Complications of hip fractures: A review

Fatal Hip Fractures From Accidental Falls From a Ground-Level Fall

Accidental femur fractures in older adults are a public health concern with a considerably high rate of mortality and morbidity. We performed a retrospective review of all deaths reported to the Connecticut Office of Chief Medical Examiner (OCME) over a 5-year period that involved a femur fracture resulting from a ground-level fall. Data on cause of death, contributing conditions, age, ethnicity, sex, comorbidities, and interval between surgery and death were extracted. There were 470 deaths caused by a hip fracture due to a ground-level fall. The majority were woman (n = 312 or 66.1%) and White (n = 435 or 95.8%). The median age of the study population was 89 years (interquartile range [IQR] = 83-94). The locations of the falls were predominantly in homes (59.8%) or skilled nursing facilities (SNFs) (26.8%). Complications following surgery occurred with 259 (87.2%) of the 297 patients who underwent surgical repair. Contributing conditions to death occurred in 76.1% of patients (n = 359), with the most common being heart disease, dementia, chronic obstructive pulmonary, and diabetes mellitus (DM). The median survival interval after injury was 9 days (IQR = 4-21 days). The Area Deprivation Index (ADI) was not associated with sex, race, medical conditions determined to have contributed to death, whether the patient underwent surgery, or with any surgical complication. This study demonstrates the important role of medicolegal death investigation in producing accurate death certifications that can inform stakeholders about risk factors and comorbidities that may enhance the overall management of hip fractures in an ageing population.

Prediction of 5-Year Survival Rate After Hip Fracture Surgery Using a Comprehensive Geriatric Assessment-Based Frailty Score Model

BACKGROUND

Hip fractures (HFs) are major osteoporotic injuries associated with morbidity, loss of independence, increased mortality, and an increased socioeconomic burden. The total number of HFs is increasing owing to an aging population. While studies have focused on 30-day or 1-year mortality after HF surgery, studies reporting long-term mortality are lacking. Our study bridges this knowledge gap by exploring the relationship between frailty, postoperative complications, and the 5-year mortality after HF surgery. This study aimed to identify the risk factors associated with 5-year mortality after HF surgery. The impact of the Hip-Multidimensional Frailty Score (Hip-MFS) and postoperative complications on 5-year mortality was compared.

METHODS

This retrospective study included 536 individuals aged 65 years and older with HFs who underwent surgery between 2009 and 2014. The Hip-MFS was calculated using the comprehensive geriatric assessment. Patients whose Hip-MFS score above 8 considered as frail. Postoperative complications included pneumonia, urinary tract infection, delirium, pulmonary thromboembolism, and unplanned intensive care unit admission after surgery. The primary outcome was 5-year mortality. Univariate and multivariate cox-regression, Kaplan-Meier analysis and log-rank tests were used to assess predictive value of frailty and postoperative complications on 5-year mortality.

RESULTS

The mean age was 80.5 ± 7.0 years and 71.3% (n = 382) were women. Overall, 48.3% (n = 259) were diagnosed with femoral neck fractures, and 51.7% (n = 277) were diagnosed with intertrochanteric fractures. A total of 223 (41.6%) patients experienced postoperative complications. The overall mortality rate was 60.4% (n = 324), with 1-year and 5-year mortality rates after HF surgery being 13.8% (n = 74) and 43.8% (n = 235), respectively. In the multivariate regression analysis, after adjusting for clinical and demographic factors, the high-risk Hip-MFS group and the group with postoperative complications had hazard ratios for 5-year survival of 1.513 (95% confidence interval [CI], 1.105-2.017; P = 0.010) and 1.470 (95% CI, 1.117-1.936; P = 0.006), respectively. Patients who had postoperative complications with a low Hip-MFS showed better 5-year survival than those without postoperative complications with a high Hip-MFS in the Kaplan-Meier curve (P = 0.013).

CONCLUSION

A high Hip-MFS risk and postoperative complications were associated with an increased 5-year mortality rate. In comparison to the occurrence of postoperative complications, the frailty status evaluated using the Hip-MFS had a more significant impact on long-term mortality after HF surgery.

Functional outcomes of patients presenting with traumatic hip dislocations at a tertiary care center: a descriptive observational study

INTRODUCTION

Traumatic hip dislocations (THD) often result from high-energy trauma and are frequently associated with fractures of the femoral head, shaft, or acetabulum. Effective management, including timely hip relocation, is essential for favorable outcomes. However, limited literature exists on the functional outcomes of THD, especially in resource-limited settings like Nepal. This study aimed to evaluate the functional outcomes of patients with complex THDs treated at a tertiary care centre in Nepal.

METHODS

This descriptive observational study included 80 patients with complex THDs treated between October 2012 and July 2023. Eligible patients had follow-ups ranging from 6 months to over five years. Data on patient demographics, injury characteristics, treatment details, and functional outcomes were collected. The Harris Hip Score (HHS) was used to assess functional outcomes, with scores categorized as "good" (≥ 80) or "poor" (< 80). Statistical analysis used logistic regression to identify factors associated with better functional outcomes.

RESULTS

In this study of 80 patients with traumatic hip dislocations (THD), the majority were male (82.5%) and aged under 40 years (53.8%), with road traffic accidents being the predominant cause (73.8%). Most injuries involved posterior dislocations (87.5%), and 76.3% had associated acetabular fractures. Good functional outcomes, defined as a Harris Hip Score (HHS) ≥ 80, were achieved in 83.8% of cases, while 16.3% had poor outcomes. Logistic regression analysis revealed several significant factors associated with better outcomes: a hospital stays of less than three weeks (OR 4.67, 95% CI 1.08-20.21, p = 0.04), anterior dislocation (OR 12.17, 95% CI 1.12-131.70, p = 0.04), and follow-up duration of less than five years (OR 0.07, 95% CI 0.01-0.43, p = 0.00). However, acetabular fractures had a significantly lower likelihood of good outcomes (OR 0.28, 95% CI 0.08-0.96, p = 0.04).

CONCLUSION

Timely management of traumatic hip dislocations, such as early discharge and treatment of associated fractures, is vital for achieving favorable functional outcomes, as reflected in the Harris Hip Score. These findings offer valuable insights for optimizing care in resource-limited settings and highlight the necessity for long-term follow-up, especially for patients with more complex injuries.

Patch-based feature mapping with generative adversarial networks for auxiliary hip fracture detection

BACKGROUND

Hip fractures are a significant public health issue, particularly among the elderly population. Pelvic radiographs (PXRs) play a crucial role in diagnosing hip fractures and are commonly used for their evaluation. Previous research has demonstrated promising performance in classification models for hip fracture detection. However, these models sometimes focus on the images' non-fracture regions, reducing their explainability. This study applies weakly supervised learning techniques to address this issue and improve the model's focus on the fracture region. Additionally, we introduce a method to quantitatively evaluate the model's focus on the region of interest (ROI).

METHODS

We propose a new auxiliary module called the patch-auxiliary generative adversarial network (PAGAN) for weakly supervised learning tasks. PAGAN can be integrated with any state-of-the-art (SOTA) classification model, such as EfficientNetB0, ResNet50, and DenseNet121, to enhance hip fracture detection. This training strategy incorporates global information (the entire PXR image) and local information (the hip region patch) for more effective learning. Furthermore, we employ GradCAM to generate attention heatmaps, highlighting the focus areas within the classification model. The intersection over union (IOU) and dice coefficient (Dise) are then computed between the attention heatmap and the fracture area, enabling a quantitative assessment of the model's explainability.

RESULTS AND CONCLUSIONS

Incorporating PAGAN improved the performance of the classification models. The accuracy of EfficientNetB0 increased from 93.61 % to 95.97 %, ResNet50 improved from 90.66 % to 94.89 %, and DenseNet121 saw an increase from 93.51 % to 94.49 %. Regarding model explainability, the integration of PAGAN into classification models led to a more pronounced attention to ROI. The average IOU improved from 0.32 to 0.54 for EfficientNetB0, from 0.28 to 0.40 for ResNet50, and from 0.37 to 0.51 for DenseNet121. These results indicate that PAGAN improves hip fracture classification performance and substantially enhances the model's focus on the fracture region, thereby increasing its explainability.

Admission deep venous thromboembolism of the lower extremity in patients of subtrochanteric fractures: a retrospective study

BACKGROUND

Subtrochanteric fractures, which constitute 5-10% of proximal femoral fractures, are particularly challenging due to their high incidence of nonunion and failure of internal fixation. The incidence of deep venous thrombosis (DVT) in the lower extremities is notably higher among patients with orthopedic trauma, leading to significantly increased healthcare costs and prolonged hospitalization. The number of studies focusing on the incidence and risk factors among the patients with subtrochanteric fractures was quite limited. Therefore, there is a lack of effective methods of identification and predication. The study aimed to examine the occurrence and contributing factors of DVT in the lower limbs following subtrochanteric fractures in patients.

MATERIALS AND METHODS

Retrospective analysis was performed on the patients with subtrochanteric fracture who were admitted from August 2019 to October 2022. All patients received ultrasound doppler scanning to detect lower extremity DVT. Demographic information, comorbid conditions, and serum markers levels from patients including red blood cell (RBC), hemoglobin (HGB), lymphocyte (LYM), triglyceride (TG) and etc. were collected for analysis. Variables that demonstrated significant differences were subsequently introduced into multiple regression models to identify the independent risk factors associated with DVT.

