In-Hospital Postoperative Pneumonia Following Geriatric Intertrochanteric Fracture Surgery: Incidence and Risk Factors

Comorbidity burden and nutritional status are associated with short-term improvement in functional independence and pain intensity after hip fracture surgery in older adults with in-hospital rehabilitation

PURPOSE

Hip fracture is a common condition among older adults. The aim of this study was to explore the influence of nutritional status and comorbidity burden on changes in functionality, fall risk, and pain intensity one month after hip surgery in older adults with in-hospital rehabilitation.

METHODS

Thirty-six hip fracture patients (55.6% female) aged 65 years or older with indication for surgical resolution were recruited. The main outcomes were functional independence (Barthel Index), risk of falls (Downton Falls Risk Index) and pain intensity (Visual Analogue Scale), assessed preoperatively and one month after discharge. Covariates included age, sex, BMI, Charlson Comorbidity Index (CCI) and nutritional status (Mini Nutritional Assessment). For the inferential analysis, a one-way analysis of covariance (ANCOVA) was applied.

RESULTS

Significant improvements were observed in functional independence (11.0 points, 95% CI: 1.7 to 20.3), risk of falls (-2.8 points, 95% CI: -4.0 to -1.7) and pain intensity (-2.6 points, 95% CI: -3.4 to -1.9). Among the covariates, a significant interaction was found between the CCI and improvements in functional independence (F=7.03, p=0.010, η2p=0.093), while nutritional status showed a significant interaction with pain reduction (F=5.65, p=0.020, η2p=0.075).

CONCLUSION

A lower comorbidity burden was associated with greater postoperative functional independence, while better nutritional status was associated with a greater reduction in postoperative pain intensity.

Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis

BACKGROUND

Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries.

METHODS

A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS.

RESULTS

Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789).

CONCLUSION

This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.

Clinical characteristics of elderly hip fracture patients with chronic cerebrovascular disease and construction of a clinical predictive model for perioperative pneumonia

INTRODUCTION

The recovery of cerebrovascular disease (CVD) will increase the incidence of perioperative pneumonia (POP). However, there is limited research on POP in elderly patients with hip fractures complicated by CVD. Therefore, our research focuses on the following two issues: (1) What are the clinical features of elderly patients with hip fractures combined with CVD? (2) What are the predictive factors for the occurrence of POP in such patients?

HYPOTHESIS

Male, femoral neck fracture and hypoalbuminemia can be predictive factors for the development of POP after hip fracture in CVD patients.

MATERIAL AND METHODS

This is a nested case-control study that included patients aged 65 to 105 years with CVD who had a hip fracture between January 2021 and January 2023. According to the occurrence of POP, they were divided into case group and control group. Collecting data includes demographic information, clinical data, and surgical information. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to select variables. The constructed predictive model was transformed into a nomogram. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).

RESULTS

We ultimately included 714 patients, 69.3% female, with a median age of 80 years. Asymptomatic cerebral infarction (ACI) is the most common CVD (55.7%). More patients developed intertrochanteric fractures than femoral neck fractures (57.1 vs. 42.9%). In total, 606 patients (84.9%) underwent surgery. The most common perioperative complications were anemia (76.9%) and hypoalbuminemia (71.8%). POP (20.0%) was more common preoperatively (89.5%). Factors such as fracture type, surgical wait time, implant used for surgery, and anesthesia type did not differ between the presence or absence of postoperative pneumonia. 143 patients with POP served as the case group. Five hundred and seventy one patients did not develop POP and served as the control group. The predictors of POP were male (OR 1.699,95%CI 1.150-2.511, p<0.05), femoral neck fracture (OR 2.182,95%CI 1.491-3.192, p<0.05), and hypoalbuminemia (OR 3.062, 95%CI 1.833-5.116, p<0.05). This model has good discrimination, calibration, and clinical practicality.

DISCUSSION

In this study, we constructed a clinical prediction model for the occurrence of POP in CVD combined with hip fracture in the elderly, with risk factors including gender, fracture type and perioperative hypoproteinemia. Therefore, we can take effective preventive measures against the occurrence of POP in patients with these factors in our clinical work.

LEVEL OF PROOF

IV; nested case-control study.

