiving surgery within 24 h (61.4 vs. 34.9%, p &lt; 0.001) and 48 h (80.9 vs. 63.5%, p &lt; 0.001) after admission to the ward was significantly higher in the MDT group compared with those in the TOC group. In addition, patients in the MDT group had significantly lower proportion of postoperative complications (25.3 vs. 44.2%, p &lt; 0.001), deep vein thrombosis (7.9 vs. 12.9%, p = 0.049), pneumonia (3.8 vs. 8.0%, p = 0.045) and delirium (4.1 vs. 9.2%, p = 0.025) compared with those in the TOC group. However, no significant changes were found for in-hospital and 30-day mortality.

Conclusion

The MDT co-management could significantly shorten the time from admission to surgery, LOS, and reduce the postoperative complications for elderly patients with intertrochanteric fractures. Further research was needed to evaluate the impact of this model on patient health outcomes.

Implementation of a Multidisciplinary "Code Hip" Protocol is Associated with Decreased Time to Surgery and Improved Patient Outcomes

Background:

The purpose of this study is to report outcomes data based on the implementation of a “Code Hip” protocol, a multidisciplinary approach to the care of fragility hip fracture patients focussing on medical optimization and early operative intervention. We hypothesized that implementation of this protocol would decrease time from presentation to surgical intervention and improve outcomes based on short term post-operative data.

Methods:

A retrospective chart review was performed on all patients aged greater than 65 years old with a fragility hip fracture from October 2015 through June 2018. In addition to demographic and patient factors, we recorded time to surgery, type of surgical interventions performed, ability to ambulate in the post-operative period, 90-day post-operative complications and overall hospital cost.

Results:

There were 114 patients in the pre-Code Hip cohort and 132 patients in the post-Code Hip cohort. Demographic factors were not different between the 2 cohorts. Time from presentation to surgery in the post-Code Hip cohort was shorter at 23.1 ± 16.4 hours versus 33.2 ± 27.2 hours (p < 0.001). 30.3% of patients in the post-Code Hip cohort had at least one post-operative complication compared to 42.1% in the pre-Code Hip cohort (RR = 0.72, CI = 0.51 -1.01, p = 0.05). The post-Code Hip cohort had a significantly lower rate of hospital readmission (p = 0.04), unplanned reoperation (p = 0.02), surgical site infection (p = 0.03), and sepsis (p = 0.05). Total hospital cost per patient decreased from an average of $14,079 +/- $10,305 pre-Code Hip cohort to $11,744 +/- $4,174 per patient in the post-Code Hip cohort (p = 0.02).

Conclusions:

Implementation of our Code Hip protocol, which invokes a multidisciplinary approach to the elderly patient with a fragility hip fracture, is associated with shorter times from presentation to surgery, increased ability to ambulate post-operatively, decreased short term post-operative complication, and decreased hospital costs.

Level of Evidence:

Therapeutic Level III

The effectiveness of a co-management care model on older hip fracture patients in China - A multicentre non-randomised controlled study

BACKGROUND

Clinical guidelines recommend orthogeriatric care to improve older hip fracture patients' outcomes, but few studies have been conducted in China. This study evaluated the effects of an orthogeriatric co-management care model in six Chinese hospitals.

METHODS

This non-randomised controlled study was designed as an exploratory trial and was conducted in 3 urban and 3 suburban hospitals. Eligible patients were aged ≥ 65 years with X-ray confirmed hip fracture and admitted to hospital within 21 days of injury. All patients received three times follow-ups within one year (1-month, 4-month and 12-month post admission). Co-management care was implemented in 1 urban hospital, while usual care continued in 5 urban and suburban hospitals. Patient demographics, pre-, peri- and post-operative information, complications and mortality were collected at baseline and follow-ups. The primary outcome was proportion of patients receiving surgery within 48 hours from ward arrival. Secondary outcomes included osteoporosis assessment, in-hospital rehabilitation, length of hospital stay, in-hospital mortality and one-year cumulative mortality.