RESULTS

A total of 120 patients were included, including 80 males and 40 females, with an average age of 58.3 ± 16.14years. A total of 51 patients were diagnosed to have DVT, with an incidence of 42.50%. There was significant difference between two groups in terms of albumin (ALB) (P = 0.0008), total protein (TP)(P = 0.019), RBC(P = 0.013), HGB (P = 0.032) and D-dimer levels (P = 0.007). However, multivariate analyses identified increased D-dimer level(>750 ng/ml) and reduced serum albumin as independent factors. The ROC curve indicated that a D-dimer level of 750 ng/ml was the optimal cut-off value for diagnosing DVT in patients with subtrochanteric fractures, with a sensitivity of 56.52% and specificity of 82.35%. The optimal cut-off value of ALB was determined to be 36.6 g/L, with a sensitivity of 73.2% and the specificity of 41.2%. The area under the curve of 0.63 indicates that this cut-off moderately effectively distinguishes between conditions related to ALB levels.

CONCLUSIONS

D-dimer level and serum albumin are independent factors of DVT in patients with subtrochanteric fractures. These data are helpful in assessing risks of DVT, and guiding the subsequent individualized intervention program.

The vulnerability of hip fracture patients with cognitive impairment: an analysis of health conditions, hospital care, and outcomes

BACKGROUND

Cognitive impairment, including dementia, and hip fracture are both common among older patients. Both conditions are associated with increased morbidity and mortality. Cognitive impairment is often underdiagnosed and may remain undetected in hip fracture patients. Little is known about the prevalence, specific characteristics, and outcomes of hip fracture patients with cognitive impairment. This analysis aimed to compare hip fracture patients with and without cognitive impairments regarding their health conditions, hospital care, and the risk of complications and mortality.

METHODS

This study used data derived from the EMAAge project, a prospective multi-center cohort study conducted in Berlin, Germany. Patients aged 40 years and older with hip fracture were stratified into three cognitive status groups: no cognitive impairment (NCI), moderate cognitive impairment (MCI), and severe cognitive impairment (SCI). Categorization was based on patients' ability to engage in interviews and their performance on the 6-item Cognitive Impairment Test (6-CIT). Standardized mean differences were used to compare various health-related parameters and health care utilization measures. Regression models, both adjusted and unadjusted, were calculated for the number of complications and the mortality rate.

RESULTS

Cognitive impairment was present in 37% of the 310 hip fracture patients in the study cohort. Patients with cognitive impairment had a worse baseline health profile, delayed admission to the emergency department, a longer time to surgery, and were less likely to be referred to a rehabilitation program. In the adjusted regression model for the number of complications, the incidence rate ratio was 1.237 (p = 0.292) for MCI patients and 2.065 (p < 0.001) for SCI patients compared with NCI patients. The adjusted odds ratio for mortality was 1.046 (p = 0.942) for MCI patients and 2.875 (p = 0.060) for SCI patients.

CONCLUSIONS

Hip fracture patients with cognitive impairment, particularly severe impairment, arrive at the ED in a considerably poorer state of health and are at a higher risk of adverse outcomes, including complications and mortality. Timely identification of this at-risk group upon arrival appears to be essential to providing adequate care. This study highlights the need for interventions and research aimed at improving prevention, emergency care and outcomes for this vulnerable group, addressing their specific risk factors, and promoting the quality of care in hospital and after discharge.

Etiological factors and clinical outcomes in extracapsular and intracapsular hip fractures among older adults: A gender-specific analysis

BACKGROUND

Compared to patients with intracapsular fractures (ICFs), those with extracapsular fractures (ECFs) had worse outcomes. However, most studies of risk factors for these fractures lacked relevant potential reasons, particularly nutritional status, and adjustment for confounding factors. Furthermore, less is known about their effects on clinical outcomes.

OBJECTIVE

To conduct a gender-specific analysis of community-dwelling individuals admitted with hip fractures to examine the association of clinical risk factors and health care measures.

DESIGN

Monocentric cross-sectional study.

SETTING

Orthopedic trauma department.

PARTICIPANTS

A total of 787 women and 318 men of similar mean age (±SD): 83.1 years (±8.6) and 82.5 years (±9.0), respectively.

MAIN OUTCOME MEASURES

Multivariable logistic regression analyzed risk factors including age, gender, dementia, stroke, ischemic heart disease, diabetes, prefracture mobility, alcohol consumption, American Society of Anesthesiologists grades, drug history, and nutrition status for assessing risk factors and outcomes associated with ECFs and ICFs.

RESULTS

Compared to ICFs, for each additional year of age, women had a 3% and men 4% greater association with ECFs. Among women only, ECFs were associated with risk of malnutrition: odds ratio [OR] = 1.70 (95% CI, 1.17-2.48) or malnourishment: OR = 1.93 (95% CI, 1.06-3.52), stroke: OR = 1.85 (95% CI, 1.16-2.97), and diabetes: OR = 1.92 (95% CI, 1.21-3.06). Women with ECFs were less likely to be discharged to their own homes: OR = 0.56 (95% CI, 0.38-0.83); but more likely to be discharged to a rehabilitation unit: OR = 1.81 (95% CI, 1.21-2.71) and readmitted to hospital within 30 days of discharge ≥1 time: OR: 2.39 (95% CI, 1.27-4.50) or ≥2 times: OR = 3.48 (95% CI, 1.05-11.57): they did not differ in discharge to residential or nursing care or in-hospital mortality. Among men, there were no differences in discharge destinations or readmissions between types of fractures.

CONCLUSIONS

Compared to ICFs, a greater number of risk factors associated with ECFs were identified more often in women than in men, and ECFs also have greater influences on clinical outcomes in women.

Effect of early rehabilitation on hospital stay and postoperative complications in elderly hip fracture patients: a prospective cohort study

BACKGROUND

Hip fractures in the elderly are a major global public health concern, with incidence projected to rise as populations age. Rehabilitation is critical to recovery after hip fracture surgery, but the ideal timing for initiation remains uncertain. While early rehabilitation, within 48 h post-surgery, is associated with better outcomes, its specific impact on hospital stay duration and postoperative complications is not yet conclusively established.

AIM

This study aims to evaluate the effects of initiating rehabilitation within 48 h after hip fracture surgery on hospital length of stay and postoperative complications, compared to rehabilitation started one-week post-surgery in elderly patients. It is hypothesized that early rehabilitation will significantly reduce hospital stays and decrease the rate of postoperative complications.

METHODS

In this prospective cohort study, patients aged 65 and older are divided into early rehabilitation (within 48 h) and delayed rehabilitation (after one week) groups. Data will be collected using electronic medical records (EMR), standardized clinical tools (Barthel Index, Timed Up and Go), and patient-reported outcome measures (SF-36, EQ-5D). Statistical analyses will include t-tests and chi-square tests for outcome comparison, with multiple regression adjusting for potential confounders such as age, gender, and comorbidities.

Comparative analysis of general and regional anesthesia applications in geriatric hip fracture surgery

BACKGROUND

This study compares the outcomes of general anesthesia (GA) and regional anesthesia (RA) in geriatric hip fracture surgery to determine optimal anesthesia strategies for this population.

METHODS

A comprehensive literature review was conducted, analyzing studies comparing GA and RA in elderly patients undergoing hip fracture surgery. Studies encompassed various designs, including randomized controlled trials, cohort studies, and meta-analyses. Key analytical techniques included comparative analysis of intraoperative complications, postoperative outcomes, mortality rates, and physiological impacts.

RESULTS

GA was associated with higher risks of intraoperative cardiovascular events, respiratory depression, and postoperative complications such as cognitive dysfunction and delirium. In contrast, RA demonstrated superior outcomes in pain management, early mobilization, and reduced incidences of complications like postoperative nausea and vomiting. RA also correlated with shorter hospital stays and lower mortality rates within the first 30 days post-surgery.

CONCLUSION

RA emerges as a preferable choice for geriatric hip fracture surgery, offering improved safety profiles, enhanced recovery trajectories, and better postoperative cognitive outcomes compared to GA. These findings underscore the importance of anesthesia selection in optimizing surgical outcomes and patient safety in elderly populations. Future research should focus on prospective trials to validate these results and refine anesthesia protocols tailored to elderly hip fracture patients.

Ipsilateral femoral head and intertrochanteric fractures with posterior subluxation of the hip: A rare case report

INTRODUCTION

Hip fractures are common in elderly patients, often accompanied by comorbidities. These fractures can be combined with other injuries, such as a femoral head, neck, or shaft dislocation. The cause of this complex injury is not well-established, but factors like high-energy trauma or falls from a certain height may contribute.

CASE PRESENTATION

A 55-year-old man presented with an ipsilateral femoral head and left intertrochanteric fracture with posterior hip subluxation after a 3-m fall. This rare and complex injury was diagnosed using X-rays and CT scans. Due to the risk of complications, open reduction and internal fixation (ORIF) using a proximal femoral nail anti-rotation (PFNA) was performed. Early surgical intervention with PFNA provided stable fixation and promoted early mobilization. A 6-month follow-up showed the patient's Lower Extremity Functional Scale (LEFS) was 82.5 %, and Harris Hip Score (HHS) was 85 %, while before surgery, the patient's LEFS was 0 % and HHS was 3,85 %.

DISCUSSION

Intertrochanteric pelvic fractures are serious injuries causing avascular necrosis and traumatic osteoarthritis. They often occur with hip dislocation or acetabular wall fractures. Diagnosis is confirmed through 3D reconstruction. Management involves realigning the dislocated hip, surgical repositioning, and stabilizing the fractured femoral head. Surgical interventions include a sliding compression hip screw, side plate, or intramedullary nail. PFNA is a medical implant for complex fractures.

CONCLUSION

Open reduction and PFNA can effectively treat ipsilateral femoral head and intertrochanteric fractures with posterior hip subluxation, requiring early intervention, meticulous surgical technique, and appropriate implant selection.

