The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures

Sharma's risk assessment score as a decision making tool to decide between total hip arthroplasty or hemiarthroplasty as a treatment option for elderly patients with fracture neck of femur. A prospective observational study

Purpose

The decision to do a total hip arthroplasty (THA) or a hemiarthroplasty (HA) in an elderly with a fracture neck of femur (FNOF) is commonly based upon the surgeon's preference, pre-anesthetic fitness, hospital setup, and intensive care backup. The author devised a Sharma's risk assessment score (SRAS), based upon all the common factors that affect the surgical outcomes following FNOF in the elderly, to help orthopedic surgeons decide between THA or HA as a treatment for FNOF.

Material & methods

It was a prospective observational study conducted in a tertiary-level institute. SRAS is based upon 10 parameters with each parameter having a max score of 4 and a minimum score of 1. So the maximum score a patient can score is 40 and the minimum a patient can score is 10. It was hypothesized that a patient with FNOF with a preop SRAS score >20 if subjected to a (HA) and a patient with a preop SRAS score ≤ 20 if subjected to a (THA) would have better outcomes and low complication rates. Out of Eighty-eight patients with FNOF, 7 were lost to follow-up. The remaining 81 patients with FNOF were prospectively followed between May 2018 and May 2022 and segregated into two groups THA (n = 47) and HA(n = 34) based on the SRAS.

Results

The average length of follow-up was 2.6 years (6 months-4 years). The average SRAS was an average 25.7(21-32) in the HA group and 16.2 (11-20) in the THA group. Complications were seen in 12.7 % of the THA group and 17.6 % of the HA group. We had a 2.1 % 90-day mortality in the THA group and a 2.9 % 90-day mortality in the HA group. One year mortality in THA was 2.1 % and it was increased to 5.8 % in the HA group.

Conclusion

SRAS is a useful decision-making tool that would guide surgeons to decide between THA or HA as a treatment option for elderly FNOF and would help minimize post-operative complications and reduce mortality.

Level 3 study

Prospective observational study.

Prediction of additional hospital days in patients undergoing cervical spine surgery with machine learning methods

BACKGROUND

Machine learning (ML), a subset of artificial intelligence (AI), uses algorithms to analyze data and predict outcomes without extensive human intervention. In healthcare, ML is gaining attention for enhancing patient outcomes. This study focuses on predicting additional hospital days (AHD) for patients with cervical spondylosis (CS), a condition affecting the cervical spine. The research aims to develop an ML-based nomogram model analyzing clinical and demographic factors to estimate hospital length of stay (LOS). Accurate AHD predictions enable efficient resource allocation, improved patient care, and potential cost reduction in healthcare.

METHODS

The study selected CS patients undergoing cervical spine surgery and investigated their medical data. A total of 945 patients were recruited, with 570 males and 375 females. The mean number of LOS calculated for the total sample was 8.64 ± 3.7 days. A LOS equal to or <8.64 days was categorized as the AHD-negative group (n = 539), and a LOS > 8.64 days comprised the AHD-positive group (n = 406). The collected data was randomly divided into training and validation cohorts using a 7:3 ratio. The parameters included their general conditions, chronic diseases, preoperative clinical scores, and preoperative radiographic data including ossification of the anterior longitudinal ligament (OALL), ossification of the posterior longitudinal ligament (OPLL), cervical instability and magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operative indicators and complications. ML-based models like Lasso regression, random forest (RF), and support vector machine (SVM) recursive feature elimination (SVM-RFE) were developed for predicting AHD-related risk factors. The intersections of the variables screened by the aforementioned algorithms were utilized to construct a nomogram model for predicting AHD in patients. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and C-index were used to evaluate the performance of the nomogram. Calibration curve and decision curve analysis (DCA) were performed to test the calibration performance and clinical utility.

RESULTS

For these participants, 25 statistically significant parameters were identified as risk factors for AHD. Among these, nine factors were obtained as the intersection factors of these three ML algorithms and were used to develop a nomogram model. These factors were gender, age, body mass index (BMI), American Spinal Injury Association (ASIA) scores, magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operated segment, intraoperative bleeding volume, the volume of drainage, and diabetes. After model validation, the AUC was 0.753 in the training cohort and 0.777 in the validation cohort. The calibration curve exhibited a satisfactory agreement between the nomogram predictions and actual probabilities. The C-index was 0.788 (95% confidence interval: 0.73214-0.84386). On the decision curve analysis (DCA), the threshold probability of the nomogram ranged from 1 to 99% (training cohort) and 1 to 75% (validation cohort).

