Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study

INTRODUCTION

Geriatric patients (GeP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCCI) occur across all age groups; however, no large-scale studies evaluating outcomes of GeP exist for this particular subset of patients. Data thus far are limited to elderly participation in recreational activities such as water and alpine skiing, snowboarding, equestrian, snowmobiles, bicycles, and all-terrain vehicles. We hypothesized that GeP with MCCI will have a higher rate of mortality when compared with their younger counterparts despite increased helmet usage.

METHODS

We performed a multicenter retrospective review of MCCI patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data were extracted from each institution's electronic medical records and trauma registry. GeP were defined as patients aged more than or equal to 65 y. The primary outcome was mortality. Secondary outcomes included ventilator days; hospital, intensive care unit, and intermediate unit length of stays; complications; and helmet use. 3:1 nongeriatric patients (NGeP) to GeP propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS), and injury severity score (ISS). P ≤ 0.05 was considered significant.

RESULTS

One thousand five hundred thirty eight patients were included (GeP: 7% [n = 113]; NGP: 93% [n = 1425]). Prior to PSM, GeP had higher median Charlson Comorbidity Index (GeP: 3.0 versus NGeP: 0.0; P ≤ 0.001) and greater helmet usage (GeP: 73.5% versus NGeP: 54.6%; P = 0.001). There was a statistically significant difference between age cohorts in terms of ISS (GeP: 10.0 versus NGeP: 6.0, P = 0.43). There was no significant difference for any AIS body region. Mortality rates were similar between groups (GeP: 1.7% versus NGeP: 2.6%; P = 0.99). After PSM matching for sex, AIS, and ISS, GeP had significantly more comorbidities than NGeP (P ≤ 0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality rates were similar (GeP: 1.8% versus NGeP: 3.2%; P = 0.417). Differences in ventilator days as well as intensive care unit length of stay, intermediate unit length of stay, and hospital length of stay were negligible. Helmet usage between groups were similar (GeP: 64.5% versus NGeP: 66.8%; P = 0.649).

CONCLUSIONS

After matching for sex, ISS, and AIS, age more than 65 y was not associated with increased mortality following MCCI. There was also no significant difference in helmet use between groups. Further studies are needed to investigate the effects of other potential risk factors in the aging patient, such as frailty and anticoagulation use, before any recommendations regarding management of motorcycle-related injuries in GeP can be made.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

Health-related quality of life (EQ-5D) after revision arthroplasty following periprosthetic femoral fractures Vancouver B2 and B3 in geriatric trauma patients

INTRODUCTION

The aim of this study was to determine the outcome parameters of revision arthroplasties for periprosthetic femoral fractures (PPFF) with a particular attention to quality of life (QoL) and mobility.

MATERIALS AND METHODS

Retrospective single-center study of PPFF with loose implants that underwent revision arthroplasty. Depending on individual patient characteristics, either an uncemented or cemented revision stem was chosen. Data collection included demographics, complications, clinical course and outcome parameters. Follow-up took place at least one year postoperatively.

RESULTS

Between 2008 and 2016, 43 patients could be included. Most patients (63%) were able to walk independently or with a walking aid after one year and amongst the surveyed patients 77% were able to reside at home. Concerning the QoL assessment, a high index of 0.8 ± 0.1 has been reached after one year. Mortality pointed out to be 9% after one year and 28% in general.

CONCLUSION

The treatment of PPFF remains challenging. Although complication rates and mortality are high in this frail collective of geriatric patients, revision arthroplasty leads to good postoperative results regarding mobility and quality of life.

Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence

INTRODUCTION

Hip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11.

METHODS

The Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant.

RESULTS

Twelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively).

CONCLUSIONS

The mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study

BACKGROUND

Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited.

AIMS

To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation.

METHODS

A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken.

RESULTS

A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes.

CONCLUSIONS

Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study

BACKGROUND

Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission.

METHODS

This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up.

RESULTS

Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01).

CONCLUSIONS

Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

There's No Place Like Home: Delirium as a Barrier in Geriatric Trauma

INTRODUCTION

Delirium is associated with a three-fold increase in frequency of 6-mo mortality following intensive care unit admission. Outside of mortality, it has been linked with severe morbidity including long-term cognitive decline, loss of autonomy, and increased risk of institutionalization. There is a paucity of literature regarding delirium and geriatric trauma patients. The aim of our study is to determine predictive factors of delirium in geriatric trauma patients.

METHODS

This is a retrospective review of all geriatric (>65 y) trauma patients with a documented frailty score at a Level I Trauma Center from 1/2019 to 9/2021. Univariate and multivariate logistic regressions were performed. Geriatric patients with delirium (D) and those without delirium (ND) were compared. Patients were excluded if they did not have a documented frailty score or died before admission.

RESULTS

One thousand three hundred and seventeen patients met criteria; 40 (3%) patients developed delirium. Neither age nor gender was different between the two groups. Frailty scores were not different between the two groups. Patients with documented delirium had a higher incidence of a positive drug screen on admission (85% versus 62.2%, P = 0.0034), higher median injury severity score (10 versus 9, P = 0.0088), and longer hospital (7 d versus 3 d, P < 0.001) and intensive care unit (1 d versus 0 d, P < 0.001) length of stay (LOS) than their ND counterparts. The D group had a higher frequency of benzodiazepine (47.5% versus 19.3%, P < 0.001) and narcotic use (77.5% versus 56.5%, P = 0.0085). Tethers nor bedrest orders were significantly associated with delirium. Incidence of urinary tract infection (12.5% versus 1%, P < 0.001) and restraint use (P < 0.001) were significantly associated with increased risk of delirium. Additionally, those with a diagnosis of delirium were more often discharged to a skilled nursing facility than those in the ND group (45% versus 30.8%, P = 0.0006).