Proximal Femur Fractures: Evaluating the Necessity of On-Call Surgery

Background: The decision of the Joint Federal Committee on the treatment of hip fractures stipulates that proximal femur fractures must be treated within the first 24 h. This leads to organizational and personnel difficulties in day-to-day care. Therefore, we investigated the question at what times of day we operate to maintain this timeline and whether there is a difference in the outcome for the patients according to treatment hours. Methods: Data from the DGU's "AltersTraumaRegister" from 2016 to 2020 were analyzed. For the analysis, the patients were divided into seven cohorts depending on the time of surgery. Pre-operative, operative, and follow-up data were analyzed. Results: A total of 29,470 patients were included in our study. The results showed that 74% of patients were treated within 24 h. 72% of patients operated on between 0-7 h had pertrochanteric fractures, while 56% of all arthroplasties were performed during normal working hours. In supra-regional trauma centers, significantly fewer operations were performed during normal working hours, while significantly more surgeries were carried out in the late evening and at night (p < 0.001). There were no significant differences in mortality and morbidity between the individual groups. Conclusions: Although we manage to treat most patients within 24 h, only 46% of patients are operated on within normal working hours. In terms of the outcome parameters, this does not appear to be a disadvantage for the patients. Nevertheless, night work and fatigue affect concentration and post-operative results in many areas, as we know. Consequently, patient care during normal working hours within 24 h creates the best possible initial situation for the patient, as significantly more personnel resources are available during normal working hours. The aim should be to create the logistical and personnel requirements for this.

Comparison of Management and Outcomes of Hip Fractures Among Low- and High-Income Patients in Six High-Income Countries

BACKGROUND

There is a perception that income-based disparities are present in most countries but may differ in magnitude. However, there are few international comparisons that describe income-based disparities across countries and none that focus on hip fractures.

OBJECTIVE

To compare treatment patterns and outcomes of high- and low-income older adults hospitalized with hip fracture across six high-income countries.

DESIGN

Retrospective serial cross-sectional cohort study.

PARTICIPANTS

Adults aged ≥ 66 years hospitalized with hip fracture from 2013 to 2019 in Canada, England, Israel, the Netherlands, Taiwan, and the USA using population-representative patient-level administrative data.

MAIN MEASURES

Older adults in the top and bottom income quintiles within countries were compared on 30-day and 1-year mortality, treatment approaches, hospital length of stay (LOS), 30-day readmission rates, time to surgery, and discharge disposition.

KEY RESULTS

Annual age- and sex-standardized incidence rates of hip fracture were higher for low- than for high-income populations in all countries except in the USA. In all countries, adjusted 1-year mortality was lower for high-income than low-income patients, with the largest difference in Israel (- 10.0 percentage points [95% confidence interval [CI], - 15.2 to - 4.8 percentage points]). Across countries, utilization of total hip arthroplasty was 0.1 (95% CI, 0.0-0.2 percentage points) to 6.9 percentage points (95% CI, 4.6-9.2 percentage points) higher among high- vs. low-income populations. With few exceptions, LOS, adjusted 30-day readmission rate, and time to surgery were shorter and lower for high-income patients.

CONCLUSIONS

Income-based disparities in treatments and outcomes for older adults hospitalized for hip fractures differed in magnitude, but were present in all six high-income countries. Defying our expectations, the USA did not have consistently larger disparities than other countries suggesting that the impacts of poverty exist in vastly different healthcare systems and transcend geopolitical borders.

Women undergoing primary total hip arthroplasty (THA) for hip fracture have lower in-hospital mortality compared to men

INTRODUCTION

We evaluated the association of patient sex with in-patient mortality and discharge disposition after primary total hip arthroplasty (THA) for hip fracture in the U.S.

METHODS

Using the 2016-2019 U.S. National Inpatient Sample (NIS), we calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association of sex with post-procedural complications and in-hospital mortality after primary THA for hip fracture, adjusting for demographics, social determinants of health, medical comorbidity, hospital characteristics, and post-procedural complications.

RESULTS

There were 400,930 primary THA procedure hospitalizations for hip fracture in the 2016-2019 NIS data. In multivariable-adjusted analysis, compared to males, female sex was associated with lower in-hospital mortality following THA for hip fracture (aOR 0.65, 95 % CI 0.58 - 0.74; p < 0.001). Multivariable-adjusted analysis showed that female sex was associated with higher odds of discharge to a non-home destination after a THA for hip fracture (aOR 1.14, 95 % CI 1.07 - 1.22; p < 0.001).

CONCLUSIONS

Female sex was associated with lower in-hospital mortality after a THA for hip fracture. Further insights into the protective mechanisms that mediate this lower mortality in women undergoing a THA for hip fracture are needed to achieve better outcomes for men in the future.

Hip Fracture in the Sportive Adult: Case Report of Complete Functional Recovery After Removal of Hardware

CONTEXT

Pertrochanteric hip fractures in sportive young adults are mainly caused by a high-energy trauma and treated in the same way as in the older population, using an osteosynthesis immediately followed by a rehabilitation program for several months. The current standard is not to remove osteosynthesis material, similar to the case of older patients.

CASE PRESENTATION

A 45-year-old male cyclist experienced a right pertrochanteric femoral fracture, treated with cephalomedullary nails. After 9 months of adequate rehabilitation, weakness of the quadriceps musculature and functional complaints persisted, objectified through an isokinetic strength test and a significantly reduced score on the Hip Disability and Osteoarthritis Outcome Score questionnaire. The patient was unable to return to his previous level of cycling performance.

MANAGEMENT AND OUTCOME

After exclusion of structural bone complications, nerve injury, and central sensitization, the functional complaints and strength deficiency were hypothesized to be related to the osteosynthesis material. Therefore, the hardware was removed 9 months after the first surgery, and the rehabilitation was continued for another 20 weeks. Very soon after the removal of the hardware, the functional complaints disappeared with a remarkable improvement of the Hip Disability and Osteoarthritis Outcome Score. The isokinetic strength test showed complete recovery of muscle strength 20 weeks after osteosynthesis removal, and preinjury cycling performance values were obtained 9 months posthardware removal.

CONCLUSION

Despite an adequate rehabilitation following a hip fracture, sporty young adults may fail to reach their previous level of functioning. Osteosynthesis removal may be indicated in this sportive population to reach complete muscle strength and functional recovery. The management of hip fractures in the sportive young adult and the identification of patients who may benefit from removal of the hardware require more research.

Mortality, perioperative complications and surgical timelines in hip fracture patients: Comparison of the Spanish with the non-Spanish Cohort of the HIP ATTACK-1 trial

BACKGROUND

Hip fractures carry a substantial risk of complications and death. This study aimed to report the 90-day incidence of mortality, major perioperative complications and in-hospital timelines after a hip fracture in the Spanish HIP ATTACK-1 trial cohort, comparing with the non-Spanish cohort.

METHODS

Prospective cohort study of Spanish patients nested in the HIP ATTACK-1 trial. The HIP ATTACK-1 was an international, randomized, controlled trial (17 countries, 69 hospitals, 7 in Spain, highest recruiting country). Patients were randomized to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. Participants were ≥45 years of age who presented with a low-energy hip fracture requiring surgery.

RESULTS

Among 534 patients in the Spanish cohort, 69 (12.9 %) patients died at 90 days follow-up, compared to 225 (9.2 %) in the non-Spanish cohort (p = 0.009), mostly due to higher nonvascular related mortality. A composite of major postoperative complication occurred in 126 patients (23.6 %). The most common perioperative complications were myocardial injury (189 patients, 35.4 %), infection with no sepsis (86 patients, 16.1 %) and perioperative delirium (84 patients, 15.7 %); all these complication rates in Spain were significantly higher than the non-Spanish patients (29.2 % p = 0.005; 11.9 % p = 0.008 and 9.2 % p < 0.0001, respectively). Spanish cohort patients were older and had more comorbidities than the non-Spanish cohort, evidencing their greater frailty at baseline. Among Spanish patients, the median time from hip fracture diagnosis to surgery was 30.0 h (IQR 21.1-53.9) in the standard-care group, with 68.8 % of patients receiving surgery within 48 h of diagnosis. This median time was lower in the non-Spanish cohort (22.8 h, IQR 9.5-37.0), where 82.1 % of patients were operated within 48 h.

CONCLUSIONS

In the HIP ATTACK-1 trial, 1 in 8 patients died 90 days after a hip fracture in Spain. The most common complication after a hip fracture was myocardial injury, followed by infection and delirium. Spanish patients had worse outcomes than non-Spanish patients. Research needs to focus on new interventions such as accelerated surgery and perioperative troponin measurement with the appropriate investment of resources, to prevent and identify early these complications with a goal of improving mortality for this high-risk population.

LEVEL OF EVIDENCE

II.

A Novel Nomogram Developed Based on Preoperative Immune Inflammation-Related Indicators for the Prediction of Postoperative Delirium Risk in Elderly Hip Fracture Cases: A Single-Center Retrospective Cohort Study

Objective

Postoperative delirium (POD) commonly occurs in elderly individuals following hip fracture surgery, with unclear pathophysiological mechanism. Inflammation is a known factor affecting the onset of delirium. The current work aimed to examine the associations of preoperative immune inflammation-related indicators with POD occurrence in elderly cases following hip fracture surgery.

Methods

The current retrospective cohort study included 437 elderly cases administered hip fracture surgery from January 2018 to December 2023. The clinicodemographic data and laboratory findings of all cases were retrospectively analyzed. Immune inflammation-related indicators were assessed, eg, MLR, NLR and PLR, as well as SII and SIRI. The bootstrap method was employed to assign cases at 7:3 to the training (48 and 258 cases in the POD and no-POD groups, respectively) and internal validation (13 and 118 cases in the POD and no-POD groups, respectively) cohorts. Next, LASSO, univariable and multivariable logistic regression analyses were applied to determine risk factors in the training cohort, based on which a nomogram model was built. The obtained nomogram was examined for accuracy by calibration plot analysis. Finally, the nomogram's clinical value was assessed by decision curve analysis (DCA), followed by internal validation based on the training cohort.