FINDINGS

There were 2,071 eligible patients enrolled (1,110 intervention, 961 control). Compared to usual care, a significantly higher proportion of intervention patients received surgery within 48 hours (75% vs 27%, p<0.0001), osteoporosis assessment (99.9% vs 60.6%, p<0.0001), rehabilitation (99.1% vs 3.9%, p<0.0001) and shorter length of hospital stay (6.1 days vs 12.0 days, p<0.0001). The intervention group saw a significant lower in-hospital mortality rate than the control group (adjusted relative risk 0.021, 95% CI 0.001 to 0.45, P=0.01). One-year cumulative mortality was also significantly reduced in the intervention group (hazard ratio 0.59, 95% CI 0.38 to 0.80, p=0.01).

INTERPRETATION

Co-management care of older hip fracture patients resulted in better outcomes, including decreased time to surgery, improved clinical management, and reduced one-year mortality. A randomised controlled trial is needed to provide definitive evidence.

FUNDING

The study is supported by Capital's Funds for Health Improvement and Research (2018-1-2071).

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use

Introduction

Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures.

Materials and Methods

This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups.

Results

Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging.

Discussion

Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ.

Conclusion

Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Risk of Mortality for Proximal Femoral Fracture in Patients With and Without COVID-19. A Retrospective Cohort Study

Background

SARS-CoV-2 (COVID-19) has resulted in a widespread loss of lives, morbidity, and major disruptions to the healthcare system. Hip fractures are an emergent condition which require early intervention to reduce increased risk of mortality and morbidity. Infection of SARS-CoV-2 may contribute to increased mortality due to the role of infection and immune response. This study investigated the impact of COVID-19 infection (defined by clinical symptoms) on mortality following proximal femoral fracture (PFF) repair procedures.

Methods

This study was a retrospective cohort study. Data from the Premier Healthcare Database® was extracted for patients presenting for PFF during 2019 for control, and February 2020-September 2020 to represent a COVID time-period.

Results

A total of N = 73 953 subjects were enrolled for the 2019 period, and a total of N = 34 842 subjects were enrolled for the COVID period. For the 2019 period, subjects who had a PFF procedure and who had flu/COVID-like illness had 2.47 (CI:2.11, 2.88) times the odds of mortality compared to those who did not have flu/COVID-like illness. Subjects who had a PFF procedure and who had flu/COVID-like illness during the COVID period had 2.85 times (CI:2.36, 3.42) the odds of mortality compared to those who did not have flu/COVID-like illness. For the COVID period, within subjects who did not have a PFF procedure, those with flu/COVID-like illness had increased odds of mortality compared to those who did not have flu/COVID-like illness (OR:2.26, CI:1.57, 3.21).

Conclusions

Hip fractures present high risk for mortality and morbidity, where timely intervention is critical to improved outcomes. Presence of infection such as flu/COVID-like illness may influence mortality in patients undergoing hip fracture repair procedures. Consideration of infection status as a comorbidity is important to proper management and achieving optimal outcomes.

Predictive Value of Blood Parameters and Comorbidities on Three-Month Mortality in Elderly Patients With Hip Fracture

Background Knowing the factors that increase the risk of death in patients with hip fractures will help us to take precautions and intervene when necessary in the pre- and postoperative periods. Therefore, it is important to have inexpensive and practical biomarkers that can predict postoperative complications and mortality. The present study aimed to identify the factors that contribute to early mortality in elderly patients with hip fractures in the first three months after trauma, as well as the parameters that may be determinants of mortality. Methods The data of 1,015 patients over 65 years of age with femoral neck and intertrochanteric fractures admitted between January 2009 and January 2020 were retrospectively reviewed. A total of 763 patients who met the inclusion criteria were included in the study. Our study was designed to include 110 (14.4%) patients in Group 1 who were determined to have died within three months after the diagnosis of hip fracture and 653 (85.6%) patients in Group 2 who were determined not to have died within one year after the trauma. Age, gender, comorbid diseases, American Society of Anesthesiologists (ASA) score, type of anesthesia, operation time, type of implant used, time until surgery, and some biochemical blood values were compared between the two groups. Our data were analyzed statistically using the IBM Statistical Product and Service Solutions (SPSS) software for Windows, v. 25.0 (IBM SPSS Statistics for Windows, Armonk, NY). Results Of all of the patients, 370 (48.5%) were female and 393 (51.5%) were male. The patients who survived had an average age of 76.08, while the patients who died had an average age of 80.57. The mean age among the groups is significantly higher in patients who died. High creatinine, alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and low albumin values were found to be associated with mortality. Conclusion It has been determined that advanced age, delayed operation time, high ASA score, and the number of comorbid diseases are associated with mortality in elderly patients with hip fractures, and biomarkers, such as creatinine, ALT, and LDH, can be used as markers for early mortality. With the increase of studies of similar nature, it will be possible to calculate a systematic risk map for mortality in elderly patients with a proximal femur fracture.