Risk factors for hospital-acquired pneumonia in hip fracture patients: A systematic review and meta-analysis

BACKGROUND

This study aimed to comprehensively assess the prevalence and risk factors for Hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched 4 English databases and 4 Chinese databases from inception until October 20, 2022. All studies involving risk factors of HAP in patients with hip fractures will be considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented through Review Manager 5.4 with the pooled odds ratio (OR) and 95% confidence interval.

RESULTS

Of 35 articles included in this study, the incidence of HAP was 8.9%. 43 risk factors for HAP were initially included, 23 were eventually involved in the meta-analysis, and 21 risk factors were significant. Among them, the 4 most frequently mentioned risk factors were as follows: Advanced age (OR 1.07, 95% CI 1.05-1.10), chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), time from injury to operation (OR 1.09, 95% CI 1.07-1.12), time from injury to operation ≥ 48 hours (OR 3.59, 95% CI 2.88-4.48), and hypoalbuminemia < 3.5g/dL (OR 2.68, 95% CI 2.15-3.36).

DISCUSSION

Hip fracture patients diagnosed with COPD have a 3.44 times higher risk of HAP compared to the general hip fracture patients. The risk of HAP also increases with age, with patients over 70 having a 2.34-fold higher risk and those over 80 having a 2.98-fold higher risk. These findings highlight the need for tailored preventive measures and timely interventions in vulnerable patient populations. Additionally, hip fracture patients who wait more than 48 hours for surgery have a 3.59-fold higher incidence of HAP. This emphasizes the importance of swift surgical intervention to minimize HAP risk. However, there are limitations to consider in this study, such as heterogeneity in selected studies, inclusion of only factors identified through multivariate logistic regression, and the focus on non-randomized controlled trial studies.

Comparison of surgical outcomes for hip fracture between older patients with and without cancer: a propensity score matching analysis

Research on the treatment outcomes and mortality of patients with cancer and hip fractures remains limited. We aimed to assess the treatment outcomes and mortality in older patients with cancer and hip fractures. We retrospectively reviewed the data of 1264 patients aged ≥ 60 years treated for hip fractures between January 2005 and April 2022. The operation time, blood transfusion-related indicators, postoperative complications, reoperation rate, length of hospital stay, admission to the intensive care unit, mortality rate, and clinical scores were compared. We also performed survival analysis. Subsequently, 1:1 propensity-score matching was performed. In the unmatched cohort, we compared 273 patients with cancer and 991 controls. The cancer group exhibited a higher incidence of pneumonia (P = 0.025) and higher in-hospital and 1-year follow-up mortality rates (P = 0.044 and P < 0.001, respectively). In the matched cohort, the 1-year mortality rate remained higher in the cancer group (P < 0.001). The control group showed a higher survival rate in both unmatched and matched cohorts (P < 0.001 for both). The surgical outcomes for hip fractures were comparable between patients with and without cancer. We recommend surgical treatment for hip fractures in patients with cancer.

Risk factors for hospital-acquired pneumonia in hip fracture patients: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess the incidence and risk factors for hospital-acquired pneumonia (HAP) in hip fracture patients by meta-analysis.

METHODS

Systematically searched four English databases (PubMed, EMBASE, The Cochrane Library, and Web Of Science) and four Chinese databases (CNKI, CQVIP, Sinomed, and WAN FANG) from inception until 20 November 2023. All studies involving risk factors of HAP in patients with hip fractures were considered. Newcastle-Ottawa Scale was used to evaluate the quality of the included studies. The results were presented with the pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Of 35 articles (337,818 patients) included in this study, the incidence of HAP was 89 per 1000 cases. Twenty-three risk factors were eventually involved in the meta-analysis, and 21 risk factors were significant. Our study has identified four significant risk factors (advanced age, preoperative time, COPD, and hypoalbuminemia) associated with HAP, as follows: Advanced age as a continuous variable (OR 1.07, 95% CI 1.05-1.10), Advanced age > 70 years (OR 2.34, 95% CI 1.77-3.09), Advanced age > 80 years (OR 2.98, 95% CI 2.06-4.31), Chronic obstructive pulmonary disease (COPD) (OR 3.44, 95% CI 2.83-4.19), Time from injury to operation as a continuous variable (OR 1.09, 95% CI 1.07-1.12), Time from injury to operation ≥48 h (OR 3.59, 95% CI 2.88-4.48), Hypoalbuminemia < 3.0 g/dL (OR 3.03, 95% CI 1.93-4.73), and Hypoalbuminemia < 3.5 g/dL (OR 2.68, 95% CI 2.15-3.36). However, it is important to note that all the studies included in our research were retrospective in nature, which introduces certain limitations to the level of evidence and the ability to establish causal inferences.