Results

Of all 437 cases, 61 developed POD, indicating a POD incidence of 13.96%. LASSO regression and multivariable analyses revealed preoperative SIRI independently predicted POD in the training cohort. The developed nomogram had an area under the curve (AUC) of 0.991 (95% CI 0.983~0.998) in the training cohort versus 0.986 (95% CI 0.966~1.000) in the validation cohort. Calibration curve analysis revealed nomogram-predicted and actual probabilities were in line. DCA demonstrated the novel nomogram could confer net benefits for POD prediction in elderly cases administered hip fracture surgery.

Conclusion

The immune inflammation-related indicators SIRI could predict POD in elderly cases following hip fracture surgery.

Utilization of the pericapsular nerve group block in preoperative rehabilitation of patients with femoral neck fractures -a case series

BACKGROUND

Elderly patients with femoral neck fractures, particularly those with severe comorbidities or living in regions with limited medical resources, may experience delays in surgical treatment. Although the benefits of preoperative rehabilitation (prehabilitation) in hip arthroplasty have been reported, pain management remains a challenge. The pericapsular nerve group (PENG) block, known for its exceptional analgesic effect and motor function preservation, may be a promising intervention during prehabilitation in these patients.

CASE

We enrolled ten patients with Garden classification 3-4 femoral neck fractures scheduled for hip arthroplasty. After receiving a PENG block with 20 ml of 0.375% ropivacaine, all patients underwent initial prehabilitation sessions comprising 9 mobility levels, ranging from bed-sitting to walking. One patient was excluded due to experiencing high blood pressure during prehabilitation. Six of the nine remaining patients (66.7%) were successfully transferred from bed to wheelchair.

CONCLUSIONS

The PENG block enhanced prehabilitation for patients with femoral neck fractures undergoing hip arthroplasty.

Nutritional care in older adults: are we doing everything? An expert opinion review

Malnutrition is a prevalent, yet often underdiagnosed and undertreated, condition in older adults. It is characterized by weight loss and/or reduced muscle mass due to diminished caloric intake, inflammation, and/or disease burden. In return, malnutrition can lead to diminished skeletal muscle functionality and disability, among others. Malnutrition plays a crucial role in the pathogenesis of two prevalent geriatric syndromes, namely sarcopenia and frailty. The complex interplay between malnutrition, sarcopenia, and frailty significantly impacts the older population, leading to increased morbidity, mortality, hospitalization rates, quality-of-life, and healthcare costs. Given the prognostic significance of malnutrition in geriatric care, recent guidelines emphasized the role of nutritional support in vulnerable populations. A group of vulnerable populations to malnutrition, sarcopenia, and frailty are older patients with hip fractures, cancer patients, and those with sarcopenic dysphagia. This article highlights the importance of individualized nutritional assessment and treatment in the management of vulnerable populations such as older patients with hip fractures, cancer, and those suffering from sarcopenic dysphagia. It presents practical protocols and guidelines that can be instrumental in enhancing the nutritional care of these groups, thereby improving their overall health outcomes.

Anesthesia Management of Hip Fracture Surgery in Geriatric Patients: A Review

Hip fractures are increasingly prominent concerns in healthcare, especially in light of a growing elderly population. These fractures contribute to mortality and morbidity in the elderly. Many hip fractures require emergent surgical intervention and may have consequences of serious postoperative complications. Multidisciplinary approaches of management have been utilized to optimize care and improve patient outcomes. Due to the myriad of multi-organ system comorbidities that are increasingly prevalent in the geriatric population, anesthetic management proves to be difficult to standardize. Enhanced Recovery After Surgery (ERAS) protocols have shown benefits for optimizing patient outcomes by focusing on premedication, nutritional support, and pain management; however, specific anesthetic management techniques are not discussed. This literature review aims to discuss ways to optimize hip fracture management in geriatric patients through effective preoperative evaluation, anesthetic considerations, and postoperative optimization and care. A review of currently available guidelines may help determine the optimal management for hip fractures in geriatric patients and improve immediate and lasting postoperative outcomes.

Ultrasound-Guided Suprainguinal Fascia Iliaca Compartment Block in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The use of fascia iliaca compartment block (FICB) has been widely encouraged for hip surgery; however, meta-analyses showed mixed results in terms of its efficacy in reduction in analgesic consumption and pain score. These meta-analyses included all forms of FICB approaches, which may diminish the effect size of the therapy. Suprainguinal FICB (s-FICB) has been shown to be superior to other FICB approaches including the ultrasound-guided infrainguinal approach and the landmark approach. This systematic review and meta-analysis aim to compare opioid consumption, pain score, and complications after s-FICB to control for patients undergoing hip surgery. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42023460377). We performed a systematic literature search in Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from inception to 16 August 2023 to identify randomized controlled trials (RCTs) that evaluated the efficacy of s-FICB versus control for patients undergoing hip surgery. Data were independently extracted by two reviewers, and disagreements were resolved by consensus or by discussion with a third investigator. The primary outcome is the 24-hour oral morphine equivalent daily dose (oMMED). The secondary outcome includes oMMED at different timepoints, and pain score. The Cochrane risk of bias tool (Cochrane, London, England) was used to assess the risk of bias. The certainty of evidence was assessed via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were synthesized using a random-effects model. Trial sequence analysis is performed on opioid consumption 24 hours post operation. Eleven randomized controlled trials were included. Arthroscopic hip surgery was performed in three studies involving 222 patients, hip and femur fracture surgeries were performed in three studies involving 149 patients, and total hip arthroplasty was performed in five studies involving 483 patients. In studies involving arthroscopic hip surgery, s-FICB did not improve intra-operative and post-operative opioid consumption and post-operative pain score. In studies involving hip and femur fracture surgeries, s-FICB was associated with a non-significant difference in opioid consumption at 24 hours after surgery and post-operative pain score at 12 hours and 24 hours after surgery. However, the result of the trial sequential analysis (TSA) was not definitive, indicating that additional research is necessary to draw conclusive outcomes. In studies involving total hip arthroplasty, s-FICB was associated with a significant reduction in post-operative opioid consumption at 24 and 48 hours with conclusive results in trial sequential analysis. In conclusion, s-FICB is superior to placebo for patients undergoing total hip arthroplasty. For patients undergoing arthroscopic hip surgery, s-FICB is unlikely to be beneficial. With regard to hip fracture surgery, additional research is necessary to draw conclusive outcomes.

Independent Walking Disability After Fragility Hip Fractures: A Prognostic Factors Analysis

Introduction

Up to one-third of patients with fragility hip fractures are totally dependent in the year following the injury which leads to later morbidity and mortality. Understanding the related factors that affect patients' ambulation helps health care providers prepare for the treatment plans to improve their functional outcomes. This study aimed to evaluate the factors associated with independent walking disability in the early postoperative period after fragility hip fractures.

Material and methods

This retrospective cohort study involved 394 patients with fragility hip fractures with either intertrochanteric, subtrochanteric, or femoral neck fractures from January 2018 to June 2023. The related factors including preoperative demographics, perioperative, and postoperative factors, were collected and analyzed. The endpoint was the independent walking disability of patients at 6 weeks after surgery.

Results

110 patients (27.9%) were disabled, whereas 284 patients (72.1%) could walk independently at postoperative 6 weeks. The multivariable risk ratio regression analysis showed that patients with age ≥80 years (RR 1.65; 95% CI 1.21-2.25; P = 0.001), pre-fracture walking with the gait aid (RR 2.03; 95% CI 1.53-2.69; P < 0.001), having ≥2 underlying comorbidities (RR 1.63; 95% CI 1.19-2.23; P = 0.002), preoperative hypoalbuminemia (RR 1.74; 95% CI 1.32-2.29; P < 0.001), and presence of the postoperative medical complication (RR 2.04; 95% CI 1.37-3.02; P < 0.001) were significantly associated with independent walking disability at the early postoperative period of 6 weeks.

Conclusions

Post-hip fracture surgery patients with the presence of postoperative medical complication have the highest risk of independent walking disability. Health care providers should concentrate on high-risk patients, correct the modifiable factors, and minimize any postoperative complications to improve functional recovery and decrease morbidity related to non-ambulation after fragility hip fractures.

Effects of body mass index on mortality in elderly patients with hip fractures

Hip fractures remain a substantial health concern, particularly among elderly individuals with osteoporosis, leading to high global mortality rates. This study aimed to analyze the association between body mass index (BMI) and postoperative mortality in patients who underwent surgery for hip fractures. A total of 680 patients treated at a single institution between January 2018 and December 2022 were included. Factors such as age, BMI, sex, Charlson Comorbidity Index (CCI), preoperative hemoglobin levels, American Society of Anesthesiologists score, anesthesia method, duration of surgery, and time from injury to surgery were assessed. Underweight status, male sex, higher CCI, and general anesthesia were significantly associated with 1-year and in-hospital mortality. Notably, underweight individuals exhibited a higher risk of mortality than normal-weight individuals, and female patients had lower mortality rates. This study underscores the importance of considering BMI, along with other demographic and clinical factors, in predicting postoperative mortality among patients with hip fractures, aiding the development of tailored management strategies to improve outcomes and reduce complications in this vulnerable patient population.

Persistent racial disparities in postoperative management after tibia fracture fixation: A matched analysis of US medicaid beneficiaries

INTRODUCTION

Racial and ethnic disparities in orthopaedic surgery are well documented. However, the extent to which these persist in fracture care is unknown. This study sought to assess racial disparities in the postoperative surgical and medical management of patients after diaphyseal tibia fracture fixation.

METHODS

Patients with surgically treated tibial shaft fractures from October 1, 2015, to December 31, 2020, were identified in the MarketScan® Medicaid Database. Exclusion criteria included concurrent fractures or amputation. Outcomes included 2-year postoperative complications, reoperation rates, and filled prescriptions. Surgically-treated Black and White cohorts were propensity-score matched using nearest-neighbor matching on patient demographics, comorbidities, fracture pattern and severity, and fixation type. Chi-square tests and survival analyses (Kaplan-Meier and Cox proportional hazard models) were conducted.