Fragility Fractures: Risk Factors and Management in the Elderly

Given the progressive ageing of Western populations, the fragility fractures market has a growing socioeconomic impact. Fragility fractures are common in the elderly, negatively impacting their quality of life, limiting autonomy, increasing disability, and decreasing life expectancy. Different causes contribute to the development of a fractures in frail individuals. Among all, targeting fragile patients before the development of a fracture may represent the greatest challenge, and current diagnostic tools suffer from limitations. This study summarizes the current evidence on the management of fragility fractures, discussing risk factors, prevention, diagnosis, and actual limitations of the clinical therapeutic options, putting forward new ideas for further scientific investigation.

The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study

Purpose

The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.

Methods

All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00–17:00) and out-of-hours surgery (17:00–08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.

Results

Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00–1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01–1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04–1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01–1.15), p = 0.022] compared to on-hour surgery.

Conclusion

Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

Debate Update: Surgery After 48 Hours of Admission for Geriatric Hip Fracture Patients Is Associated With Increase in Mortality and Complication Rate: A Study of 27,058 Patients Using the National Trauma Data Bank

OBJECTIVE

To determine the association between surgical timing and short-term morbidity and mortality in elderly patients who sustain hip fractures using a national trauma database (OTA/AO 31A1-3, 31B1-3).

DESIGN

Retrospective cohort study.

SETTING

Level I-IV trauma centers in the United States.

PATIENTS/PARTICIPANTS

All patients ≥65 years of age who underwent surgery for hip fracture from 2011 to 2013.

INTERVENTION

Time to surgery of <24, 24-48, and >48 hours from admission.

MAIN OUTCOME MEASUREMENTS

Primary outcome was mortality by hospital discharge. Secondary outcomes were complications of myocardial infarction, cardiac arrest, acute respiratory distress syndrome (ARDS), unplanned reintubation, pneumonia, stroke, severe sepsis, and intensive care unit length of stay.

RESULTS

Twenty-seven thousand fifty-eight patients were included in the study. Relative to the <24 hours cohort, patients in the >48 hours cohort were at increased risk for mortality (OR 1.89, 95% CI 1.52-2.33, P < 0.001), ARDS (OR 2.57, 95% CI 1.94-3.39, P < 0.001 for ARDS), myocardial infarction (OR 2.19, 95% CI 1.64-2.94, P < 0.0001), pneumonia (OR 2.04, 95% CI 1.71-2.44, P < 0.001), severe sepsis (OR 2.34, 95% CI 1.52-3.58, P = 0.003), and intensive care unit stay (OR 2.48, 95% CI 2.25-2.74, P < 0.0001). A subgroup analysis showed that healthier patients (modified Charlson Comorbidity Index less than 5) who had surgery >48 hours were not at increased risk of mortality.

CONCLUSIONS

For elderly patients with hip fractures, delaying surgery for more than 48 hours may be associated with increased short-term morbidity and mortality. This association may be pronounced for patients with more medical comorbidities.

LEVEL OF EVIDENCE

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

Enhanced recovery after surgery for hip fractures: a systematic review and meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have achieved promising results in many surgical specialties. However, uncertainty still remains regarding the effect of ERAS on hip fractures. The objective of this review was to investigate the clinical prognosis of ERAS programs in terms of (1) hospital-related endpoints (time to surgery [TTS], length of stay [LOS]), (2) readmission rate, (3) complications, and (4) mortality.

METHODS

Published literature was searched in the PubMed, EMBASE, and Cochrane Library databases. All of the included studies met the inclusion criteria. The primary outcomes were TTS and LOS. The secondary outcomes included the 30-day readmission rate, overall complication rate, specific complication rate (delirium and urinary tract infection), and 30-day and 1-year mortality. Language was restricted to English. The data analysis was carried out by Review Manager 5.3.