CONCLUSIONS

We aimed to identify key predictive factors of delirium in our study population and found that certain factors correlated with higher frequencies of delirium in our geriatric trauma patients. Preadmission and early controlled substance use were significantly associated with delirium, as were the presence of urinary tract infection and extended intensive care unit LOS. By recognizing some of these modifiable factors, LOS may decrease while increasing the likelihood of discharge home.

Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia

BACKGROUND

Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level.

METHODS

We performed a 5-year (2011-15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality.

RESULTS

A total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3-15], median chest AIS was 3 [2-4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4-10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000).

CONCLUSION

The use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration.

LEVEL OF EVIDENCE

III STUDY TYPE: Therapeutic/Care Management.

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION

It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.

STUDY DESIGN

Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days.

RESULTS

110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05).

CONCLUSION

Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

[The severely injured older cyclist-Evaluation of the TraumaRegister DGU® : Retrospective, multicenter cross-sectional study based on the TraumaRegister DGU®]

BACKGROUND

Contrary to the trend of decreasing traffic fatalities, the number of cyclists killed in Germany has been steadily increasing in recent years. With the increasing popularity of cycling in all age groups, the number of accidents with sometimes serious injuries is rising. In the course of this, the question arises what influence age has on the type and severity of injuries, the probability of survival and the length of hospital stay in seriously injured cyclists.

METHODS

A retrospective analysis of data from the TraumaRegister DGU® (TR-DGU) from 2010 to 2019 was performed. All severely injured cyclists with a maximum abbreviated injury scale (MAIS) of 3+ (n = 14,651) in the TR-DGU were included in this study and the available parameters were evaluated. A subdivision into three age groups (60-69, 70-79, and ≥ 80 years) and a control group (20-59 years) was carried out.

RESULTS

Injuries to the head were by far the most common, accounting for 64.2%. There was a marked increase in severe head injuries in the 60-plus years age group. Furthermore, with increasing age, the probability of prehospital intubation, catecholamine requirement, intensive care and hospital length of stay, and mortality increased.

CONCLUSION

Head injuries represent the most common serious injury, especially among older cyclists. As helmet wearing was not recorded in the TraumaRegister DGU® during the evaluation period, no conclusion can be drawn about its effect. Furthermore, a higher age correlates with a longer hospital stay and a higher mortality, but does not represent an independent risk factor for death in severely injured patients.

[Periprosthetic fractures-Diagnostics, classification and treatment]

BACKGROUND

Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed.

OBJECTIVE

The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications.

MATERIAL AND METHOD

Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective.

CONCLUSION

With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

BACKGROUND

Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures.

METHODS

A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates.

RESULTS

Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6 months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort.

CONCLUSION

Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

[Conservative treatment of distal radial fractures]

OBJECTIVE

Distal fracture of the radius is common in all age groups. Under careful consideration of individual indications and contraindications, conservative treatment with reduction and immobilization can have significant advantages over the frequently applied surgical approach, particularly in older patients.

THERAPEUTIC GOAL

Immobilization after closed reduction enables satisfactory wrist function to be achieved according to individual patient expectations.

INDICATIONS

A. Patients with a. significant comorbidities, b. high surgical risk from an anesthesiology perspective (ASA > 3), c. low functional requirements, d. low cosmetic expectations regarding residual visible deformity. B. Young patients with an extension fracture and additional a. < 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. < 5 mm radial shortening after closed reduction, c. < 2 mm intraarticular displacement after closed reduction.

CONTRAINDICATIONS

A. Patient age < 65 years with an extension fracture and additional a. > 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. > 5 mm radial shortening after closed reduction, c. > 2 mm intraarticular displacement after closed reduction. B. Flexion fracture for which ligamentotaxis for closed reduction is not possible. C. Open distal radial fracture. D. Fracture dislocations. E. Impairments of peripheral circulation, motor or sensory function of the hand after reduction.

TECHNIQUE

After puncturing the fracture hematoma and infiltrating the fracture gap with local anesthetic, the forearm is suspended using Chinese finger traps on the thumb and middle finger. Constant traction in the longitudinal axis of the forearm is ensured by a weight applied via a wide cushioned cuff to the distal upper arm. Reduction then is enabled with the additional reductive effect of ligamentotaxis. After minimal cushioning of the forearm with cotton wool and crepe bandage, a dorsal gypsum longuette is applied. After the plaster bandage has hardened, peripheral circulation, motor function, and sensitivity are checked. The reduction is controlled by X‑ray and documented.

POSTPROCEDURAL MANAGEMENT

A. General procedures to reduce swelling; sufficient analgesics should be prescribed. B. The circular plaster cast is applied once swelling has subsided sufficiently, generally after 2-3 days. C. The duration of cast wearing should be planned at 5 weeks.

RESULTS

A total of 73 patients (55 women and 18 men) aged 65-88 years were followed up for 12 months to investigate functional outcomes after surgical and conservative therapy. While surgical patients had better functional scores up to 12 weeks after treatment begin, there was no longer a significant difference in the 6‑ and 12-month follow-up results. The measured grip strength was consistently better in the surgically treated group. Clinically visible deformities were present in 78% of the conservatively treated patients; however, the patients were satisfied with the functional or cosmetic results. No deformities were seen in the surgically treated patients. All fractures were completely healed after 6 months. The rate of complications was significantly higher in the surgery group, with 13 complications compared to 5 in the conservative treatment group.

Orthogeriatric care-outcome of different fragility fractures

INTRODUCTION

Fragility fractures (FF) are associated with increased morbidity and mortality and reflect a dramatic turning point in the life of older adults. The scientific discourse is dominated by proximal femoral fractures, but FF affect multiple parts of the body and often precede hip fractures. Orthogeriatric co-management has multiple shown to improve patient's outcome. We hypothesize that all geriatric patients with FF benefit from orthogeriatric co-management.