DISCUSSION

Patients who have suffered hip fractures are at an increased risk of developing postoperative hospital-acquired pneumonia, which can lead to prolonged hospital stays and adverse clinical outcomes. Consequently, the identification of these risk factors offers novel insights and methodologies for healthcare professionals in terms of both prevention and treatment.

TRIAL REGISTRATION

Registration number: INPLASY2022100091.

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) to predict postoperative pneumonia in elderly hip fracture patients

PURPOSE

Investigate the association between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) about the presence of postoperative pneumonia (POP) in geriatric patients with hip fractures. Compare the predictive value of these biomarkers for POP and assess their potential for early detection of POP.

METHODS

We retrospectively included elderly patients with hip fractures who underwent surgical treatment at our institution. POP was diagnosed according to the guidelines provided by the American Thoracic Society. We collected neutrophil, lymphocyte, and platelet counts upon admission to calculate the NLR, PLR, and SII. Receiver operating characteristic curves were utilized to establish the optimal cutoff values for each index. Multivariate logistic regression analysis and propensity score matching analysis were utilized to assess the independent association between each index and POP after adjusting for demographic, comorbidity, and surgery-related variables.

RESULTS

The study included a total of 1199 patients, among whom 111 cases (9.26%) developed POP. NLR exhibited the highest predictive value for POP in elderly patients with hip fractures compared to PLR and SII (AUC = 0.648, 95% CI 0.594-0.701). A high NLR, using the optimal cutoff value of 5.84, was significantly associated with an increased incidence of POP (OR = 2.24, 95% CI 1.43-3.51). This finding remained statistically significant even after propensity score matching (OR = 2.04, 95% CI 1.31-3.20).

CONCLUSIONS

Among the three inflammatory/immune markers considered, the NLR demonstrates the highest reliability as a predictor for POP in elderly patients with hip fractures. Therefore, it serves as a valuable tool for early identification.

Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study

BACKGROUND

Osteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery.

METHODS

The study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls.

RESULTS

The seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS.

CONCLUSION

Patients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.

Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation

INTRODUCTION

Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery.

METHODS

This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO₂) values between the 4^th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs.

DISCUSSION

We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures.

ETHICS AND DISSEMINATION

This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals.

ETHICS APPROVAL NUMBER

2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021.

TRIAL STATUS

Recruiting. Recruitment is expected to be completed in December 2024.

Frailty is associated with an increased risk of postoperative pneumonia in elderly patients following surgical treatment for lower-extremity fractures: A cross-sectional study

Elderly patients with lower-extremity fractures are at high risk of postoperative pneumonia (POP) after surgery due to longtime bed rest. This study aimed to explore whether preoperative frailty is an independent risk factor for POP in elderly patients undergoing surgical treatment for lower-extremity fractures. The study adopted a cross sectional design with 568 patients (≥60 years) admitted to a tertiary hospital in China from January 1, 2021 to June 30, 2022, for surgical intervention of a significant lower-extremity fracture. Preoperative frailty was assessed using the CFS (Clinical Frailty Scale). POP was assessed based on the classic diagnostic criteria reported in previous studies. Univariate and multiple logistic regression analyses were conducted to determine the impacts of preoperative frailty on POP. Of the 568 elderly patients, 65 (11.4%) developed pneumonia during postoperative hospitalization. There were significant differences among gender, hypoproteinemia, type of anesthesia, history of chronic obstructive pulmonary disease (COPD), and CFS scores. Multiple regression analysis revealed that the risk of POP in vulnerable, mildly frail, and severely frail patients increased by 2.38 times (P = .01, 95% CI [1.22-1.91]), 3.32 (P = .00, 95% CI [2.39-5.61]), and 5.36 (P = .00, 95% CI [3.95-6.52]), significantly. 12.8% of patients with hip fractures and 8.9% of patients with other main types of lower-extremity fractures developed POP. However, the difference between hip and non-hip fractures was not statistically significant (P > .05). Preoperative frailty increases the risk of POP in elderly patients after surgical treatment of main lower-extremity fractures. The severer the preoperative frailty is, the higher the risk of preoperative pneumonia is in elderly patients with lower-extremity fractures. CFS is simple and feasible for the assessment of frailty in elderly patients with lower-extremity fractures. Preoperative frailty assessment and appropriate management strategies should be considered in the perioperative management of elderly patients with lower-extremity fractures.