CONCLUSION

We successfully developed an ML model for predicting AHD in patients undergoing cervical spine surgery, showcasing its potential to support clinicians in AHD identification and enhance perioperative treatment strategies.

The effect of distal locking mode on postoperative mechanical complications in intertrochanteric fractures: a retrospective cohort study of five hundred and seven patients

PURPOSE

The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II.

METHODS

Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings.

RESULT

Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215-9.041; and OR = 3.652, 95% CI: 1.451-9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses.

CONCLUSION

Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture.

Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population

PURPOSE

Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated.

METHODS

A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated.

RESULTS

Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018).

CONCLUSION

Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Risk factors for urinary tract infection in geriatric hip fracture patients: a systematic review and meta-analysis

Background

Urinary tract infection (UTI) is a prevalent and consequential complication in hip fracture patients, leading to significant disability and heightened healthcare expenditures. Consequently, there is a critical need for a comprehensive systematic review to identify risk factors and establish early and effective preventive measures.

Methods

A comprehensive search was performed across the PubMed, Cochrane, Embase, Web of Science, and Scopus databases (up to August 31, 2023). Article screening, data extraction, and quality assessment were independently completed by two reviewers.

Results

Forty-four studies were eligible for inclusion, yielding an overall incidence rate of 11% (95% CI: 8%-14%). Our pooled analysis revealed 18 significant risk factors, including being female (OR = 2.23, 95% CI: 1.89-2.63), advanced age (MD = 1.35, 95% CI: 0.04-2.66), obesity (OR = 1.21, 95% CI: 1.11-1.31), catheterization (OR = 3.8, 95% CI: 2.29-6.32), blood transfusion (OR = 1.39, 95% CI: 1.21-1.58), American Society of Anesthesiologists ≥III (OR = 1.28, 95% CI: 1.18-1.40), general anesthesia (OR = 1.26, 95% CI: 1.11-1.43), intertrochanteric fracture (OR = 1.25, 95% CI: 1.01-1.54), hemiarthroplasty (OR = 1.43, 95% CI: 1.19-1.69), prolonged length of hospital stay (MD = 1.44, 95% CI: 0.66-2.23), delirium (OR = 2.66, 95% CI: 2.05-3.47), dementia (OR = 1.82, 95% CI: 1.62-2.06), Parkinson's disease (OR = 1.53, 95% CI: 1.46-1.61), diabetes (OR = 1.27, 95% CI: 1.13-1.43), hypertension (OR = 1.14, 95% CI: 1.03-1.26), congestive heart failure (OR = 1.35, 95% CI: 1.10-1.66), history of sepsis (OR = 7.13, 95% CI: 5.51-9.22), and chronic steroid use (OR = 1.29, 95% CI: 1.06-1.57).

Conclusion

Our study identifies numerous risk factors strongly associated with UTI, offering compelling evidence and actionable strategies for improving clinical prediction, enabling early intervention, and facilitating targeted UTI management.

Systematic review registration

identifier [CRD42023459600], https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=459600.

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. β coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted β -0.829 [95% CI -1.313, -0.345] and adjusted β -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted β -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted β -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted β -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2  ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Association of preoperative nutritional status evaluated by the controlling nutritional status score with walking independence at 180 days postoperatively: a prospective cohort study in Chinese older patients with hip fracture

BACKGROUND

Malnutrition is significantly associated with unfavorable outcomes, but there is little high-level evidence to elucidate the association of malnutrition with losing walking independence (LWI) after hip fracture surgery. This study aimed to assess the association between preoperative nutritional status evaluated by the Controlling Nutritional Status (CONUT) score and walking independence at 180 days postoperatively in Chinese older hip fracture patients.

METHODS

This prospective cohort study included 1958 eligible cases from the SSIOS database. The restricted cubic spline was used to assess the dose-effect relationship between the CONUT score and the recovery of walking independence. Propensity score matching was performed to balance potential preoperative confounders, and multivariate logistic regression analysis was applied to assess the association between malnutrition and LWI with perioperative factors for further adjustment. Furthermore, inverse probability treatment weighting and sensitivity analyses were performed to test the robustness of the results and the Fine and Gray hazard model was applied to adjust the competing risk of death. Subgroup analyses were used to determine potential population heterogeneity.

RESULTS

The authors found a negative relationship between the preoperative CONUT score and recovery of walking independence at 180 days postoperatively, and that moderate-to-severe malnutrition evaluated by the CONUT score was independently associated with a 1.42-fold (95% CI, 1.12-1.80; P =0.004) increased risk of LWI. The results were overall robust. And in the Fine and Gray hazard model, the result was still statistically significant despite the apparent decrease in the risk estimate from 1.42 to 1.21. Furthermore, significant heterogeneities were observed in the subgroups of age, BMI, American Society of Anesthesiologists score, Charlson's comorbidity index, and surgical delay ( P for interaction < 0.05).