MATERIALS AND METHODS

We retrospectively evaluated all patients over 70 years with FF (hip joint, periprosthetic, spine, pelvic ring, and humerus) of our geriatric trauma center for the years 2019-2021, who received orthogeriatric co-management. Demographic data, fracture type, complications, discharge modality and in-hospital mortality were recorded. For patients transferred to geriatrics, the Barthel Index (BI) and the discharge modality were recorded. Primary outcome parameters were discharge modality and BI difference. Secondary outcome parameters were complication rates and in-hospital mortality. Logistic regression analysis was performed.

RESULTS

555 patients (83.8 ± 6.5 years, 182 males, 373 females) were evaluated. 245 (44.1%) patients were referred to geriatrics for further orthogeriatric treatment. Positive predictors were age, surgery, and a high Charlson Comorbidity Index. The overall in-hospital mortality was 8.6% (n = 48) (5.8% (n = 32) during acute trauma care and 6.5% (n = 16) during stay in geriatrics). The mortality rate of nursing home residents was significantly higher compared to patients living at home (10.4% vs. 5.6%). The rate of non-surgical complications was 44.5%. 26.9% of patients living at home were discharged to a nursing home, while 51.3% were able to return home. The risk of admission to a nursing home was reduced for thoracolumbar fractures (OR = 0.22) and increased markedly for periprosthetic fractures (OR = 3.95). During orthogeriatric treatment, all fractures showed a significant increase in BI. Patients living at home benefited more than nursing home residents (20.5 ± 19.5 vs. 8.7 ± 18.0 points). The chance of a BI increase (> 19 points) was increased for hip and pelvic ring fractures. Devastating results showed patients with dementia. In comparison, mentally healthy patients had a 4.5-fold increased chance of increasing their BI (> 19 points).

CONCLUSIONS

Presented data shows that all patients with FF are at high risk for complications and could benefit from standardized orthogeriatric management. Modern patient care requires a holistic orthogeriatric approach to improve patient's outcome.

Trauma (Excluding Falls) in the Older Adult

Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.

[Sacral H-shaped fractures between traumatic, insufficiency and fatigue fractures : Similarities, differences and controversies]

In the basic entirety of stress fractures, insufficiency fractures are defined as fractures caused by prolonged normal or physiological loading of a bone with insufficient elastic resistance. This clearly distinguishes it from fatigue fractures, in which excessive loads are continuously applied to a bone with normal elastic resistance. According to Pentecost (1964) both entities of stress fracture result from "the inherent inability of the bone to withstand stress applied without violence in a rhythmical, repeated, subthreshold manner". This distinguishes them from acute traumatic fractures. In the clinical routine these differences are not always so clearly presented. The example of the H‑shaped sacral fracture is used to illustrate the relevance of a clear terminology. In this context, current controversies in the treatment of sacral insufficiency fractures are discussed.

Hospitalization and readmission after single-level fall: a population-based sample

BACKGROUND

Single-level falls (SLFs) in the older US population is a leading cause of hospital admission and rates are increasing. Unscheduled hospital readmission is regarded as a quality-of-care indication and a preventable burden on healthcare systems. We aimed to characterize the predictors of 30-day readmission following admission for SLF injuries among patients 65 years and older.

METHODS

We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2019. Included patients were 65 and older, admitted emergently following a SLF with a primary injury diagnosis. Hierarchical logit regression was used to model factors associated with readmission within 30 days of discharge.

RESULTS

Of 1,338,905 trauma patients, 65 years or older, 61.3% had a single-level fall as the mechanism of injury. Among fallers, the average age was 81.1 years and 68.5% were female. SLF patients underwent more major therapeutic procedures (56.3% vs. 48.2%), spent over 2 million days in the hospital and incurred total charges of over $28 billion annually. Over 11% of SLF patients were readmitted within 30 days of discharge. Increasing income had a modest effect, where the highest zip code quartile was 9% less likely to be readmitted. Decreasing population density had a protective effect of readmission of 16%, comparing Non-Urban to Large Metropolitan. Transfer to short-term hospital, brain and vascular injuries were independent predictors of 30-day readmission in multivariable analysis (OR 2.50, 1.31, and 1.42, respectively). Palliative care consultation was protective (OR 0.41). The subsequent hospitalizations among those 30-day readmissions were primarily emergent (92.9%), consumed 260,876 hospital days and a total of $2.75 billion annually.

CONCLUSIONS

SLFs exact costs to patients, health systems, and society. Transfer to short-term hospitals at discharge, along with brain and vascular injuries were strong predictors of 30-day readmission and warrant mitigation strategy development with consideration of expanded palliative care consultation.

The Geriatric Patient One Year After Trauma: Palliative Performance Scale Predicts Functional Outcomes

INTRODUCTION

Frailty in trauma has been found to predict poor outcomes after injury including additional in-hospital complications, mortality, and discharge to dependent care. These gross outcome measures are insufficient when discussing long-term recovery as they do not address what is important to patients including functional status and quality of life. The purpose of this study is to determine if the Palliative Performance Scale (PPS) predicts mortality and functional status one year after trauma in geriatric patients.

MATERIAL AND METHODS

Prospective observational study of trauma survivors, age ≥55 years. Patients were stratified by pre-injury PPS high (>70) or low (≤70). Outcomes were functional status at 1 year measured by Glasgow Outcome Scale Extended (GOSE), Euroqol-5D and SF-36. Adjusted relative risks (aRR) were obtained using modified Poisson regression.

RESULTS

Follow-up was achieved on 215/301 patients. Mortality was 30% in low PPS group vs 8% in the high PPS group (P<0.001). A greater percentage of patients in the high group had a good functional outcome at one year compared to patients in the low group (78% vs 30% p<0.001). The high PPS patients were more likely to have improvement of GOSE at 1 year from discharge compared to low group (66% vs 27% P<0.001). Low PPS independently predicted poor functional outcome (aRR, 2.64; 95% confidence interval, 1.79-3.89) and death at 1 year (aRR, 3.64; 95% confidence interval 1.68-7.92). An increased percentage of low PPS patients reported difficulty with mobility (91% vs 46% p<0.0001) and usual activities (82% vs 56% p=0.002). Both groups reported pain (65%) and anxiety/depression (47%).