Relationship between preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fracture: a retrospective cohort study

OBJECTIVE

The relationship between the preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fractures remains unclear. This study investigated whether the preoperative red blood cell distribution width was associated with postoperative pneumonia in elderly patients with hip fractures.

METHODS

Clinical data of patients with hip fractures in the Department of orthopedics of a hospital from January 2012 to December 2021 were retrospectively analyzed. A generalized additive model was used to identify both linear and nonlinear relationships between red blood cell distribution width and postoperative pneumonia. A two-piecewise linear regression model was used to calculate the saturation effect. Subgroup analyses were performed using stratified logistic regression.

RESULTS

This study included a total of 1444 patients. The incidence of postoperative pneumonia was 6.30% (91/1444), the mean age of the patients was 77.55 ± 8.75 years, and 73.06% of them (1055/1444) were female. After full adjustment for covariates, the preoperative red blood cell distribution width showed a nonlinear relationship with postoperative pneumonia. The two-piecewise regression model showed an inflection point at 14.3%. On the left side of the inflection point, the incidence of postoperative pneumonia increased by 61% for every 1% increase in red blood cell distribution width (OR: 1.61, 95% CI 1.13-2.31, P = 0.0089). The effect size was not statistically significant on the right side of the inflection point (OR: 0.83, 95% CI 0.61-1.12, P = 0.2171).

CONCLUSION

The relationship between preoperative red blood cell distribution width and incidence or postoperative pneumonia was nonlinear in elderly patients with hip fractures. The incidence of postoperative pneumonia was positively correlated with red blood cell distribution width when it was < 14.3%. A saturation effect was observed when the red blood cell distribution width reached 14.3%.

Mortality and morbidity following operative management of tibial shaft fractures in octogenarians

PURPOSE

As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old.

METHODS

Data were collected through the National Surgical Quality Improvement Program database for the years 2007-2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p  <  0.05.

RESULTS

In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts.

CONCLUSION

After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.

What are Risk Factors of Postoperative Pneumonia in Geriatric Individuals after Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Postoperative pneumonia (POP) is a common postoperative complication. Negative consequences associated with POP included prolonged hospital length of stay, more frequent intensive care unit (ICU) stays, and a higher rate of sepsis, readmission, and mortality. This meta-analysis aimed to assess the incidence and risk factors associated with POP after hip fracture surgery in elderly patients. PubMed, Web of Science, and Cochrane Library were searched (up to March 31, 2022). All studies on the risk factors for POP after hip fracture surgery in elderly patients, published in English, were reviewed. The qualities of the included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled, and a meta-analysis was performed. Ten studies, including 12,084 geriatric patients undergoing hip fracture surgery, were included. Of these 12,084 patients, POP occurred in 809 patients. The results indicated that age (mean difference [MD] = 4.95, 95% confidence interval [CI]: 3.22-6.69), male (odds ratio [OR] = 1.41, 95% CI: 1.02-1.93), the American Society of Anaesthesiologists classification ≥3 (OR = 3.48, 95% CI: 1.87-6.47), dependent functional status (OR = 5.23, 95% CI: 2.18-12.54, P = 0.0002), smoking (OR = 1.33, 95% CI: 1.07-1.65), chronic obstructive pulmonary disease (OR = 3.76, 95% CI: 2.07-6.81), diabetes mellitus (OR = 1.19, 95% CI: 1.01-1.40), coronary heart disease (OR = 1.74, 95% CI: 1.23-2.46), arrhythmia (OR = 1.47, 95% CI: 1.01-2.14), cerebrovascular disease (OR = 1.88, 95% CI: 1.56-2.27), dementia (OR = 2.36, 95% CI: 1.04-5.36), chronic renal failure (OR = 1.85, 95% CI: 1.29-2.67), hip arthroplasty (OR = 1.30, 95% CI: 1.08-1.56), delayed surgery (OR = 6.40, 95% CI: 3.00-13.68), preoperative creatinine (MD = 5.32, 95% CI: 0.55-10.08), and preoperative serum albumin (MD = -3.01, 95% CI: -4.21 - -1.80) were risk factors for POP. Related prophylactic measures should be provided in geriatric patients with the above-mentioned risk factors to prevent POP after hip fracture surgery.