RESULTS

5,472 patients were included, 2,209 Black and 3,263 White patients. After matching, 2,209 were retained in each cohort. No significant differences in complication rates were observed in the matched Black vs White cohorts. Rates of reoperation, however, were significantly lower in Black as compared to White patients (28.5 % vs. 35.5 % rate, risk difference = 7.0 % (95 % confidence interval (CI): 4.2 % to 9.7 %)). Implant removal was also significantly lower in Black (17.9 %) vs. White (25.1 %) patients (Risk difference = 7.2 %, (95 %CI: 4.8 % to 9.6 %)). The adjusted hazard ratio comparing the reoperation rate in Black versus White patients was 0.77 (95 %CI: 0.69-0.82, p < 0.0001). Significantly lower proportions of Black vs White patients filled at least one prescription for benzodiazepine, antidepressants, strong opiates, or antibiotics at every time point post-index.

DISCUSSION

Fewer resources were used in post-operative management after surgical treatment of tibial shaft fractures for Black versus White Medicaid-insured patients. These results may be reflective of the undertreatment of complications after tibia fracture surgery for Black patients and highlight the need for further interventions to address racial disparities in trauma care.

Comparative analysis of geriatric hip fracture management outcomes in teaching and nonteaching hospitals in Jordan

Hip fractures are common orthopedic injuries that have significant impacts on patients and healthcare systems. Previous studies have shown varying outcomes for hip fracture management in different settings, with diverse postoperative outcomes and complications. While teaching hospital settings have been investigated, no studies have specifically examined hip fracture outcomes in teaching hospitals in Jordan or the broader Middle East region. Therefore, the aim of this study was to investigate this important outcome. A cohort comprising 1268 patients who underwent hip fracture fixation from 2017 to 2020 was analyzed for nine distinct outcomes. These outcomes encompassed time to surgery, ICU admissions, perioperative hemoglobin levels, length of hospital stay, readmission rates, revision procedures, and mortality rates at three time points: in-hospital, at 6-months, and at 1-year post-surgery. The analysis of 1268 patients (616 in teaching hospitals, 652 in non-teaching hospitals) showed shorter mean time to surgery in teaching hospitals (2.2 days vs. 3.6 days, p < 0.01), higher ICU admissions (17% vs. 2.6%, p < 0.01), and more postoperative blood transfusions (40.3% vs. 12.1%, p < 0.01). In-hospital mortality rates were similar between groups (2.4% vs. 2.1%, p = 0.72), as were rates at 6-months (3.1% vs. 3.5%, p = 0.65) and 1-year post-surgery (3.7% vs. 3.7%, p = 0.96). Geriatric hip fracture patients in teaching hospitals have shorter surgery times, more ICU admissions, and higher postoperative blood transfusion rates. However, there are no significant differences in readmission rates, hospital stays, or mortality rates at various intervals.

Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review

BACKGROUND

Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support.

METHODS

We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies.

RESULTS

Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them.

CONCLUSIONS

This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Effect of pericapsular nerve group block and suprainguinal fascia iliaca block on postoperative analgesia and stress response in elderly patients undergoing hip arthroplasty: a prospective randomized controlled double-blind trial

BACKGROUND

As a novel regional analgesic technique, ultrasound-guided pericapsular nerve group (PENG) block has some potential advantages, and we designed a randomized clinical trial (RCT) to investigate whether the ultrasound-guided PENG block combined with general anesthesia can better reduce stress response, maintain intraoperative hemodynamic stability, and reduce postoperative analgesia in elderly hip arthroplasty compared with ultrasound-guided suprainguinal fascia iliaca block (SIFIB) combined with general anesthesia.

METHODS

Seventy-four subjects were enrolled over an 8-month period (20 April 2023 to 31 December 2023). All patients were divided into the test group (group P) and the control group (group S) using the envelope as the randomization method. The test group was treated with preoperative ultrasound-guided PENG block analgesia combined with general anesthesia and the control group was treated with preoperative ultrasound-guided SIFIB analgesia combined with general anesthesia. The primary outcome selected was the patient Visual Analogue Scale (VAS) score at 12 h postoperatively.

RESULTS

After generalized estimating equations (GEE) analysis, there was a statistically significant difference in the main effect of postoperative VAS score in group P compared with group S (P = 0.009), the time effect of VAS score in each group was significantly different (P < 0.001), and there was no statistically significant difference in the group-time interaction effect (P = 0.069). There was no statistically significant difference in the main effect of intraoperative mean arterial pressure (MAP) change (P = 0.911), there were statistically significant differences in the time effect of MAP in each group (P < 0.001), and there were statistically significant differences in the interaction effect (P < 0.001).

CONCLUSIONS

In summary, we can conclude that in elderly patients undergoing hip fracture surgery, postoperative analgesia is more pronounced, intraoperative hemodynamic parameters are more stable, and intraoperative stress is less induced in patients receiving SIFIB than in patients receiving PENG block.

Impact of diabetes on the risk of subsequent fractures in 92,600 patients with an incident hip fracture: A Danish nationwide cohort study 2004-2018

PURPOSE

We investigated the incidence rates of a subsequent hip fracture (HF) and other subsequent fractures than HF after first incident HF, comparing patients with and without diabetes.

METHODS

Using Danish medical databases, we identified 92,600 incident HF patients in the period 2004-2018. Diabetes exposure was examined overall, by type of diabetes (T2D and T1D), and by presence of diabetes complications. We estimated cumulative incidence of subsequent HFs and fractures other than HF within two years of the incident HF. Using Cox regression, adjusted hazard ratios (aHRs) with 95 % confidence interval (CI) were calculated.

RESULTS

Among incident HF patients, 11,469 (12 %) had diabetes, of whom 10,253 (89 %) had T2D and 1216 (11 %) had T1D. The 2-year incidence rates for a new subsequent HF were 4.8 % (95 % CI: 4.6-4.9) for patients without diabetes (reference group), 4.1 % (95 % CI: 3.8-4.6) for T2D, and 4.3 % (95 % CI: 3.3-5.6) for T1D. Corresponding aHRs were 1.01 (95 % CI 0.90-1.14) for T2D and 1.17 (95 % CI 0.87-1.58) for T1D. There was effect modification by sex, as women with T1D had an aHR of 1.52 (95 % CI: 1.09-2.11) for subsequent HF, and by specific diabetes complications (for example, patients with T2D and prior hypoglycemia had an aHR of 1.75 (95 % CI: 1.24-2.42) for subsequent HF, while patients with T1D and neuropathy had an aHR of 1.73 (95 %: 1.09-2.75), when compared with patients without diabetes). For fractures other than HF, the 2-year incidence rates were 7.3 % (95 % CI: 7.2-7.5) for patients without diabetes, 6.6 % (95 % CI: 6.1-7.1) for T2D, and 8.5 % (95 % CI: 7.0-10.1) for T1D, with corresponding aHRs of 1.01 (95 % CI 0.92-1.11) for T2D and 1.43 (95 % CI: 1.16-1.78) for T1D. T2D was only a risk factor for other subsequent fractures among HF patients of high age (age 86-89 years: aHR 1.22 (95 % CI 0.99-1.55), age 90+ years: aHR 1.37 (95 % CI 1.08-1.74)), whereas T1D was robustly associated with increased risk of fractures other than HF in all subgroups.

CONCLUSION

Among HF patients, we found no strong overall association of T2D or T1D with increased risk of subsequent HF, but diabetes patients with prior hypoglycemic events or neuropathy were at increased risk. In contrast, patients with T1D had a clearly increased risk of subsequent fractures other than HF.

Right Ventricular Subclinical Dysfunction as a Predictor of Postoperative Adverse Clinical Outcomes in Patients with Femoral Fracture

BACKGROUND

Femoral fractures often lead to complications such as altered pulmonary hemodynamics. Right ventricular global longitudinal strain (RV GLS), which correlates with pulmonary hemodynamics, indicates the subclinical function of the right ventricle (RV). This study aimed to investigate the predictive value of RV GLS for the risk of adverse clinical composite outcomes in patients with femoral fractures.

METHODS

Data were obtained from a prospective single-center cohort of patients hospitalized for femoral fractures and followed up for at least 1 year between March 2021 and October 2022. The primary outcome was the development of an adverse composite clinical event, which included pneumonia, pulmonary oedema or effusion, pulmonary thromboembolism, and all-cause mortality within the 1-year period following surgery.

RESULTS

Among the 163 patients, 36 (22.09%) experienced adverse composite clinical events during 1-year follow-up. The adverse outcome group demonstrated poorer RV GLS and RV free wall strain values than the non-adverse outcome group. The optimal cut-off value of RV GLS for predicting composite adverse clinical events was -12.55%. The cumulative composite event-free survival rate was significantly lower in the RV GLS ≥ -12.55% group (log-rank p-value = 0.003). After adjusting for confounding factors, multivariate Cox proportional hazards regression analyses showed that RV GLS ≥ -12.55% independently increased the risk of composite adverse clinical events by 2.65-fold.

CONCLUSIONS

Poor RV GLS is a significant predictor of adverse clinical outcomes in patients with femoral fractures. Specifically, an RV GLS value of ≥ -12.55% indicated a substantially increased risk of adverse events.

Risk factors for postoperative urinary retention in fragility hip fracture patients: a prospective study

BACKGROUND

Postoperative urinary retention (POUR) among older patients with hip fractures is common and may result in delayed ambulation, prolonged hospital stays, and urinary tract infections. Although preoperative urinary catheter indwelling and early postoperative removal can prevent perioperative urinary retention, this condition may occur in some patients after catheter removal, which requires urinary catheter re-indwelling or intermittent catheterization. Therefore, this study aims to identify risk factors and develop a screening tool for postoperative urinary retention in patients who have undergone operative treatment for fragility hip fractures subsequent to urinary catheter removal.