CONCLUSION

Low pre-Injury PPS predicts mortality and poor functional outcomes one year after trauma. Low PPS patients were more likely to decline, rather than improve. Regardless of PPS, most patients have persistent pain, anxiety, and limitations in performing daily activities.

Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures

BACKGROUND

Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures.

METHODS

This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS).

RESULTS

After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001).

CONCLUSIONS

Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.

Stress-Induced (Not Diabetic) Hyperglycemia is Associated With Mortality in Geriatric Trauma Patients

INTRODUCTION

Stress-induced hyperglycemia (SIH) is associated with worse outcomes among trauma patients. It is also known that injured geriatric patients have higher mortality when compared to younger patients. We sought to investigate the association of all levels of SIH with mortality among geriatric trauma patients at a level 1 academic trauma center. We hypothesized that SIH in the geriatric trauma population would be associated with increased mortality.

METHODS

A retrospective review of all geriatric patients admitted to our level 1 trauma center over a 3-year period (January 2018-December 2020) was performed using the institutional trauma database. Data collected included demographics, injury severity score (ISS), emergency department (ED) blood glucose level, ED systolic blood pressure (SBP), and mortality. Patients were divided into 4 groups based on emergency room blood glucose level, as follows: normoglycemic (<120 mg/dL), mild hyperglycemia (120-150 mg/dL), moderate hyperglycemia (151-199 mg/dL), and severe hyperglycemia (≥200 mg/dL). Multivariable logistic regression analysis was performed to evaluate the association of SIH and in-hospital mortality adjusting for ISS, age, comorbidities, and ED SBP.

RESULTS

A total of 4432 geriatric trauma patients were admitted during the study period, of which 3358 patients (75.8%) were not diabetic. There were 2206 females (65.7%), 2993 were White (89.2%), with a mean age of 81.5 y. There were 114 deaths (3.4%). Univariate results showed that there was a statistically significant association between mortality and glucose groups (P < 0.01). The number of deaths in the four glucose groups were, as follows: 30 (2.0%), 32 (3.8%), 20 (6.2%), and 10 (12.2%), respectively. Multivariable logistic regression analysis results showed that compared to the normoglycemic group, the risk of death was higher in the mild, moderate, and severe glucose groups, as follows: mild group (OR 1.80, 95% confidence interval [CI] 1.04-3.13, P 0.04), moderate group (OR 2.53, 95% CI 1.34-4.80, P < 0.01), and severe group (OR 5.04, 95% CI 2.18-11.67, P < 0.01).

CONCLUSIONS

Mild, moderate, and severe SIH are statistically significant predictors of death among geriatric trauma patients independently of ISS, age, comorbidities, and SBP.

Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU)

BACKGROUND

Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU).

METHODS

A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models.

RESULTS

A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 - 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 - 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group.

CONCLUSIONS

SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS.

Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems

BACKGROUND

The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem.

METHODS

In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate.

RESULTS

A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group.

CONCLUSIONS

In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

All about the Benjamins: Efficacy of a modified triage protocol for trauma activation in geriatric patients

BACKGROUND

The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes.

METHODS

A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared.

RESULTS

2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group.

CONCLUSION

Using SBP <100 mmHg threshold for TTA criteria in geriatric trauma patients improves over-triage without leading to under-triage.

Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients

BACKGROUND

The Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients.

METHODS

We conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve.

RESULTS

There were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue.

CONCLUSION

CCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.

Insertion of a urinary catheter on admission lowers acute kidney injury incidence in patients with hip fractures

PURPOSE

Acute kidney injury (AKI) is a common adverse event in patients undergoing hip fracture repair surgery, increasing morbidity and mortality. Our study hypothesis was that routine insertion of a urinary catheter, on admission to the hospital or immediately before surgery, will reduce AKI incidence in hip fracture patients.

METHODS

Determined by alternating days of admission, a urinary catheter was inserted routinely on admission (catheter group) or as needed (non-catheter group) in 250 consecutive patients who presented with a hip fracture to our emergency department. The incidence of AKI according to the KDIGO criteria and morbidity and mortality were compared between the study groups.

RESULTS

The overall incidence of AKI was 11.6% (29/250). The catheter group (N = 122) had a significantly lower rate of AKI (6.6% vs. 16% p = 0.018). At 12-month follow-up, the overall mortality was 10.8% (27/250), in-hospital 7.4% (2/27), short-term (within 30 days) 7.4% (2/27), and long-term (30 days to 1 year) 85.8% (23/27). All in-hospital mortality occurred in the AKI group. Patients with no AKI had a better survival rate; however, the difference was not significant (p-value = 0.21). Mortality rate was lower in the catheter group but not significant (8.2% compared with 13.8% in the non-catheter group, p = 0.225). Post-operative respiratory and cardiac complications were more frequent in the AKI group (p = 0.02 and 0.043 accordingly).

CONCLUSIONS

Insertion of a urinary catheter upon admission or before surgery lowered AKI incidence significantly. Peri-operative AKI was associated with higher rates of post-operative complications and worse survival.

Concomitant fractures in patients with proximal femoral fractures lead to a prolonged hospital stay but not to increased complication rates or in-house mortality if treated surgically: a matched pair analysis

BACKGROUND

Impact of concomitant fractures on patients sustaining a proximal femur fracture remains unclear. Rising numbers and patient need for rehab is an important issue. The objective of our study was to investigate the impact of concomitant fractures, including all types of fractures, when treated operatively, for proximal femur fractures on the length of hospital stay, in-house mortality and complication rate.

METHODS

Observational retrospective cohort single-center study including 85 of 1933 patients (4.4%) with a mean age of 80.5 years, who were operatively treated for a proximal femoral and a concomitant fracture between January 2016 and June 2020. A matched pair analysis based on age, sex, fracture type and anticoagulants was performed. Patient data, length of hospital stay, complications and mortality were evaluated.