Thirty-day morbidity and mortality following primary total elbow arthroplasty in octogenarians

Background

Octogenarians are at an increased risk of morbidity and mortality following various orthopaedic procedures, but this has not been explored among total elbow arthroplasty (TEA) patients. Thus, this study analyzed whether octogenarians undergoing TEA are at an increased risk of postoperative complications relative to the younger geriatric population.

Methods

A national database was queried to identify TEA patients. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, comorbidities, and complications were assessed, with the use of bivariate and multivariate analyzes.

Results

In total, 390 patients underwent TEA, with 289 (74.1%) between the ages of 65 to 79 and 101 (25.9%) between the ages of 80 to 89. On bivariate analyzes, patients aged 80 to 89 were more likely to undergo postoperative transfusion (p = 0.001) compared to those aged 65 to 79. Following adjustment on multivariate analyzes, the aged 80 to 89 cohort no longer had an increased risk of postoperative transfusion. There were no differences in mortality, readmission, and reoperation between the two groups.

Discussion

Age greater than 80 should not be used as an independent factor when evaluating whether a geriatric patient is an appropriate candidate for TEA.

Artificial intelligence to detect the femoral intertrochanteric fracture: The arrival of the intelligent-medicine era

Objective: To explore a new artificial intelligence (AI)-aided method to assist the clinical diagnosis of femoral intertrochanteric fracture (FIF), and further compare the performance with human level to confirm the effect and feasibility of the AI algorithm.

Methods: 700 X-rays of FIF were collected and labeled by two senior orthopedic physicians to set up the database, 643 for the training database and 57 for the test database. A Faster-RCNN algorithm was applied to be trained and detect the FIF on X-rays. The performance of the AI algorithm such as accuracy, sensitivity, miss diagnosis rate, specificity, misdiagnosis rate, and time consumption was calculated and compared with that of orthopedic attending physicians.

Results: Compared with orthopedic attending physicians, the Faster-RCNN algorithm performed better in accuracy (0.88 vs. 0.84 ± 0.04), specificity (0.87 vs. 0.71 ± 0.08), misdiagnosis rate (0.13 vs. 0.29 ± 0.08), and time consumption (5 min vs. 18.20 ± 1.92 min). As for the sensitivity and missed diagnosis rate, there was no statistical difference between the AI and orthopedic attending physicians (0.89 vs. 0.87 ± 0.03 and 0.11 vs. 0.13 ± 0.03).

Conclusion: The AI diagnostic algorithm is an available and effective method for the clinical diagnosis of FIF. It could serve as a satisfying clinical assistant for orthopedic physicians.

Perioperative administration of methylprednisolone was associated with postoperative pulmonary complications in elderly patients undergoing hip fracture surgery

BACKGROUND

Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderly patients during hip fracture surgery.

PATIENTS AND METHODS

In this retrospective cohort study, records of 584 patients (≥ 65 years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed.

RESULTS

The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017).

CONCLUSION

Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery.

Risk factors for postoperative pneumonia in patients undergoing hip fracture surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative pneumonia (POP) is a devastating complication that can frequently occur after hip fracture surgery. This study aimed to quantitatively and comprehensively summarize the risk factors for POP following hip fracture surgery.

METHODS

PubMed, Embase, and Cochrane Library were systematically searched for studies assessing risk factors for POP following hip fracture surgery. The pooled odds ratio (OR) and standardized mean difference (SMD) between patients with and without POP were calculated. Evidence was assessed using the Newcastle-Ottawa scale.