METHODS

A prospective cohort study of 145 fragility hip fracture in older patients who were operatively treated between September 2020 and May 2022 was conducted. All patients were evaluated for urine retention after urinary catheter removal using a bladder scan. In addition, factors related to urinary retention were collected and utilized for screening tool development.

RESULTS

Of the included patients, 22 (15.2%) were diagnosed with POUR. A multivariable logistic regression model using a stepwise backward elimination algorithm identified the current use of drugs with anticholinergic effect (OR = 11.9, p = 0.012), international prostate symptom score (IPSS) ≥ 8 (OR = 9.3, p < 0.001), and inability to independently get out of bed within 24 h postoperatively (OR = 6.5, p = 0.051) as risk factors of POUR. The screening tool that has been developed revealed an excellent performance (AuROC = 0.85, 95%CI 0.75 to 0.91) with good calibration and minimal optimism.

CONCLUSIONS

Current use of drugs with anticholinergic effects, IPSS ≥ 8, and inability to independently get out of bed within 24 h postoperatively are significant variables of POUR. For additional external validation, a proposed scoring system for POUR screening was developed.

TRIAL REGISTRATION

The study protocol was retrospectively registered in The Thai Clinical Trials Registry (TCTR20220502001: 2 May 2022).

Unplanned emergency department visits within 90 days of hip hemiarthroplasty for osteoporotic femoral neck fractures: Reasons, risks, and mortalities

Objectives

Bipolar hemiarthroplasty is commonly performed to treat displaced femoral neck fractures in osteoporotic patients. This study aimed to assess the occurrence and outcomes of unplanned return visits to the emergency department (ED) within 90 days following bipolar hemiarthroplasty for displaced femoral neck fractures.

Methods

The clinical data of 1322 consecutive patients who underwent bipolar hemiarthroplasty for osteoporotic femoral neck fractures at a tertiary medical center were analyzed. Data from the patients' electronic medical records, including demographic information, comorbidities, and operative details, were collected. The risk factors and mortality rates were analyzed.

Results

Within 90 days after surgery, 19.9% of patients returned to the ED. Surgery-related reasons accounted for 20.2% of the patient's returns. Older age, a high Charlson comorbidity index score, chronic kidney disease, and a history of cancer were identified as significant risk factors for unplanned ED visits. Patients with uncemented implants had a significantly greater risk of returning to the ED due to periprosthetic fractures than did those with cemented implants (P = 0.04). Patients who returned to the ED within 90 days had an almost fivefold greater 1-year mortality rate (15.2% vs 3.1%, P < 0.001) and a greater overall mortality rate (26.2% vs 10.5%, P < 0.001).

Conclusions

This study highlights the importance of identifying risk factors for unplanned ED visits after bipolar hemiarthroplasty, which may contribute to a better prognosis. Consideration should be given to the use of cemented implants for hemiarthroplasty, as uncemented implants are associated with a greater risk of periprosthetic fractures.

Informal care after hip fracture: prospective cohort

BACKGROUND

Hip fracture is very common and it has life-shattering consequences for older persons. After discharge the older persons need help with even basic everyday activities from formal and informal caregivers. In Scandinavia formal care are well-developed however the presence of informal caregivers likely reflect on the amount of formal care and wears on the informal caregivers. This study explore how often and how much informal care (IC) older persons receive after hip fracture.

METHOD

We contacted 244 community-dwelling older persons every two weeks the first twelve weeks after discharge after hip fracture and asked them if they received care from family and/or friends and how much. We used non-parametric statistics and level of significance was 95%.

RESULTS

The proportion of older persons receiving IC was 90% and the median amount of IC was 32 hours (IQR 14-66). The number of older persons who received IC was highest the first four weeks after discharge and so was the amount of hours of IC. The older persons that were high-dependence on IC received a median of 66 (IQR 46-107) hours compared to the low-dependent of 11 hours (IQR 2-20).

CONCLUSION

IC is very frequent, especially the first two to four weeks after discharge. The median IC was 32 hours from discharge to the 12-week follow-up. However, this figure tended to rise for persons with, among other, reduced functionality and those residing with a partner.

IMPLICATIONS

With respect to local differences, the findings in this study are likely applicable to other Scandinavian countries. We strongly suggest that the variation in older person need for informal caregiver be given consideration in the prioritisation of resources.

TRIAL REGISTRATION

This prospective cohort study of informal care, was part of a cluster-randomised stepped-wedge clinical controlled trial. Written consent was obtained required by regional ethics committee S-20200070. Data was collected in accordance with the Danish Data Protection Agency (20-21854).

Characteristics of Postoperative Heart Failure in Older Hip Fractures Patients Combined with Coronary Heart Disease and Construction of a Prediction Model of Nomogram, a Retrospective Cohort Study

INTRODUCTION

Older patients combined with coronary heart disease (CHD) develop acute heart failure (AHF) after hip fracture surgery is common, and this study aimed to investigate the risk factors of postoperative AHF in older hip fracture patients and to construct a nomogram prediction model.

METHODS

We retrospectively collected older hip fracture patients with CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2017 to December 2021. We divided them into a training set and a validation set. We collected the demographic data, laboratory indicators and imaging examination results. We identified risk factors for postoperative AHF and used R language software to establish a nomogram prediction model, plot ROC curves, calibration curves and DCA decision curves.

RESULTS

We retrospectively collected 1288 older hip fractures patients with CHD. After excluding 214 patients who did not meet the criteria, 1074 patients were included in our research and we divided them into the training set and the validation set. In the training set, a total of 346 (42.8%) patients developing postoperative AHF. Through univariate and multivariate logistic regression analysis, we identified the risk factors for postoperative AHF and constructed a nomogram prediction model. The AUC of the prediction model is 0.778. The correction curve shows that the model has good consistency. The decision curve analysis shows that the model has good clinical practicality.

CONCLUSION

There were 42.8% older patients combined with CHD develop postoperative AHF. Among them, fracture type, age, anemia at admission, combined with COPD, ASA ≥ 3, and preoperative waiting time >3 days are risk factors for postoperative AHF. We constructed a nomogram prediction model that can effectively predict the risk of postoperative AHF in older hip fracture patients combined with CHD.

The Impact of Dementia on Patients with Hip Fracture

Hip fractures are a serious global health concern with a substantial impact on senior patients' mobility, quality of life, and morbidity. Patients with psychiatric pathology may experience heightened levels of distress, making pain management more challenging. The presence of multiple comorbidities may complicate the therapeutic management of hip fractures. Treatment plans must be carefully tailored to accommodate each individual's unique medical history and current health status. We looked for improving pain evaluation and management in patients with dementia and choosing the best treatment according to age and comorbidities. This study highlights the mortality rate in surgically and non-surgically treated patients and possible correlations with other factors. We conducted a prospective study on 184 patients over 60 years old, with dementia and hip fractures, between 2018 and 2020 in Romania, within the Galati County Clinical Hospital. We applied the Charlson Comorbidity Index, ACE III test, EQ5D5L, and Harris test scores to assess the comorbidities, respectively, pain levels, mobilization in daily life activities, self-care and severity of dementia to exert the optimal treatment for patients with dementia and hip fracture. Our study pointed out that pain was frequently excruciating in non-operated patients compared to those who were operated. Most non-operated patients were immobilized in bed, they required careful and permanent care, while most of the operated patients experienced lower pain levels. While some risk factors of morbidity and mortality, such as comorbidities, severity of dementia, high age, and previous living situations are not preventable, delayed surgery, and general anesthesia risks may be prevented. Despite the treatment, mortality was high both at 6 months and 2 years, with increased survival rate in surgical treated patients. Our study addresses issues such as the importance of mental state evaluation in elderly patients in therapeutic decisions, the surgical intervention and the particularities in pre- and postoperative pain control in patients with dementia, topics that are insufficiently established in the current practical guidelines.

[Effects of the COVID-19 pandemic on the course of geriatric trauma patients with proximal femoral fractures]

BACKGROUND/OBJECTIVE

In 2020 the COVID-19 pandemic posed a major challenge to the healthcare system. The hypothesis is that the COVID-19 pandemic in 2020 had an impact on the care of older adults with proximal femoral fractures due to resource scarcity, regardless of whether or not the patient was infected.

MATERIAL AND METHODS

This study analyzed the data of 87 hospitals which entered 15,289 patients in the Geriatric Trauma Register ("AltersTraumaRegister DGU®", ATR-DGU) in Germany in 2019 and 2020. In this study we analyzed the influence of the COVID-19 pandemic on the inpatient treatment of hip fractures as well as the mid-term follow-up during the first 120 days. For the main analysis, we compared patients documented during the COVID-19 pandemic in 2020 (April-December) with a control group in 2019 (April-December). Additionally, we performed a subgroup analysis of the periods with high COVID-19 incidence rates.

RESULTS

Between 2019 and 2020 a total of 11,669 patients (2020: n = 6002 patients vs. 2019: n = 5667 patients) were included in this study. Only minor differences were found between the patients treated during the pandemic; however, when the COVID-19 incidence in Germany was greater than 50/100,000 residents, significantly fewer patients (p < 0.001) were discharged to a geriatric rehabilitation ward (27.2% vs. 36.3%) and an increased mortality rate during inpatient treatment was determined (8.4% vs. 4.6%) (p < 0.001).