RESULTS

The most common fractures were osteoporosis-associated fractures of the distal forearm (n = 34) and the proximal humerus (n = 36). The group of concomitant fractures showed a higher CCI than the control group (5.87 vs. 5.7 points; p < 0.67). Patients with a concurrent fracture had a longer hospital stay than patients with an isolated hip fracture (15.68 vs. 13.72 days; p < 0.056). Complications occurred more often in the group treated only for the hip fracture (11.8%, N = 20), whilst only 7.1% of complications were recorded for concomitant fractures (p < 0.084). The in-house mortality rate was 2.4% and there was no difference between patients with or without a concomitant fracture.

CONCLUSIONS

A concomitant fracture to a hip fracture increases the length of hospital stay significantly but does not increase the complication rate or the in-house mortality. This might be due to the early mobilization, which is possible after early operative treatment of both fractures.

Intercontinental validation of a clinical prediction model for predicting 90-day and 2-year mortality in an Israeli cohort of 2033 patients with a femoral neck fracture aged 65 or above

PURPOSE

Mortality prediction in elderly femoral neck fracture patients is valuable in treatment decision-making. A previously developed and internally validated clinical prediction model shows promise in identifying patients at risk of 90-day and 2-year mortality. Validation in an independent cohort is required to assess the generalizability; especially in geographically distinct regions. Therefore we questioned, is the SORG Orthopaedic Research Group (SORG) femoral neck fracture mortality algorithm externally valid in an Israeli cohort to predict 90-day and 2-year mortality?

METHODS

We previously developed a prediction model in 2022 for estimating the risk of mortality in femoral neck fracture patients using a multicenter institutional cohort of 2,478 patients from the USA. The model included the following input variables that are available on clinical admission: age, male gender, creatinine level, absolute neutrophil, hemoglobin level, international normalized ratio (INR), congestive heart failure (CHF), displaced fracture, hemiplegia, chronic obstructive pulmonary disease (COPD), history of cerebrovascular accident (CVA) and beta-blocker use. To assess the generalizability, we used an intercontinental institutional cohort from the Sheba Medical Center in Israel (level I trauma center), queried between June 2008 and February 2022. Generalizability of the model was assessed using discrimination, calibration, Brier score, and decision curve analysis.

RESULTS

The validation cohort included 2,033 patients, aged 65 years or above, that underwent femoral neck fracture surgery. Most patients were female 64.8% (n = 1317), the median age was 81 years (interquartile range = 75-86), and 80.4% (n = 1635) patients sustained a displaced fracture (Garden III/IV). The 90-day mortality was 9.4% (n = 190) and 2-year mortality was 30.0% (n = 610). Despite numerous baseline differences, the model performed acceptably to the validation cohort on discrimination (c-statistic 0.67 for 90-day, 0.67 for 2-year), calibration, Brier score, and decision curve analysis.

CONCLUSIONS

The previously developed SORG femoral neck fracture mortality algorithm demonstrated good performance in an independent intercontinental population. Current iteration should not be relied on for patient care, though suggesting potential utility in assessing patients at low risk for 90-day or 2-year mortality. Further studies should evaluate this tool in a prospective setting and evaluate its feasibility and efficacy in clinical practice. The algorithm can be freely accessed: https://sorg-apps.shinyapps.io/hipfracturemortality/ .

LEVEL OF EVIDENCE

Level III, Prognostic study.

Biomechanical stability of short versus long proximal femoral nails in osteoporotic subtrochanteric A3 reverse-oblique femoral fractures: a cadaveric study

PURPOSE

Due to the demographic change towards an older society, osteoporosis-related proximal femur fractures are steadily increasing. Intramedullary nail osteosyntheses are available in different lengths, where the field of application overlaps. The aim of this study was to investigate whether subtrochanteric fractures can also be treated stably using a short femoral intramedullary nail in cadaveric bones.

METHODS

A short PFNA and a long PFNA were implanted in both seven artificial bones and osteoporotic human specimens. A standardized AO 31-A3 (reverse-oblique) fracture was placed in the specimens with a lateral fracture spur 2 cm proximal to the distal locking screw (short PFNA) and embedded. The simulated iliotibial tract was preloaded to 50 N. The force was applied at 10 mm/min up to a force of 200-800 N (artificial bones) and 200-400 N (human specimens). The dislocation of the fracture gap, the axial bone stiffness of bone construct and the force curve of the tractus iliotibialis were measured.

RESULTS

There is no difference in the use of a short versus long PFNA in terms of stiffness of the overall construct and only a slight increase in dislocation in the fracture gap results with short PFNA compared to a long intramedullary nail.

CONCLUSION

In summary of the available literature, the present study supports the thesis that there is no clinical difference between long versus short nails in A3 femur fractures. Furthermore, the present study defines a safe biomechanical range of fracture extension above the locking screw of the short intramedullary nail.

LEVEL OF EVIDENCE

III.

Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique

PURPOSE

Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail.

METHODS

This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses.

RESULTS

This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion.

CONCLUSION

The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BACKGROUND

Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.

METHODS

We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.

RESULTS

We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications.

CONCLUSIONS

Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.

LEVEL OF EVIDENCE

IV.

Fall Risk Identification Throughout the Continuum of Care for Elderly Trauma Patients: An Injury Prevention Initiative

INTRODUCTION

Falls are the second leading cause of trauma-related deaths worldwide. Identifying fall risk patients and initiating interventions reduces injuries and mortality, particularly in the elderly. The primary aim of this retrospective study was to identify missed opportunities for fall risk identification and intervention for geriatric trauma patients.

PATIENTS AND METHODS

In this retrospective observational cohort study, the trauma registry was queried to identify geriatric patients admitted for a fall over 36 months. The electronic medical record (EMR) was reviewed to evaluate patients' fall risk in the 12 months prior to the index fall admission. The EMR was also queried for repeat falls within 12 months after discharge, and to determine if fall prevention education was provided at discharge.