RESULTS

Ten studies including 37,130 patients with hip fractures were selected. POP occurred in 1768 cases with an accumulated incidence of 7.8% (95% confidence interval [CI]: 0.061-0.094). Advanced age (SMD: 0.50, 95% CI: 0.10-0.90), male sex (OR: 1.50, 95% CI: 1.12-2.01), American Society of Anesthesiologists physical status scale ≥3 (OR: 3.17, 95% CI: 1.25-8.05), chronic obstructive pulmonary disease (OR: 2.05, 95% CI: 1.43-2.94), coronary heart disease (OR: 1.82, 95% CI: 1.27-2.60), arrhythmia (OR: 1.49, 95% CI: 1.04-2.15), congestive heart failure (OR: 1.41, 95% CI: 1.14-1.75), chronic kidney disease (OR: 2.09, 95% CI: 1.28-3.41), and cerebrovascular accident (OR: 2.14, 95% CI: 1.60-2.85) were risk factors for POP. Hemoglobin (SMD: -0.14, 95% CI: - 0.25 to - 0.03), albumin (SMD: -0.97, 95% CI: - 1.54--0.41), blood urea nitrogen (SMD: 0.20, 95% CI: 0.03-0.37), alanine aminotransferase (SMD: 0.27, 95% CI: 0.10-0.44), arterial oxygen pressure (SMD: -0.49, 95% CI: - 0.71--0.27), time from injury to surgery (SMD: 0.13, 95% CI: 0.08-0.17), and surgery within 48 h (OR: 3.74, 95% CI: 2.40-5.85) were associated with the development of POP.

CONCLUSION

Patients with the aforementioned risk factors should be identified preoperatively, and related prophylaxis strategies should be implemented to prevent POP following hip fracture surgery.

Risk Factors for Postoperative Pneumonia in the Elderly Following Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Introduction: Pneumonia is a serious complication following hip fracture surgery in older people. However, the prevalence and risk factors of postoperative pneumonia (POP) are not well-established. This study identified pre- and peri-operative factors associated with the development of POP following hip fracture surgery. Methods: We searched the Cochrane library, PubMed, and Embase databases for relevant articles published up to June 2021. Studies involving older patients who underwent hip fracture surgery were considered if they detailed the demographic or surgical characteristics of the participants. For all analyses, the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. Results: A total of 24 studies (288819 participants) were included. The overall prevalence of POP following hip fracture surgery was 5.0%. There were 36 risk factors for POP, and the meta-analysis included the five most common: delayed surgery (OR: 1.84, 95% CI: 1.29-2.63), low serum albumin (OR: 2.34, 95% CI: .82-6.73), chronic respiratory diseases (OR: 2.42, 95% CI: 1.82-3.24), increased age (OR: 1.25, 95% CI:1.11-1.40), and male sex (OR: 2.22, 95% CI: 2.00-2.47). Conclusions: The prevalence of POP was 5.0% following hip fracture surgery in the elderly. Older age, male sex, chronic respiratory diseases, delayed surgery, and low serum albumin were significant risk factors. Clinicians treating hip fracture patients must remain be aware of these risk factors.

Risk factors for preoperative deep venous thrombosis in hip fracture patients: a meta-analysis

Study design

A meta-analysis.

Background

Hip fracture (HF), as common geriatric fracture, is related to increased disability and mortality. Preoperative deep vein thrombosis (DVT) is one of the most common complications in patients with hip fractures, affecting 8–34.9% of hip fracture patients. The study aimed to assess the risk factors of preoperative DVT after hip fractures by meta-analysis.

Methods

An extensive search of the literature was performed in the English databases of PubMed, Embase, and the Cochrane Library; and the Chinese databases of CNKI and WAN FANG. We collected possible predictors of preoperative DVT from included studies, and data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

A total of 26 English articles were included, and the rate of DVT was 16.6% (1627 of 9823 patients) in our study. Our findings showed that advanced age [p = 0.0003, OR = 0.13 95% CI (0.06, 0.21)], female patients [p = 0.0009, OR = 0.82 95% CI (0.72, 0.92)], high-energy injury [p = 0.009, OR = 0.58 95% CI (0.38, 0.87)], prolonged time from injury to admission [p < 0.00001, OR = 0.54 95% CI (0.44, 0.65)], prolonged time from injury to surgery [p < 0.00001, OR = 2.06, 95% CI (1.40, 2.72)], hemoglobin [p < 0.00001, OR = − 0.32 95% CI (− 0.43, − 0.21)], coronary heart disease [p = 0.006, OR = 1.25 95% CI (1.07, 1.47)], dementia [p = 0.02, OR = 1.72 95% CI (1.1, 2.67)], liver and kidney diseases [p = 0.02, OR = 1.91 95% CI (1.12, 3.25)], pulmonary disease [p = 0.02, OR = 1.55 95% CI (1.07, 2.23)], smoking [p = 0.007, OR = 1.45 95% CI (1.11, 1.89)], fibrinogen [p = 0.0005, OR = 0.20 95% CI (0.09, 0.32)], anti-platelet drug [p = 0.01, OR = 0.51 95% CI (0.30, 0.85)], C-reactive protein [p = 0.02, OR = 5.95 95% CI (1.04, 10.85)], < 35 g/l albumin [p = 0.006, OR = 1.42 95% CI (1.1, 1.82)], and thrombosis history [p < 0.00001, OR = 5.28 95% CI (2.85, 9.78)] were risk factors for preoperative DVT.