CONCLUSION

Preoperative malnutrition is a significant risk factor for LWI after hip fracture surgery, and nutrition screening on admission would generate potential health benefits.

[Analysis of rising treatment cost of elevated BMI in patients with proximal femoral fracture]

Driven by the aging population, the proximal femoral fracture is a rising fracture entity, challenging trauma surgeons as well as the German healthcare system as a whole. The rising average age of the population is accompanied by a rising BMI in the German population, resulting in longer operation times, longer average length of stay (ALOS) as well as more postoperative complications.The aim of this study was to demonstrate the economic correlation between body mass index and hospital costs. The retrospective analysis of 950 patient cases suffering from a proximal femoral fracture resulted in the finding of rising treatment costs being positively associated with rising BMI due to longer operation times and longer length of hospitalization (10,452 €, 11,505 €, 12,085 € and 13,681 € for patients with BMI < 18.5 kg/m², BMI = 18.5-24.9 kg/m², BMI = 25.0-29.9 kg/m² and BMI ≥ 30.0 kg/m², respectively).

Obese elderly patients with hip fractures may have better survival outcomes after surgery

BACKGROUND

In recent years, there has been an increasing amount of research on the "obesity paradox". So our primary objective was to explore whether this phenomenon exists in our study, and secondary objective was to determine the effect of body mass index (BMI) on major complications, and the incidence of acute kidney injury (AKI) after hip fracture surgery after controlling for confounding factors.

METHODS

We included patients over 70 years old with hip fracture who were admitted to the Department of Orthopedics, Peking University First Hospital between 2015 and 2021. Patients were classified as underweight (UW, < 18.5 kg/m²), normal weight (NW, 18.5-24.9 kg/m²), overweight (OW, 25.0-29.9 kg/m²) and obese (OB, ≥ 30.0 kg/m²). We analyzed demographic characteristics, operation information and postoperative outcomes. Using multivariate regression with normal-weight patients as the reference, we determined the odds of 1-year mortality, major complications, and AKI by BMI category.

RESULTS

A total of 644 patients were included. Nine percent of patients died after 1 year, 18% had major postoperative complications, and 12% had AKI. There was a U-shaped relationship between BMI and the rates of major complications or AKI. However, there was a linear decreasing relationship between 1-year mortality and BMI. After controlling for confounding factors, multivariate regression analysis showed that the risk of 1-year mortality after surgery was 2.24 times higher in underweight patients than in normal-weight patients (P < 0.05, OR: 2.24, 95% CI 1.14-4.42). Compared with normal-weight patients, underweight patients had a 2.07 times increased risk of major complications (P < 0.05, OR 2.07, 95% CI 1.21-3.55), and the risk of major complications in obese patients was 2.57 times higher than that in normal-weight patients (P < 0.05, OR 2.57, 95% CI 1.09-6.09). Compared with normal-weight, underweight patients had a 2.18 times increased risk of AKI (P < 0.05, OR 2.18, 95% CI 1.17-4.05).

CONCLUSIONS

The 1-year mortality risk of patients with higher BMI was significantly reduced. Besides, compared with normal-weight patients, underweight patients and obese patients have a higher risk of major complications; low-weight and obese patients are at higher risk for AKI.

The impact of body mass index on mortality rates of hip fracture patients: a systematic review and meta-analysis

Obesity has been recognized as a global epidemic as approximately one-third of the world's population. Findings on early and late mortality rates between obese, overweight, and underweight vs normal body mass index (BMI) patients confirm that the obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients. It is unclear if the "obesity paradox" exists with survival outcomes of hip fracture patients. We hereby reviewed early (in-hospital and 30-day mortality) and late mortality (≥ 1-year) rates between obese, overweight, and underweight vs normal body mass index (BMI) patients with hip fractures. PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies reporting mortality rates of hip fracture patients based on BMI. We pooled crude and adjusted mortality rates in a random-effects model. Eleven studies were included. Meta-analysis indicated significantly reduced risk of early (RR: 0.64 95% CI: 0.59, 0.69 I² = 0% p < 0.00001) and late mortality rates (RR: 0.78 95% CI: 0.67, 0.91 I² = 93% p = 0.002) in obese vs normal BMI patients. Meta-analysis failed to demonstrate any statistically significant difference in early mortality (RR: 0.90 95% CI: 0.54, 1.53 I² = 44% p = 0.71) but significantly reduced risk of late mortality in overweight vs normal BMI patients (RR: 0.85 95% CI: 0.73, 0.93 I² = 84% p = 0.003). Scarce data suggested increased risk of early (RR: 1.44 95% CI: 1.08, 1.93 I² = 26% p = 0.01) and late mortality (RR: 1.23 95% CI: 1.08, 1.41 I² = 7% p = 0.002) in underweight vs normal BMI patients. Adjusted data corroborated the reduced risk of mortality in overweight (HR: 0.78 95% CI: 0.74, 0.83 I² = 0% p < 0.0001) and obese patients (HR: 0.66 95% CI: 0.60, 0.73 I² = 0% p < 0.0001). Our results indicate that the "obesity paradox" exists with survival outcomes of hip fracture patients. Obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients.