RESULTS

597 patients met inclusion criteria; 68.3% were female. 64.7% were at risk for falling in the year before admission. 2% had documented fall prevention education at discharge. 32% of patients fell again within a year of discharge and 19.4% were readmitted for a repeat fall. Patients at high risk for falls (on the Hester-Davis scale) were significantly more likely to be readmitted (p = 0.005) and expire within six months (p = 0.033) than moderate risk patients. Mortality at 12 months post-admission for all patients was 19.4%.

CONCLUSION

This large study demonstrated that geriatric trauma patients admitted for a fall were already at risk for falling in the 12 months prior to admission. This is a novel finding that presents a substantial prevention opportunity for healthcare systems. Education and implementation of proven techniques to prevent falls as soon as at-risk patients are identified has the potential to change the course for a patient who may not only fall, but also fall again. This proactive approach could significantly impact the fall epidemic in our elderly population.

Epidemiology and outcomes of older trauma patients in Singapore: A multicentre study

BACKGROUND

An ageing population has caused rising trauma cases amongst older patients. Multiple comorbidities, polypharmacy and limited reserves predispose them to poorer outcomes following a traumatic event. The Comorbidity Polypharmacy Score (CPS) has been found to predict outcomes and mortality in older trauma patients, but has not been studied in Asians.

AIM

We aim to describe the epidemiological characteristics of older trauma patients and explore the association of CPS on clinical outcomes.

METHODS

We conducted a retrospective observational study using data from the trauma registries of 2 tertiary trauma centres. Patients aged 45 years and above attending the emergency departments (EDs) from January 2011 to December 2015 with traumatic injuries (Injury Severity Score [ISS] of 9 and above) were included. Demographics, clinical data including number of comorbidities and medications used were collected to calculate the CPS. Outcomes of mortality, ED disposition and hospital discharge venue were examined.

RESULTS

There were 4,522 patients (median age 70 years; males 53.8%), with majority sustaining Tier 2 injuries (ISS 9 to 15; 68.9%). Falls were the predominant mechanism for those aged above 60 years and above (76%). Median CPS was 6 (interquartile range [IQR] 1 to 11). Amongst patients 75 years and older, 56% comprised the moderate to morbid CPS groups (CPS ≥ 8). Overall mortality was 8.4%; patients above 75 years had longer median length of stay (10 versus 7.1-8.9 days in other ages). Male gender (adjusted odds ratio [aOR] 1.51; 95% confidence interval [CI] 1.12-2.02), increasing age (aOR 1.04; 95% CI 1.03-1.05), injury to abdomen (aOR 3.24; 95% CI 1.93-5.45) and severe CPS category (aOR 1.88; 95% CI 1.23-2.89) were associated with increased odds of death. Increasing age and moderate CPS category increased odds of discharge to a rehabilitation (aOR for age 1.03, 95% CI 1.02-1.04; aOR for moderate CPS 1.72, 95% CI 1.43-2.07) or long-term care facility (aOR for age 1.05, 95% CI 1.03-1.06; aOR for CPS 1.60, 95% CI 1.10-2.32).

CONCLUSION

CPS predicted mortality and discharge to a rehabilitation or care facility in this urban, ageing Asian population. Its use may aid future trauma research and needs assessments in such patients.

Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes

INTRODUCTION

Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury.

METHODS

ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes.

RESULTS

There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites.

CONCLUSION

Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery.

TRIAL REGISTRATION

ANZCTR: ACTRN12618001548224, approved 17/09/2018.

All elderly are fragile, but some are more fragile than others: an epidemiological study from one of the busiest trauma centers in Italy

As the older population increases, the number of elderly accessing the emergency department following a trauma increases accordingly. High-level trauma enters together with the identification of predictive parameters for poor outcome and mortality, may result in a death rate improvement of up to 30% in this group of patients. This study analyzes the epidemiology of major trauma admissions at Niguarda Trauma Center in Milan, Italy, focusing on the geriatric population and aiming to discriminate the trauma outcomes in the range of population between 65 and 75 years old (Senior Adult) and to compare it with the outcomes among people over 75 years old (Elderly). The variables analyzed included mortality, mechanism of injury, body district injured, Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), Geriatric Trauma Score (GTO), and outcome. Head trauma remains the main cause of mortality with falls and road accidents being the most common mechanism of injury. Frailty and associated use of anticoagulant and antiplatelet therapy increased the risk of death by 42%. The subdivision of the elder patients into two groups (65-75 and > 75) showed a difference in the probability of death and effective mortality rate.

Undertriage of Geriatric Trauma Patients in Florida

INTRODUCTION

Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients.

MATERIALS AND METHODS

This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC.

RESULTS

Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38).

CONCLUSIONS

Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls

Introduction

Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement.

Methods

We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation.

Results

A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15–0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36–7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15–2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06–1.87) compared to controls.

Conclusion

Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study

INTRODUCTION

Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients.

METHODS

This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs.

RESULTS

A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score.

CONCLUSIONS

The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

External validation of the U-HIP prediction model for in-hospital mortality in geriatric hip fracture patients

INTRODUCTION

Identification of high-risk hip fracture patients in an early stage is vital for guiding surgical management and shared decision making. To objective of this study was to perform an external international validation study of the U-HIP prediction model for in-hospital mortality in geriatric patients with a hip fracture undergoing surgery.

MATERIALS AND METHODS

In this retrospective cohort study, data were used from The American College of Surgeons National Surgical Quality Improvement Program. Patients aged 70 years or above undergoing hip fracture surgery were included. The discrimination (c-statistic) and calibration of the model were investigated.