RESULTS

A total of 7 published studies (9869 patients) were finally included, and these were all cohort studies. The meta-analysis showed that the TTS, LOS, and overall complication rate were significantly reduced in the ERAS group compared with the control group (p < 0.01). Moreover, no significant change was found in the 30-day readmission rate or 30-day and 1-year mortality.

CONCLUSIONS

ERAS significantly decreases the TTS, LOS, and complication rate without increasing readmission rate and mortality, which adds to the evidence that the implementation of ERAS is beneficial to patients undergoing hip fracture repair surgeries.

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

BACKGROUND

Femoral neck fractures in elderly patients typically warrant operative treatment and are related to high risks of mortality and morbidity. As early hip arthroplasties for elderly femoral neck fractures are widely accepted, rapid predicting models that allowed quantitative and individualized prognosis assessments are strongly needed as references for orthopedic surgeons during preoperative conversations.

METHODS

Data of patients aged ≥ 65 years old who underwent primary unilateral hemiarthroplasty or total hip arthroplasty due to femoral neck fracture between January 1st, 2012 and June 30th, 2019 in our center were collected. Candidate variables included demographic data, comorbidities, and routine preoperative screening tests. The main outcomes included 1-year mortality and free walking rate after hip arthroplasty. 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. One thousand bootstraps were used for internal validation. Those models were further tested in the validation group for external validation.

RESULTS

The final analysis was performed on 702 patients after exclusion and follow-up. All-cause 1-year mortality of the entire data set was 23.4%, while the free walking rate was 57.3%. Preoperative walking ability showed the biggest impact on predicting 1-year mortality and walking ability. Static nomograms were created from the final multivariable models, which allowed simplified graphical computations for the risks of 1-year mortality and walking ability in a certain patient. The bias-corrected C index of those nomograms for predicting 1-year mortality in the derivation group and the validation group were 0.789 and 0.768, while they were 0.807 and 0.759 for predicting postoperative walking ability. The AUC of the mortality and walking ability predicting models were 0.791 and 0.818, respectively.

CONCLUSIONS

Our models enabled rapid preoperative 1-year mortality and walking ability predictions in Asian elderly femoral neck fracture patients who planned for hip arthroplasty, with adequate predictive discrimination and calibration. Those rapid assessment models could help surgeons in making more reasonable clinical decisions and subsequently reducing the risk of potential medical dispute via quantitative and individualized prognosis assessments.

Hip fracture surgery within 36 hours reduces both 30-day and 1-year mortality rates

BACKGROUND AND PURPOSE

Currently the Irish Hip Fracture Standards [IHFS] recommend a Time-to-Surgery [TTS] of within 48 h of admission. The aim of our research is to determine if there was a statistically significant relationship between TTS and 30-day or one-year mortality and to assess whether a 48 h window for surgery is still the most appropriate recommendation.

METHODS USED

This was a single-hospital retrospective review of all of the fragility hip fractures between 1st January 2013 and 31st December 2017. Patient demographics were described using descriptive statistics. Dependent variables of interest were 30-day mortality and one-year mortality. Independent predictor variables analysed included age, ASA grade, fracture type, surgery performed, anaesthesia administered, length of stay and TTS (hours as an interval variable), TTS in less than 36 h (binary variable) and TTS in less than 48 h (binary variable). When the significant predictor variables were identified, in order to control for confounder variables, a multivariate regression analysis was performed to identify which predictors were still significantly associated with the outcome variables even after controlling for all other known confounder variables.

RESULTS

In total, 806 patients were identified. TTS within 36 h was predictive of a significantly lower 30-day mortality when compared to those undergoing surgery after 36 h (p = 0.031). In contrast, TTS within 48 h did not demonstrate a significantly lower 30-day mortality when compared to those undergoing surgery after 48 h (p = 0.104). On multivariate regression analysis, TTS <36 h (p = 0.011) and age (p < 0.0001) were all independently predictive of 30-day mortality. On multivariate regression analysis, both age (p < 0.0001) and TTS < 36 h (p = 0.002) were significantly predictive of one-year mortality.