Conclusions

Many factors, including advanced age, female patients, high-energy injury, prolonged time from injury to admission, prolonged time from injury to surgery, patients with a history of coronary heart disease, dementia, liver and kidney diseases, pulmonary disease, smoking, and thrombosis, fibrinogen, C-reactive protein, and < 35 g/l albumin, were found to be associated with preoperative DVT. Our findings suggested that the patient with above characteristics might have preoperative DVT.

Level of evidence: Level III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-022-00639-6.

The application of patient-centered care bundle significantly reduces incidence of perioperative respiratory complications in hip fracture patients aged 80 and over

This study was designed as a pilot test to analyze the effect of patient-centered care (PCC) bundle intervention on perioperative respiratory complications and other outcomes in hip fracture patients aged ≥80. Between Jan 2018 and Dec 2019, 198 patients comprised the routine care group and 187 comprised the PCC bundle group. After propensity score matching, 151 remained in each group. Incidence of perioperative respiratory complications in the PCC bundle group was significantly lower than in the routine care group (all P < 0.05). Furthermore, significant reductions were observed in surgery delay, length of stay, incidence of arrhythmia, hypoproteinemia, and electrolyte disturbance (all P < 0.05) in the PCC bundle group. Age-Adjusted Charlson Comorbidity Index score was related, but only weakly, to length of stay and the number of perioperative complications. These results suggested that the PCC bundle might be a more suitable care modality for patients ≥80 with hip fracture.

Effect of Wearing Medical Masks on Perioperative Respiratory Complications in Older Adults with Hip Fracture: A Retrospective Cohort Study

Purpose

Respiratory complication is one of the major challenges in the treatment of older adults with hip fractures. However, no study so far has investigated the effect of wearing medical masks on the prevention of perioperative respiratory complications in these patients.

Patients and Methods

In this retrospective cohort study, 1016 consecutive patients aged ≥65 years with hip fractures were included and assigned to two groups: the control group and the observation group. The two groups received the same perioperative management modalities. In addition, patients in the observation group were asked to wear medical masks for protection. Data of patients’ demographics, fracture type, surgical methods, comorbidities, the incidence of perioperative respiratory and other complications, and hospital outcomes were collected and compared between the two groups. Subgroup analyses were also performed stratified by fracture types.

Results

A total of 1016 patients (292 females and 724 males) with a mean age of 79.4±7.3 years were analyzed in the study, including 533 in the control group and 483 in the observation group. The overall incidence of perioperative respiratory complication, and the incidence of pulmonary infection, respiratory failure and arrhythmia in the observation group were significantly lower than the control group, especially in winter and spring. There was no difference in other complications, hospital length of stay, and total hospital costs. Further subgroup analyses showed that the incidence of heart failure and arrhythmia in the observation group was lower than that in the control group for patients with femoral neck fractures, which was different from patients with intertrochanteric fractures.

Conclusion

The incidence of perioperative respiratory complications, including pulmonary infection and respiratory failure, could be reduced in older adults with hip fractures by strengthening personal protection, including wearing medical masks, especially in winter and spring. Wearing medical masks could also effectively reduce the incidence of perioperative heart failure and arrhythmia in femoral neck fracture patients and do not increase the incidence of other complications and the burden of hospitalization.

Morbidity and Mortality After Surgical Management of Tibial Plateau Fractures in Octogenarians

BACKGROUND

Because the geriatric population continues to increase in number, the incidence of geriatric tibial plateau fractures in octogenarians is projected to increase. The functional and physiological status varies within this population. The purpose of this study was to compare the complications after surgical management of tibial plateau fractures in patients aged 65 to 79 years with those in patients aged 80 to 89 years.