Inverse relation of body weight with short-term and long-term mortality following hip fracture surgery: a meta-analysis

Background

The obesity paradox, which suggests that high body weight is positively associated with survival in some diseases, has not been proven in patients with hip fracture. In this study, meta-analysis of previous studies on the impacts of body weight on postoperative mortality following hip fracture surgery in older adults was conducted.

Methods

PubMed, Embase, and Cochrane library were searched for studies investigating the correlation between mortality after hip fracture surgery and body weight. The search main items included: (“Body mass index” OR “BMI” or “body weight”) and (“hip fracture” or “hip fractures”). Studies contained data on short-term (≤ 30-day) and long-term (≥ 1 year) mortality after hip fracture and its association with distinct body weight or BMI groups were reported as full-text articles were included in this meta-analysis.

Results

Eleven separate studies were included. The definitions of underweight and obesity differed among the included studies, but the majority of the enrolled studies used the average body weight definition of a BMI of 18.5 to 24.9 kg/m²; underweight referred to a BMI of < 18.5 kg/m²; and obesity pertained to a BMI of > 30 kg/m². Based on the generalized definitions of body-weight groups from the enrolled studies, the group with obesity had lower long-term (odds ratio [OR]: 0.63, 95% CI: 0.50–0.79, P < 0.00001) and short-term (OR: 0.63, 95% CI: 0.58–0.68, P ≤ 0.00001) mortality rates after hip fracture surgery when compared with patients with average-weight group. However, compared with the average-weight group, the underweight group had higher long-term (OR: 1.51, 95% CI: 1.15-1.98, P=0.003) and short-term (OR: 1.49, 95% CI: 1.29-1.72, P<0.00001) mortality rates after hip fracture surgery.

Conclusions

Current evidence demonstrates an inverse relation of body weight with long-term and short-term mortality after hip fracture surgery in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03131-3.

Functional Application of Tricks for Super Obese Patient Positioning: A Technical Guide for Hip Fractures on a Fracture Table With a Case Example

Obese patients with hip fractures are at increased risk of perioperative complications due to both their size and associated medical conditions. The purpose of this report is to describe a technique for intraoperative positioning of obese patients who sustain a hip fracture. A 62-year-old female with a history of morbid obesity (BMI 48.06kg/m²), type II diabetes mellitus, and hypertension presented with a right intertrochanteric fracture and was admitted for operative fixation on a fracture table. A standardized approach for systematic patient positioning and abdominal panniculus taping is described, which facilitates operative repair of the hip fracture using a cephalomedullary nail. This report describes the intraoperative positioning technique of a morbidly obese patient with an intertrochanteric hip fracture in order to highlight specific techniques used to deal with the physical aspects of obesity that can improve the surgical efficiency of the procedure. By positioning obese patients in a standardized way, intraoperative time and complications will be decreased, potentially mitigating some of the risks associated with this patient population.

Management of femoral shaft infected nonunion through customised Ilizarov external fixator assembly in a morbidly obese patient

A 19-year-old morbidly obese man presented with infected nonunion of femoral shaft fracture. Patient had history of 13 failed fixation surgeries, assessment revealed 3-centimetre limb-length discrepancy with 3-centimetre gap nonunion. Wound debridement, primary compression and external fixation using a customised Ilizarov external fixation assembly were planned. A four-ring customised assembly was applied. Partial weight bearing was allowed from first postoperative day on walker. Patient was kept on a monthly follow-up. After complete union at 10 months after surgery, frame was dynamised. After 6 months of dynamisation, frame was removed, at that time patient was full weight bearing. Knee was still stiff with a range of motion of 0°-20°, and there was 6 cm of limb length discrepancy, which was managed with a shoe raise. At 9 months after frame removal, patient is mobile with fully united bone. Ilizarov external fixator can be a good managing option in such difficult and complicated cases.