Attributable Mortality of Hip Fracture in Older Patients: A Retrospective Observational Study

Unilateral Spinal Anesthesia in Hip Fracture Surgery for Geriatric Patients With High Cardiovascular Risk due to Aortic Stenosis is Safe and Effective

Introduction

Aortic stenosis is a cause of mortality or morbidity. It complicates the selection and management of anesthetic procedures. The aim of this study was to evaluate the efficacy, hemodynamic effects and postoperative outcome of unilateral spinal anesthesia in geriatric patients with hip fractures with moderate or severe aortic stenosis.

Material and Method

A retrospective observational study was conducted on geriatric high-risk patients with cardiac conditions who underwent surgery for hip fractures under unilateral spinal anesthesia with low-dose hyperbaric bupivacaine. The study period spanned from January 2018 to December 2021. The inclusion criteria were individuals with moderate to severe aortic stenosis, as defined by the American Heart Association Criteria. Data on demographic information, cardiac pathologies, hemodynamic data, data on motor and sensory block, perioperative complications, and mortality rates at 30th and 180th days were collected.

Results

Mortality rates at the 30th day and 180th day were 8.9% (n:4) and 24.4% (n:11), respectively. T6 level was predominantly obtained level of anesthesia (44.4%). Motor and sensory block formation times averaged 7.6 and 4.8 minutes, respectively. Surgical procedures were performed mostly within 1 hour (66.7%), and complications were rare (11.1% hypotension). Initial analgesic effect showed a rapid resolution, with 64.4% of patients requiring analgesic within the first hour postoperatively.

Conclusion

In elderly patients with moderate to severe aortic stenosis scheduled for hip fracture surgery, we posit that unilateral spinal anesthesia with ultra-low dose is safe and effective option.

Retrospective In-Hospital Mortality Analysis of GeriatricPatients Treated in a Level 1 Trauma Center

The aim of this study is to determine the critical time intervals and influencing covariates for in-hospital mortality in geriatric trauma and orthopedic patients. During a period of five years, we retrospectively review patients aged > 60 years who were hospitalized at the Department of Trauma, Orthopedic, and Plastic Surgery. The primary outcome is the mean time to death. Survival analysis is performed using an accelerated failure time model. A total of 5388 patients are included in the analysis. Two-thirds underwent surgery (n = 3497, 65%) and one-third were conservatively treated (n = 1891, 35%). The in-hospital mortality rate is 3.1% (n = 168; surgery, n = 112; conservative, n = 56). The mean time to death is 23.3 days (±18.8) after admission in the surgery group and 11.3 days (±12.5) in the conservative treatment group. The greatest accelerating effect on mortality is found in the intensive care unit (16.52, p < 0.001). We are able to identify a critical time interval for in-hospital mortality between days 11 and 23. The day of death on weekend days/holidays, hospitalization for conservative treatment, and treatment at the intensive care unit significantly increase the risk of in-hospital mortality. Early mobilization and a short hospitalization duration seem to be of major importance in fragile patients.

Determinants of Higher Mortality at Six Months in Patients with Hip Fracture: A Retrospective Study

(1) Background: Hip fracture is a pathology with high mortality, but the lack of a universal adaptation of the factors associated with death makes it difficult to predict risk and implement prevention in this group. This study aimed to identify the factors that determine a higher mortality at six months following hip fracture. (2) Methods: A retrospective longitudinal study, whose study population consisted of patients over 65 years of age. The main variable was mortality at 6 months of fracture. Relevant data related to sociodemographic and clinical variables for subsequent bivariate (χ²) and multivariate analysis were obtained. (3) Results: In all, 665 people participated in the study, 128 of whom died within 6 months of the fracture. The multivariate adjusted analysis demonstrated significant relationships between the main variable and aspects such as institutionalization at discharge (Odds Ratio (OR) = 2.501), a worse overall functional capacity (OR = 2.453) and cognitive capacity (OR = 3.040) at admission, and complications such as heart failure (OR = 5.767) or respiratory infection (OR = 5.308), in addition to the taking of certain drugs and the presence of a greater number of comorbidities. (4) Conclusions: There are certain factors related to higher mortality at six months in patients with hip fracture who are aged 65 years or older.

Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway

OBJECTIVES

Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS.

DESIGN

Observational, prospective, single-center study.

SETTING AND PARTICIPANTS

All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included.

MEASUREMENTS

A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders.

RESULTS

1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively).

CONCLUSION

Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

Lack of Association Between Perioperative Medication and Postoperative Delirium in Hip Fracture Patients in an Orthogeriatric Care Pathway

OBJECTIVES

Units for perioperative geriatric care are playing a growing role in the care of older patients after hip fracture surgery. Postoperative delirium is one of the most common complications after hip fracture, but no study has assessed the impact of therapeutics received during a dedicated orthogeriatric care pathway on its incidence. Our main objective was to assess the association between drugs used in emergency, operating, and recovery departments and postoperative delirium during the acute stay.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All patients ≥70 years old admitted for hip fracture to the emergency department and hospitalized in our unit for perioperative geriatric care after hip fracture surgery under general anesthesia between July 2009 and December 2019 in an academic hospital in Paris.