RESULTS

A total of 25,502 patients were included, of whom 618 (2.4%) died. The mean predicted probability of in-hospital mortality was 3.9% (range 0%-55%). The c-statistic of the model was 0.74 (95% CI 0.72-0.76), which was comparable to the c-statistic of 0.78 (95% CI 0.71-0.85) that was found in the development cohort. The calibration plot indicated that the model was slightly overfitted, with a calibration-in-the-large of 0.015 and a calibration slope of 0.780. Within the subgroup of patients aged between 70 and 85, however, the c-statistic was 0.78 (95% CI 0.75-0.81), with good calibration (calibration slope 0.934).

DISCUSSION AND CONCLUSION

The U-HIP model for in-hospital mortality in geriatric hip fractures was externally validated in a large international cohort, and showed a good discrimination and fair calibration. This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients and aid clinical decision making.

Musculoskeletal trauma and artificial intelligence: current trends and projections

Musculoskeletal trauma accounts for a significant fraction of emergency department visits and patients seeking urgent care, with a high financial cost to society. Diagnostic imaging is indispensable in the workup and management of trauma patients. However, diagnostic imaging represents a complex multifaceted system, with many aspects of its workflow prone to inefficiencies or human error. Recent technological innovations in artificial intelligence and machine learning have shown promise to revolutionize our systems for providing medical care to patients. This review will provide a general overview of the current state of artificial intelligence and machine learning applications in different aspects of trauma imaging and provide a vision for how such applications could be leveraged to enhance our diagnostic imaging systems and optimize patient outcomes.

Association between the plasma-to-red blood cell ratio and survival in geriatric and non-geriatric trauma patients undergoing massive transfusion: a retrospective cohort study

BACKGROUND

The benefits of a high plasma-to-red blood cell (RBC) ratio on the survival of injured patients who receive massive transfusions remain unclear, especially in older patients. We aimed to investigate the interaction of age with the plasma-to-RBC ratio and clinical outcomes of trauma patients.

METHODS

In this retrospective study conducted from 2013 to 2016, trauma patients who received massive transfusions were included. Using a generalized additive model (GAM),we assessed how the plasma-to-RBC ratio and age affected the in-hospital mortality rates. The association of the plasma-to-RBC ratio [low (< 0.5), medium (0.5-1.0), and high (≥ 1.0)] with in-hospital mortality and the incidence of adverse events were assessed for the overall cohort and for patients stratified into non-geriatric (16-64 years) and geriatric (≥ 65 years) groups using logistic regression analyses.

RESULTS

In total, 13,894 patients were included. The GAM plot of the plasma-to-RBC ratio for in-hospital mortality demonstrated a downward convex unimodal curve for the entire cohort. The low-transfusion ratio group was associated with increased odds of in-hospital mortality in the non-geriatric cohort [odds ratio 1.38, 95% confidence interval (CI) 1.22-1.56]; no association was observed in the geriatric group (odds ratio 0.84, 95% CI 0.62-1.12). An increase in the transfusion ratio was associated with a higher incidence of adverse events in the non-geriatric and geriatric groups.

CONCLUSION

The association of the non-geriatric age category and plasma-to-RBC ratio for in-hospital mortality was clearly demonstrated. However, the relationship between the plasma-to-RBC ratio with mortality among geriatric patients remains inconclusive.

Distal humerus fracture in patients over 70 years of age: results of open reduction and internal fixation

BACKGROUND

Due to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients.

METHODS

Between 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation.

RESULTS

After a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA).

CONCLUSION

The present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded.

LEVEL OF EVIDENCE

IV.

Factors associated with mortality in older patients sustaining pelvic or acetabular fractures

INTRODUCTION

This study aimed to investigate potential factors, including delay to surgical stabilisation, affecting mortality in older patients sustaining pelvic or acetabular (PA) fractures.

MATERIALS AND METHODS

A retrospective review of the Trauma Audit and Research Network (TARN) database was performed to identify older patients (aged 65 and over) sustaining PA fractures treated surgically in a UK Major Trauma Centre (MTC) between 2015 and 2019. Chi-squared and Fisher tests were used to compare 1-year mortality rates following operative intervention between patients treated within 72 h and after 72 h. Kaplan-Meier curves were used to visualise survival probability; significant predictors of survival were found using Cox proportional hazard models.

RESULTS

Of 564 older patients with PA fractures, 70 met the inclusion criteria. The mean age was 76.1 years. The overall 1-year mortality rate was 20%. When patients were grouped by time to surgery (fracture fixation within or greater than 72 h), there was no statistically significant difference in 1-year mortality. Patients whose surgery was delayed more than 72 h were more likely to have longer hospital stays (p = 0.002) or to have suffered from polytrauma (p = 0.025). Age, Charlson Co-morbidities Index (CCI) and pre-op mobility status were associated with statistically significant differences in overall mortality. The same factors were associated with a significantly increased hazard of death in the multivariate Cox proportional hazards model. Patient gender, mechanism of injury, Injury Severity Score (ISS) > 15 and head injury were not significant predictors of mortality.

CONCLUSION

Surgical intervention within 72 h of injury did not result in decreased mortality in older patients with PA fractures. The 1-year mortality rate between older PA fractures and hip fractures was comparable. Consideration should be given to a combined multidisciplinary approach between orthogeriatric and expert PA surgeons for these patients.

Effect of age on the efficacy of tranexamic acid: An analysis of heterogeneity of treatment effect within the CRASH-2 dataset

BACKGROUND

Trauma is a major cause of morbidity and mortality in older adults and will become more common as the population ages. Tranexamic acid (TXA) is a lysine analogue frequently used in the setting of significant trauma with hemorrhage. The aim of this study is to investigate the heterogeneity of treatment effect of TXA as it relates to patient age during trauma care.

METHODS

We included patients from the CRASH-2 trial who were randomized within 3 h of injury. Patients were stratified into age groups <26 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and >55 years. Multiple logistic regression models were utilized to evaluate adjusted odds ratios (OR) with 95% confidence intervals (CI) for mortality. Heterogeneity of treatment effect was evaluated using Akaike and Bayesian information criteria to determine the optimum logistic regression model after which a Wald Chi-square test was utilized to evaluate statistical significance.