CONCLUSION

Performing hip fracture surgery within 36 h confers a significant reduction in both 30-day and one-year mortality rates when compared to patients undergoing surgery outside of this time frame. A 36-h window also appears to be superior to a 48-h window because performing surgery within 48 h has no significant impact on the reduction of 30-day mortality rates. We recommend that national guidelines reflect these important findings.

The association between surgical fixation of hip fractures within 24 hours and mortality : a systematic review and meta-analysis

AIMS

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

METHODS

MEDLINE and Embase were searched from inception to June 2020. Reference lists were manually assessed to identify additional papers. Primary comparative research studies that recruited patients aged over 60 years, with non-pathological primary proximal femoral fractures that were treated surgically, were included. Studies that did not include a group operated on within 24 hours or which reported time to surgery in calendar days were excluded. Two investigators extracted data on study characteristics, methods, and outcomes. The pre-defined primary outcome was 30-day mortality. Secondary outcomes were complications and mortality at other time points. Relative risks (RRs) with 95% confidence intervals (CIs) were aggregated and were grouped by study-level characteristics.

RESULTS

This review included 46 studies (January 1991 to June 2020), comprising 521,857 hip fractures with 64,047 postoperative deaths. No randomized controlled trials were eligible for inclusion. In a pooled analysis of 15 studies, RR of mortality at 30 days comparing time to surgery < 24 hours with > 24 hours was 0.86 (95% CI 0.82 to 0.91; I 2 = 69%; 95% CI 50% to 81%; p-value for heterogeneity < 0.001). The association was stronger in observational studies that did not adjust for confounders than in those that adjusted for multiple covariates. In a pooled analysis of six studies, the RR of mortality at 30 days comparing time to surgery < 24 hours with 24 to 36 hours was 0.87 (95% CI 0.81 to 0.93; I 2 = 65%; 95% CI 16% to 85%; p-value for heterogeneity = 0.014).

CONCLUSION

This meta-analysis indicates reduced mortality for patients operated within 24 hours compared with those operated on beyond 24 hours or within 24 to 36 hours. Where resources allow and there is no specific reversible contraindication to early surgery, we recommend that hip fractures should be surgically treated within 24 hours. Cite this article: Bone Joint J 2021;103-B(7):1176-1186.

Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes?

BACKGROUND

Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals.

OBJECTIVE

We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes.

SETTING

Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area.

PARTICIPANTS

We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital.

METHODS

Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index.

RESULTS

We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]).

CONCLUSION

We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.

Is it a matter of time? The effect of transfer time on femur fracture outcomes

Background

Trauma systems in rural areas often require longdistance transfers for definitive care. Delays in care, such as delayed femurfracture repair have been reported to be associated with poorer outcomes, butlittle is known about how transfer time affects time to repair or outcomesafter femur fractures.

Methods

We conducted a retrospective review of all trauma patients transferred to our level 1 rural trauma center between May 1, 2016-April 30, 2019. Patient demographics and outcomes were abstracted from chart and trauma registry review. All patients with femur fractures were identified. Transfer time was defined as the time from admission at the initial hospital to admission at the trauma center, and time to repair was defined as time from admission to the trauma center until operative start time. Our outcome variables were mortality, in-hospital complications, and hospital length of stay (LOS).

Results

Over the study period1,887 patients were transferred to our level 1 trauma center and 398 had afemur fracture. Compared to the entire transfer cohort, femur fracture patientswere older (71 versus 57 years), and more likely to be female (62% versus 43%). The majority (74%) of patients underwent fracture repair within 24hours. Delay in fracture fixation >24 hours wasassociated with increased length of stay (5 days versus 4 days; p<0.001), higher complication rates (23% versus 12%; p=0.01), and decreased dischargehome (19% vs. 32%, pp=0.02), but was not associated with mortality (6% versus5%; p=0.75). Transfer time and time at the initial hospital were not associatedwith mortality, complication rate, or time to femur fixation.

Discussion

Fixation delay greater than 24 hours associated with increased likelihood of in-hospital complications, longer length of stay, and decreased likelihood of dischargehome. Transfer time not related to patient outcomes or time to femur fixation.

Level of evidence

Level III; therapeutic/care management.