METHODS

Demographic, clinical, and biological data and all medications administered pre-, peri-, and postoperatively were prospectively collected by 3 geriatricians. Postoperative delirium in the unit for perioperative geriatric care was assessed by using the confusion assessment method scale. Logistic regression analysis was used to assess variables independently associated with postoperative delirium.

RESULTS

A total of 490 patients were included [mean (SD) age 87 (6) years]; 215 (44%) had postoperative delirium. The occurrence was not associated with therapeutics administered during the dedicated orthogeriatric care pathway. Probability of postoperative delirium was associated with advanced age [>90 years, odds ratio (OR) 2.03, 95% confidence interval (CI) 1.07-3.89], dementia (OR 3.51, 95% CI 2.14--5.82), depression (OR 1.85, 95% CI 1.14-3.01), and preoperative use of beta-blockers (OR 1.75, 95% CI 1.10-2.79).

CONCLUSIONS AND IMPLICATIONS

No emergency or anesthetic drugs were significantly associated with postoperative delirium. Further studies are needed to demonstrate a possible causal link between preoperative use of beta-blockers and postoperative delirium.

Lower 1-Year Postoperative Mortality After Acetabular Versus Proximal Femoral Fractures in Elderly Patients

BACKGROUND

Geriatric acetabular fractures are becoming more common due to demographic changes. Compared with proximal femoral fractures, surgical treatment is more complex and often does not allow full-weight-bearing. The aims of this study were to compare operatively treated acetabular and proximal femoral fractures with regard to (1) cumulative 1-year mortality, (2) perioperative complications, and (3) predictive factors associated with a higher 1-year mortality.

METHODS

This institutional review board-approved comparative study included 486 consecutive surgically treated elderly patients (136 acetabular and 350 proximal femoral fractures). After matching, 2 comparable groups of 129 acetabular and 129 proximal femoral fractures were analyzed. Cumulative 1-year mortality was evaluated through Kaplan-Meier survivorship analysis, and perioperative complications were documented and graded. After confirming that the proportionality assumption was met, Cox proportional hazard modeling was conducted to identify factors associated with increased 1-year mortality.

RESULTS

The acetabular fracture group had a significantly lower cumulative 1-year mortality before matching (18% compared with 33% for proximal femoral fractures, log-rank p = 0.001) and after matching (18% compared with 36%, log-rank p = 0.005). Nevertheless, it had a significantly higher overall perioperative complication rate (68% compared with 48%, p < 0.001). In our multivariable Cox regression analysis, older age, perioperative blood loss of >1 L, and wheelchair mobilization were associated with lower survival rates after acetabular fracture surgery. Older age and a higher 5-item modified frailty index were associated with a higher 1-year mortality rate after proximal femoral fractures, whereas postoperative full weight-bearing was protective.

CONCLUSIONS

Despite the complexity of operative treatment and a higher complication rate after acetabular fractures in the elderly, the 1-year mortality rate is lower than that after operative treatment of proximal femoral fractures, even after adjustment for comorbidities.

LEVEL OF EVIDENCE

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

Blood transfusion practices affect CD4+ CD25+ FOXP3+ regulatory T cells/T helper-17 cells and the clinical outcome of geriatric patients with hip fracture

Hip fracture (HF) is common among older individuals and associated with high mortality, poor vitality and functional impairment. HF patients suffer whole body immunological changes and that lead to severe consequences, including immobilization, physical impairment and a high risk of complications. The objective of this study was to decipher the pattern of dynamic immunological changes, especially in two major T cell subsets, CD4⁺ CD25⁺ FOXP3⁺ regulatory T (Treg) cells and T helper-17 (Th17) cells, and their balance, during the hospital stay and to observe whether blood transfusion could influence these cells and clinical patietns' prognosis. In this study, ninety-eight consecutive HF patients were initially enrolled, and finally fifty-one patients qualified for the study, and correlation analysis of their clinical parameters was carried out to predict the meaning of their distribution in clinical practice. Our results showed that the frequency of Tregs gradually decreased, while the frequency of Th17 cells slowly increased in HF patients who received blood transfusion. The Treg frequency was inversely correlated with the level of hemoglobin (Hb), and Th17 cell frequency was positively related to fluctuations in Hb levels in HF patients after trauma. HF patients with a better prognosis and survival time showed decreased a Treg frequency and a decreased Treg/Th17 ratio. Transfusion helped reverse the imbalance in the frequencies of Tregs and Th17 cells and the Treg/Th17 ratio and especially contributed to a better outcome in HF patients with moderate-to-severe anemia. In conclusion, a higher frequency of peripheral blood Tregs and a higher Treg/Th17 ratio may be associated with unfavorable outcomes in HF patients, and blood transfusion may benefit moderate-to-severe HF patients rebalance their immune response.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.