DISCUSSION

The healthcare system was able to respond to the pandemic and patients' clinical courses were not impaired as long as the incidences were low. Nevertheless, the healthcare system reached its limits in times of higher incidence, which was also directly reflected in the patient outcome, mortality and place of discharge.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

Comparative effectiveness of pericapsular nerve group block versus fascia iliac compartment block on postoperative wound pain management in patients undergoing hip fracture surgery: A systematic review and meta-analysis

Hip fracture surgeries are challenging, with postoperative pain management being a critical component of patient care. This systematic review and meta-analysis aimed to compare the effectiveness of Pericapsular nerve group block (PENGB) and fascia iliac compartment block (FICB) in postoperative wound pain management for patients undergoing hip fracture surgery. The study followed the PRISMA guidelines and was structured around the PICO framework. Comprehensive searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library. Inclusion criteria were limited to RCTs comparing the effectiveness of PENGB and FICB in adult patients undergoing hip fracture surgery. Key outcomes included pain control effectiveness, safety, and complication incidence. The quality of studies was assessed using the Cochrane Collaboration's risk of bias tool. Statistical heterogeneity was evaluated using I2 statistics, and meta-analysis effect values were calculated using random-effects or fixed-effect models, depending on the degree of heterogeneity. The search identified 1095 articles, with 5 studies meeting inclusion criteria. The meta-analysis revealed that PENGB and FICB were comparable in managing postoperative pain and opioid consumption. However, PENGB significantly reduced the incidence of quadriceps muscle weakness (RR = 0.12, p < 0.05) and did not increase the risk of PONV (RR = 1.36, p = 0.51), suggesting its advantage in maintaining motor function without adding to PONV complications. No significant publication bias was detected. PENGB is comparable to FICB in pain and opioid consumption management after hip fracture surgeries. Its significant benefit lies in reducing the incidence of quadriceps muscle weakness, facilitating better postoperative mobility. Additionally, PENGB does not increase the risk of postoperative nausea and vomiting, underlining its suitability for comprehensive postoperative care in hip fracture patients.

The Efficiency of Antiosteoporosis Medicine after Intertrochanteric Fracture Surgery: A Retrospective Study of Refracture Rate, Function Recovery, Complications, and Mortality in the Chinese Elderly Population

Objective  This research aimed to discern the effects of antiosteoporosis medication on postoperative functional recovery, refracture incidence, complications, and mortality in geriatric patients with intertrochanteric fractures. Methods  A retrospective study was conducted on 250 patients aged 65 years and above who underwent surgery for intertrochanteric fractures between January 2013 and December 2014. Intertrochanteric fracture is diagnosed with International Classification of Diseases 10th Revision code (S72.101) and classified by the Evans-Jensen system. Collected data encompassed demographic details, pre- and postoperative histories of antiosteoporotic medication, functional outcomes (measured using Harris hip score, Parker Mobility Score, and EuroQol-5 Dimension [EQ-5D] scores), refracture incidences, complications, and survival rates. The antiosteoporotic regimen was categorized into essential (calcium, vitamin D) and advanced medications (bisphosphonate, calcitonin, etc.). Outcomes between patients on antiosteoporosis treatment (AO group) and those without (control group) were compared. Results  The cohort comprised 250 patients, with a gender distribution of 85 males (34%) and 165 females (66%), and a mean age of 79.8 ± 7.0 years. The median follow-up period was 15.82 months (maximum 31.13 months). Postoperatively, 126 (50.4%) patients were administered antiosteoporotic treatment. The refracture incidence in the AO group (2.4%, n  = 3) was notably lower than the control group (8.9%, n  = 11), manifesting a substantial risk reduction (odds ratio 0.251, 95% confidence interval 0.068-0.920, p  = 0.024). While no marked differences in functional outcomes between the AO and control groups were observed (Harris score [96.17 ± 7.77 vs. 97.29 ± 6.74, p  = 0.074), Parker score [8.54 ± 1.26 vs. 8.62 ± 1.18, p  = 0.411], EQ-5D [0.83 ± 0.05 vs. 0.82 ± 0.06, p  = 0.186]), patients administered a combination of essential and advanced drugs showcased significantly improved Harris and EQ-5D scores compared to those on essential drugs alone (Harris score [77.93 ± 2.04 vs. 84.94 ± 2.73, p  = 0.015], EQ-5D [0.65 ± 0.03 vs. 0.75 ± 0.04, p  = 0.015]). Conclusion  Postoperative antiosteoporosis treatment acts as a deterrent against refracture following intertrochanteric fracture surgeries, evidenced by a decline in refracture rates. However, the treatment's impact on functional recovery, quality of life, complications, and mortality remains indistinct. Interestingly, the combined administration of essential and advanced antiosteoporotic drugs seems to foster enhanced functional outcomes, warranting further exploration in future studies.

Assessing lower extremity loading during activities of daily living using continuous-scale physical functional performance 10 and wireless sensor insoles: a comparative study between younger and older adults

PURPOSE

This study aims to investigate the lower extremity loading during activities of daily living (ADLs) using the Continuous Scale of Physical Functional Performance (CS-PFP 10) test and wireless sensor insoles in healthy volunteers.

METHODS

In this study, 42 participants were recruited, consisting of 21 healthy older adults (mean age 69.6 ± 4.6 years) and 21 younger healthy adults (mean age 23.6 ± 1.8 years). The performance of the subjects during ADLs was assessed using the CS-PFP 10 test, which comprised 10 tasks. The lower extremity loading was measured using wireless sensor insoles (OpenGo, Moticon, Munich, Germany) during the CS-PFP 10 test, which enabled the measurement of ground reaction forces, including the mean and maximum total forces during the stance phase, expressed in units of body weight (BW).

RESULTS

The total CS-PFP 10 score was significantly lower in older participants compared to the younger group (mean total score of 57.1 ± 9.0 compared to 78.2 ± 5.4, respectively). No significant differences in the mean total forces were found between older and young participants. The highest maximum total forces were observed during the tasks 'endurance walk' (young: 1.97 ± 0.34 BW, old: 1.70 ± 0.43 BW) and 'climbing stairs' (young: 1.65 ± 0.36 BW, old: 1.52 ± 0.28 BW). Only in the endurance walk, older participants showed a significantly higher maximum total force (p < 0.001).

CONCLUSION

The use of wireless sensor insoles in a laboratory setting can effectively measure the load on the lower extremities during ADLs. These findings could offer valuable insights for developing tailored recommendations for patients with partial weight-bearing restrictions.

Anticoagulation drug use and rehabilitation outcomes in post-acute hip fractured patients

PURPOSE

To assess the relationship between anticoagulant use and rehabilitation outcomes in post-acute hip fracture patients.

METHODS

A retrospective study (1/2017 to 5/2019) of 299 hip fractured patients.

OUTCOME MEASURES

Functional Independence Measure (FIM) and the motor FIM's effectiveness.

RESULTS

Patients treated with anticoagulation drugs exhibited a significant longer latency time from fracture to surgery (U = -4.37, p < 0.001) and from surgery to rehabilitation (U=-2.27, p = 0.023), and a significantly higher rate of cardiovascular diseases (χ2=0.15, p= 0.023) compared with untreated patients. No significant differences between the two patient groups were found regarding the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures.

CONCLUSIONS

Oral anticoagulants are not associated with rehabilitation outcomes of hip fracture patients.Implications rehabilitationAnticoagulation drug use is not associated with functional outcome of post-acute hip fracture patients.It is recommended to renew oral anticoagulants for patients on chronic treatment after surgery since no negative outcomes were found during rehabilitation under anticoagulant treatment and in light of the importance of these drugs in preventing thromboembolic complications.

Characteristics of Preoperative Acute Myocardial Infarction in Elderly Hip Fracture Patients and Construction of a Clinical Prediction Model: A Retrospective Cohort Study

BACKGROUND

The prognosis of elderly patients with acute myocardial infarction (AMI) is poor, and this study aimed to investigate the characteristics and predictors of preoperative AMI in elderly hip fracture patients and to propose a valid clinical prediction model.

METHODS

We collected clinical data of older hip fracture patients from January 2019 to December 2020. The data collected include demographic and clinical characteristics, underlying diseases and laboratory results. In AMI patients, we further collected type of myocardial infarctions, clinical symptoms, electrocardiogram (ECG), Killip class and diagnosis method. The prediction model was constructed by using Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses. In addition, the constructed prediction model was transformed into a nomogram. The performance of the model was evaluated using the area under receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA). Bootstrapping was used for validation.

RESULTS

There are 40 (4.2%) cases developed AMI in all 958 patients. There were 685 (71.5%) female patients and 273 (28.5%) male patients. Among 40 AMI patients, 38 (95.0%) had Type 2 myocardial infarction (T2MI) and 2 (5.0%) had Type 1 myocardial infarction (T1MI). The majority of these ECG were ST segment depression (57.5%). Most elderly AMI patients (67.5%) presented asymptomatic. Predictors for preoperative AMI were higher age (OR 2.386, 95% CI 1.126-5.057), diabetes (OR 5.863, 95% CI 2.851-12.058), Hb≤100 g/L (OR 3.976, 95% CI 1.478-10.695), CRP≥40 mg/L (OR 6.998, 95% CI 2.875-17.033), and ALB≤35 g/L (OR 2.166, 95% CI 1.049-4.471). Good discrimination and calibration effect of the model was showed. Interval validation could still achieve the C-index value of 0.771. DCA demonstrated this nomogram has good clinical utility.

CONCLUSION

This model has a good predictive effect on preoperative AMI in elderly patients with hip fracture, which can help to better plan clinical evaluation.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture

AIMS

The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively.

PATIENTS AND METHODS

Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups.

RESULTS

The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters.

CONCLUSION

Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus.

LEVEL OF EVIDENCE

III; case-control comparative study.

Femoral Neck System vs. four cannulated screws in the treatment of Pauwels III femoral neck fracture

OBJECTIVE

To compare the clinical efficacy of the Femoral Neck System (FNS) vs. four cannulated screws in Pauwels III femoral neck fractures.

METHODS

This retrospective study included patients with newly occurred type Pauwels III femoral neck fracture treated at author' Hospital of between January 2017 and February 2021. The patients received FNS (n = 27) or four cannulated screws (control group, n = 31). The operation time, blood loss, fracture healing time, incidence of complications (such as short femoral neck, necrosis of femoral head, nonunion of fracture, and failure of internal fixation withdrawal), and hip Harris score at the last follow-up were analyzed.