RESULTS

On univariate analysis, TXA administration decreased mortality within the <26 years cohort (decrease of 2.1%, 95% CI 0.2 to 4.0), 46 to 55 years cohort (decrease 6.7%, 95% CI 2.7 to 10.7), and >55 years cohort (decrease of 5.3%, 95% CI 0.4 to 10.3). On adjusted analysis, when compared to the 36 to 45 years cohort, the <26 year cohort experienced a decreased mortality (OR 0.72, 95% CI 0.62 to 0.85) whereas the >55 year cohort experienced increased mortality (OR 1.8, 95% CI 1.5 to 2.2). Assessment for heterogeneity of treatment effect of TXA administration between groups approached but did not reach statistical significance (p = 0.11).

CONCLUSIONS

Mortality related to trauma increases with age, however, there does not appear to be heterogeneity of treatment effect for TXA administration among different age groups.

Health Services Use and Functional Recovery Following Blunt Trauma in Older Persons - A National Multicentre Prospective Cohort Study

OBJECTIVE

Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period.

DESIGN

Prospective, nationwide, multicenter cohort study.

SETTING AND PARTICIPANTS

All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018.

METHODS

Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty.

RESULTS

Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period.

CONCLUSIONS AND IMPLICATIONS

In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.

Geriatric All-Terrain Vehicle Trauma: An Unhelmeted and Severely Injured Population

BACKGROUND

All-terrain vehicle (ATV) use is widespread, however, little is known about injury patterns and outcomes in geriatric patients. We hypothesized that geriatric patients would have distinct and more severe injuries than non-geriatric adults after ATV trauma.

METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing non-geriatric (18-64) and geriatric adults (≥65) presenting after ATV trauma at Level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, and outcomes data were collected, including injury severity score (ISS), abbreviated injury scale (AIS) score, discharge disposition, and mortality. We performed univariate statistical tests between cohorts and multiple logistic regression models to assess for risk factors associated with severe injury (ISS>15) and mortality.

RESULTS

23,568 ATV trauma patients were identified, of whom 1,954 (8.3%) were geriatric. Geriatric patients had higher rates of severe injury(29.2 v 22.5%,p<0.0001), and thoracic (55.2 v 37.8%,p<0.0001) and spine (31.5 v 26.0%,p<0.0001) injuries, but lower rates of abdominal injuries (14.6 v 17.9%,p<0.001) as compared to non-geriatric adults. Geriatric patients had overall lower head injury rates (39.2 v 42.1%,p=0.01), but more severe head injuries (AIS>3) (36.2 vs 30.2%,p<0.001). Helmet use was significantly lower in geriatric patients (12.0 v 22.8%,p<0.0001). On multivariate analysis age increased the odds for both severe injury (OR 1.50, 95% CI 1.31-1.72, p<0.0001) and mortality (OR 5.07, 95% CI 3.42-7.50, p<0.0001).

CONCLUSIONS

While severe injury and mortality after ATV trauma occurred in all adults, geriatric adults suffered distinct injury patterns and were at greater risk for severe injury and mortality.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

BACKGROUND

Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality.

METHODS

A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05.

RESULTS

3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line-related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States' states with higher quantities of geriatric trauma patients experienced reduced preventable mortality.

CONCLUSION

Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States' states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

Disparity in prehospital scene time for geriatric trauma patients

BACKGROUND

Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults.

METHODS

Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity.

RESULTS

Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29.

CONCLUSIONS

Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

Patterns and clinical outcomes of injuries related to two-wheeled vehicles (bicycle and motorcycle) in the geriatric population: a nationwide analysis in South Korea (2016-2018)

Background

South Korea has a rapidly ageing population. This study aimed to provide epidemiologic data and to identify the characteristics of the patterns and clinical outcomes of two-wheeled vehicle-related injuries (bicycle and motorcycle) in elderly riders.

Methods

This study retrospectively analyzed data from the National Emergency Department Information System from 2016 to 2018. Adult patients (≥ 20 years old) who were injured while using two-wheeled vehicles were included. Elderly patients were defined as being 65 years and older. The analysis was performed for 65,648 bicycle-related injuries (15,272 elderly patients) and 87,855 motorcycles-related injuries (17,292 elderly patients).

Results

In emergency departments (EDs), the average injury severity score (ISS) for motorcycle-related accidents was 9.8 ± 11.2 in the younger group and 14.1 ± 14.7 in the elderly group (p = 0.001). In addition, the average ISS of bicycle-related accidents was 7.1 ± 8.9 in the younger group and 10.5 ± 12.3 in the elderly group (p = 0.001). Two-wheeled vehicle accident mortality rates of elderly riders (0.9% for bicycle and 1.8% for motorcycle in the ED; 4.1% for bicycle and 3.8% for motorcycle in the hospital) were more than twice those of younger riders.

The elderly stayed in the hospital longer than younger patients (485.2 ± 543.0 h vs 336.8 ± 385.5 h, p = 0.001) for bicycle-related injuries. They also stayed longer for motorcycle-related injuries (529 ± 598.6 h vs 452.0 ± 543.55 h, p = 0.001).

The logistic regression analysis showed that age ≥ 65 years was an independent factor associated with severe trauma (ISS ≥ 16) for both bicycle-related injuries (adjusted odds ratio [OR] 2.185 [95% Confidence Interval (CI) 2.072–2.303]) and motorcycle-related injuries (adjusted OR 1.220 [95% CI 1.137–1.287]).

Conclusion

Two-wheeled vehicle-related injuries in the elderly were associated with higher ISS, length of hospital stay, and mortality than in younger riders. Analysing the characteristics of two-wheeled vehicle-related injuries in the elderly can be the basis for planning to reduce and prevent injuries in elderly riders.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.