METHODS

In this retrospective cohort study, data were collected from the National Surgical Quality Improvement Program database for the years 2006 to 2018. The Current Procedural Terminology codes and International Classification of Diseases codes were used to identify all tibial plateau fractures that were treated with open reduction and internal fixation. Patients were divided into two groups: 65- to 79-year-old group and 80- to 89-year-old group. Primary and secondary outcomes were studied and included the 30-day mortality. Univariate and multivariate analyses were done with a statistical significance set at P < 0.05.

RESULTS

In total, 718 patients with tibial plateau fractures who underwent open reduction and internal fixation were included in this study. Of these, 612 were aged 65 to 79 years, and 106 were aged 80 to 89 years. On multivariate analysis, patients aged 80 to 89 years were at increased risk of postoperative anemia requiring transfusion (odds ratio 2.83; 95% confidence interval 1.37 to 5.84; P = 0.005) and extended length of hospital stay (odds ratio 2.72; 95% confidence interval 1.64 to 4.51; P < 0.001) in comparison with patients aged 65 to 79 years.

CONCLUSION

In appropriately selected octogenarian patients, surgical management of tibial plateau fractures was associated with greater risks of transfusion and longer hospital stay. However, comparisons of the rates of late complications and reoperations remain unknown.

Incidence of and risk factors for pre-operative deep venous thrombosis in geriatric intertrochanteric fracture patients

PURPOSE

The purpose of this prospective study was to investigate the pre-operative incidence of and risk factors for deep venous thrombosis (DVT) in geriatric intertrochanteric fractures to help facilitate the peri-operative management of them.

MATERIALS AND METHODS

Data of 1515 geriatric intertrochanteric fracture patients were extracted from a prospective intertrochanteric fractures database according to the inclusion criteria and exclusion criteria. The demographics, fracture characteristics, and pre-operative laboratory indicators of patients were evaluated statistically.

RESULTS

The incidence of pre-operative DVT was 10.2% (155 in 1360 patients) in the present study. The rates of proximal DVT, distal DVT, and mixed DVT were 18.1% (28 patients), 56.8% (88 patients), and 25.2% (39 patients), respectively. The percentages of DVT developing in the affected limb, uninjured limb, and bilateral limbs were 74.2% (115 in 55 patients), 16.8% (26 in 155 patients), and 9% (14 in 155 patients), respectively. After the multivariable analysis, the time from injury to surgery (TIS) > 4 days [odds ratio (OR) = 1.870, p = 0.001], the number of comorbidities > 2 (OR = 2.124, p = 0.014), and albumin (ALB) < 35 g/L (OR = 1.516, p = 0.043), etc. were significantly associated with the development of preoperative DVT in geriatric intertrochanteric fracture patients.

CONCLUSIONS

Although routine anticoagulant therapy was used to prevent the formation of DVT, the incidence of which was still high. Therefore, pre-operative ultrasound of both lower extremities was advised for pre-operatively, especially for patients with delayed surgery, hypoproteinemia, three or more comorbidities, and a D-dimer level > 1.59 mg/L.

Relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

It is well established that the postoperative results were affected by the surgeon volume in a variety of elective and emergent orthopaedic surgeries; however, by far, no evidences have been available as for surgically treated displaced intra-articular calcaneal fractures (DIACFs). We aimed at investigating the relationship between surgeon volume and deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of DIACFs. This was a further analysis of prospectively collected data from a validated database. Patients with DIACFs stabilised by ORIF between 2016 and 2019 were identified. Surgeon volume was defined as the number of surgically treated calcaneal fractures within one calendar year and was dichotomised based on the optimal cut-off value. The outcome measure was DSSI within 1 year postoperatively. Multivariate logistics regression analyses were performed to examine the relationship, adjusting for confounders. Among 883 patients, 19 (2.2%) were found to have a DSSI. The DSSI incidence was 6.5% in surgeons with a low volume (<6/year), 5.5 times as that in those with a high volume (≥6/year) (incidence rate, 1.2%; P < 0.001). The multivariate analyses showed a low volume <6/year was associated with a 5.8-fold increased risk of DSSI (95% confidence interval, 2.2-16.5, P < 0.001). This value slightly increased after multiple sensitivity analyses, with statistical significances still unchanged (OR range, 6.6-6.9; P ≤ 0.001). The inverse relationship indicates a need for at least six cases/year for a surgeon to substantially reduce the DSSIs following the ORIF of DIACFs.

Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture

BACKGROUND

Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture.

METHODS

This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups.

RESULTS

Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5).

CONCLUSION

The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.