RESULTS

The operation time, blood loss, and fracture healing time were not significantly different between the two groups (all P > 0.05). In the FNS group, three and one patients were with femoral neck shortening and femoral head necrosis, respectively, while no fracture nonunion or failure of internal fixation withdrawal occurred. In the control group, seven, two, one, and two patients were with femoral neck shortening, femoral head necrosis, nonunion, and internal fixation failure, respectively. The cumulative complication incidence was 14.8% and 38.7% in the FNS and control groups (P = 0.042). The excellent and good rates of the hip Harris score at the last follow-up were 92.6% and 71.0% in the FNS and control groups, respectively (P = 0.036).

CONCLUSION

The study suggested that the clinical efficacy of FNS was better than internal fixation using four cannulated screws in treating Pauwels III type femoral neck fracture.

Use of Conditionally Essential Amino Acids and the Economic Burden of Postoperative Complications After Fracture Fixation: Results from a Cost Utility Analysis

Objective

To measure the economic impact of conditionally essential amino acids (CEAA) among patients with operative treatment for fractures.

Methods

A decision tree model was created to estimate changes in annual health care costs and quality of life impact due to complications after patients underwent operative treatment to address a traumatic fracture. The intervention of interest was the use of CEAA alongside standard of care as compared to standard of care alone. Patients were required to be aged ≥18 and receive the surgery in a US Level 1 trauma center. The primary outcomes were rates of post-surgical complications, changes in patient quality adjusted life years (QALYs), and changes in cost. Cost savings were modeled as the incremental costs (in 2022 USD) of treating complications due to changes in complication rates.

Results

The per-patient cost of complications under CEAA use was $12,215 compared to $17,118 under standard of care without CEAA. The net incremental cost savings per patient with CEAA use was $4902, accounting for a two-week supply cost of CEAA. The differences in quality-adjusted life years (QALYs) under CEAA use and no CEAA use was 0.013 per person (0.739 vs 0.726). Modeled to the US population of patients requiring fracture fixations in trauma centers, the total value of CEAA use compared to no CEAA use was $316 million with an increase of 813 QALYs per year. With a gain of 0.013 QALYs per person, valued at $150,000, and the incremental cost savings of $4902 resulted in net monetary benefit of $6852 per patient. The incremental cost-effectiveness ratio showed that the use of CEAA dominated standard of care.

Conclusion

CEAA use after fracture fixation surgery is cost saving. Level of Evidence: Level 1 Economic Study.

Experimental and numerical analysis of the influence of intramedullary nail position on the cut-out phenomenon

BACKGROUND AND OBJECTIVE

Proximal femur fractures, colloquially known as hip fractures, are a common pathology with increasing incidence in the last years due to the enhanced ageing population. Regarding the extracapsular fracture, the treatment for this pathology consists of a fixation of the fragments using an osteosynthesis device, mainly the intramedullary nail. This repairing method implies several complications, which may include the failure of the fixation device, frequently occurring due to the "cut-out" mechanism. The present work focuses on the study of how the position of the cephalic screw, which should be fixed during surgery, affects the cut-out risk. Through experimental tests and numerical models some variables that can be critical for the cut-out phenomenon are analysed.

METHODS

This study has been carried out through a numerical model based on the finite element method and experimental tests. The digital image correlation technique has been used in experimental tests to measure displacements on the femoral surface with the objective of numerical model validation. Some basic daily activities with different intramedullary nail positions have been analysed through the numerical model, considering variables that can induce the cut-out complication.

RESULTS

The results show how the intramedullary nail position clearly influences the cut-out risk, showing that displacements in the upper, anterior and posterior direction increase the cut-out risk, while displacement in the lower direction endangers the intramedullary nail itself. Thus, the centred position is the one which reduces the cut-out risk.

CONCLUSIONS

This work supposes an improvement in the knowledge of the cut-out phenomenon thanks to the combination of experimental testing and validated numerical models. The effects of different intramedullary nail positions in the femoral head are studied, including a novelty variable as torque, which is critical for the structural integrity of the fixation. The main conclusion of the work is the determination of the central intramedullary nail position as the most favourable one for decreasing the cut-out risk.

Hip fractures and outcome in elderly patients in a tertiary care hospital of Sri Lanka

This study assessed how elderly patients with hip fractures were affected by factors such as comorbidities, fracture type, treatments, complications, and health-related quality of life. The majority of participants had surgery for their fracture with good prognoses despite having comorbidities. Reductions in the general level of activities related to daily living were proportionately higher even after one year.

INTRODUCTION

Hip fractures in older adults are associated with significant morbidity, mortality, loss of independence, and financial burdens. In this study, we assessed how these effects were influenced by factors such as comorbidities, fracture type, treatment methods, complications, and health-related quality of life (HRQoL) in elderly patients presented with hip fractures.

METHODS

A prospective observational study was conducted over 6 months on all patients with fall and hip fractures above 65 years of age that presented to the Accident and Emergency Department (A&E) of Provincial General Hospital Kurunegala. The subjects were followed up with for up to 1 year. Data forms were made according to the Charlson comorbidity index, the Johns Hopkins Fall Risk Assessment tool, and the International Society of Fracture Repair-International Osteoporosis Foundation (ISFR-IOF)) hip fracture outcome working group recommendations. Direct questions from these assessment guides were not used in data collection. Being able to walk independently and return to a premorbid state following surgery was considered a good outcome.

RESULTS

There were 117 patients (mean age 78 (± 7.31) years); 80% were female. Out of them, 81% had comorbidities without significant morbidity or mortality during surgery. Ninety-six (88%) had surgery for their fracture with good prognoses (p<0.05) and better outcomes due to early surgery (p=0.008). Independent walking was significantly better in intracapsular fractures than extracapsular fractures (p<0.05). Patients with post-surgical complications had significant mortality (p<0.001). Ninety-nine per cent, 81%, and 75% of patients remained dependent 1 month, 3 months, and 1 year following surgery, respectively. HRQoL was impaired in 3 months (95% SF, 12<50) and in 1 year (78.6% SF, 12 <50) following surgery. The mortality during admission, in 1 month, 3 months, and 1 year was 8.5% (10), 14.5% (17), 21.3% (25), and 35% (41), respectively.

CONCLUSION

A greater majority of hip fracture victims were female. Prognoses were good after surgery irrespective of the comorbidities with better outcomes in early surgery. Independent walking was significantly better in intracapsular fractures than extracapsular fractures. Patients with post-surgical complications had significant mortality. Significant loss of HRQoL increased in patients even after surgery, which resulted in an increased burden to families.

Functional ability before and after rehabilitation in elderly patients with shortening and/or rotational deformity of the lower limb after hip fracture

BACKGROUND

Shortening and rotational deformity of the lower limb (SRD) is a major complication of hip fracture surgery. It causes not only hip joint dysfunction but also functional impairments due to abnormal gait parameters, decreased gait velocity, and poor balance. Despite a number of previous studies, the effect of SRD on the postsurgical recovery of these patients is still not clear.

OBJECTIVE

To compare the functional abilities and balance before and after rehabilitation for people with and without SRD after hip fracture surgery and to assess whether SRD affects rehabilitation.

DESIGN

Prospective observational study.

SETTING

Inpatients of a rehabilitation unit.

PARTICIPANTS

A total of 102 people with hip fracture (62 without SRD and 40 with SRD at the time of admission to the unit).

MAIN OUTCOME MEASURES

Berg Balance Scale (BBS) and Functional Independence Measure (FIM) motor score, administered before and after rehabilitation.

INTERVENTIONS

Motor rehabilitation.

RESULTS

Before rehabilitation, patients with SRD had lower motor-FIM (p = .002) and BBS (p = .001) scores than those without SRD. After rehabilitation, both groups showed similar improvements in motor-FIM, BBS, range of motion, muscle strength, and pain scores (p < .001, for all), but patients with SRD still had lower motor-FIM and BBS scores (p = .014 and .003, respectively) and lower effectiveness in motor-FIM and BBS (p = .039 and p = .034, respectively) than those without SRD.

CONCLUSIONS

SRD is associated with lower levels of balance and functional abilities before and after rehabilitation and it adversely affects rehabilitation for patients with hip fractures.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Effect of different analgesic treatments on the pulmonary function in elderly hip fracture patients: A prospective study

BACKGROUND

To investigate the effect of different analgesic methods on lungs in elderly patients with hip fractures.

METHODS

A prospective study was conducted on 78 elderly hip fracture patients undergoing spinal anesthesia for surgery, where 3 analgesic methods were used: postoperative Patient-controlled intravenous analgesia pump (PCIA) (group I), pre and postoperative PCIA (group II), and preoperative fascia iliaca compartment block (FICB) + postoperative PCIA (group III). The following indicators were monitored at admission (T1), on the day of surgery before anesthesia (T2), and 7 days after surgery (T3): heart rate (HR), respiratory rate (RR), forced expiratory volume during the first second, arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), C-reactive protein (CRP), and interleukin 6 (IL-6). Pulmonary complications such as pulmonary atelectasis and respiratory insufficiency were analyzed.

RESULTS

The HR, RR, forced expiratory volume during the first second, PaO2, PaCO2, IL-6, and CRP levels at T1 after fracture did not significantly differ among the 3 groups (P > .05). After different analgesic treatments post-admission, all indicators at T2 were significantly higher in group I than in groups II and III (P < .05), while there was no significant difference between groups II and III (P > .05). At T3, there were no significant differences in RR, HR, PaO2, PaCO2, and CRP levels among the groups (P > .05), but IL-6 levels at T3 were significantly higher in group I than in groups II and III (P < .05).

CONCLUSION

The use of effective pain relief during surgery can help protect the lung function of elderly patients with hip fractures. When using PCIA with FICB before surgery, respiratory performance may be better protected compared to using unsustained analgesia. This could be due to a decrease in the levels of inflammatory markers such as CRP and interleukin-6.