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

Impact of dementia and hip fracture onset on the healthcare and long-term care burden: Healthcare and long-term care insurance data analyses in Sendai City, Japan

AIM

This study aimed to examine the differences in the impact of dementia and hip fracture onset on the burden of healthcare and long-term care.

METHODS

This retrospective cohort study utilized electronic medical receipt data issued between April 2019 and March 2023 from the National Health Insurance scheme and the medical care system for older individuals aged ≥75 years from Sendai City. Female patients aged ≥65 years who were newly registered as patients with dementia (n = 2696) and/or hip fracture (n = 1118) were investigated. Monthly healthcare and long-term care costs for 12 months before and after the entry were analyzed.

RESULTS

After the onset of dementia, a very small temporary change was observed in healthcare and long-term care costs, which then tended to increase gradually throughout the entire course. By contrast, after the onset of hip fracture with and without dementia, healthcare costs temporarily increased for 3-4 months, while the long-term care costs temporarily decreased. Subsequently, long-term care costs rose and high costs followed compared with before the onset of hip fracture. In the hip fracture with dementia group, an upward trend in long-term care costs was observed within 12 months before entry but not after entry. Long-term care costs could not increase further because they might reach the maximum cost.

CONCLUSIONS

With the onset of hip fractures, the level of care for patients with dementia would further increase. Hence, fracture prevention measures for patients with dementia are important. Geriatr Gerontol Int 2025; ••: ••-••.

Association of Inflammatory and Metabolic Markers with Mortality in Patients with Postoperative Femur Fractures in the Intensive Care Unit

Background and Objectives: Postoperative femur fracture in elderly patients is associated with high morbidity and mortality, especially in the intensive care unit (ICU). Various factors, including demographic and laboratory parameters, may influence mortality in this population. The aim of this study was to evaluate the association of inflammatory and metabolic markers with mortality in ICU patients with postoperative femur fractures and to identify key predictors to enhance risk stratification and improve patient outcomes. Materials and Methods: In this retrospective single-center study, we analyzed 121 patients aged over 65 years with postoperative femur fractures who were admitted to the ICU between January 2023 and January 2024. Demographic and clinical data, including comorbidities, Charlson Comorbidity Index (CCI), and Acute Physiology and Chronic Health Evaluation (APACHE II) score, were collected. Laboratory parameters such as white blood cell count (WBC), albumin, C-reactive protein (CRP), D-dimer, Pan-Immune-Inflammation Value (PIV), CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and others were analyzed. Linear regression, logistic regression, and Receiver Operating Characteristic (ROC) analyses were performed to determine the predictive value of these markers for ICU mortality. Results: The mean age of the patients was 76.3 ± 9.6 years, and 52.1% were female. The most common comorbidities were hypertension (67.8%) and diabetes (49.6%). ICU mortality occurred in 24 patients (20%). Significant predictors of mortality included higher CRP (>62.8 mg/L), NLR (>10.0), PIV (>450), and APACHE II scores (>23) (p < 0.001 for all). Lower albumin levels (<2.5 g/dL) were strongly associated with increased mortality (p < 0.001). ROC analysis demonstrated that the APACHE II score had the highest predictive accuracy for mortality (AUC = 0.83), followed by albumin (AUC = 0.79) and PIV (AUC = 0.76). Extended ICU stay (>10 days) was also significantly correlated with increased mortality (p < 0.001). Conclusions: This study successfully demonstrates the utility of combining traditional clinical markers, such as APACHE II score, with novel inflammatory markers, such as PIV, CAR, and NLR, in predicting mortality in ICU patients following femur fracture surgery. The integration of emerging biomarkers with well-established scoring systems offers enhanced predictive accuracy and provides valuable insights into patient management.

Cephalomedullary Nailing vs. Dynamic Hip Screw for the Treatment of Pertrochanteric Fractures: The Role of Cytokines in the Prediction of Surgical Invasiveness

Background/Objectives: Limited surgical invasiveness is desirable in elderly patients with femur fracture. Serum cytokines have been considered as a possible marker but with inconclusive evidence. The present study aimed to assess the systemic inflammatory response to surgical trauma through the serum levels of several cytokines (IL1β, IL6, IL8, and IL-10), inflammatory markers (c reactive protein-CRP), and muscular damage markers (creatinkinase-CK) at different time intervals in a consecutive series of patients affected by pertrochanteric fractures (PFs) and treated by two different surgical devices (intramedullary nailing (IM) vs. dynamic hip screw plate-DHS). Methods: A total of 60 consecutive patients (45 female and 15 male, mean age 85.6 years) with PFs (AO31A1.2-2.2) were randomly assigned to two groups according to the surgical procedure used (IM vs. DHS). Specimens of venous blood were collected 1 h preoperatively and at 24, 48, and 72 h postoperatively. Commercial ELISA kits were used. Results: In the adjusted linear mixed model, the serum levels of IL-1β, IL-8, IL-10, CRP, and CK revealed no statistically significant correlation with the type of surgical intervention performed. A significant (p < 0.001) correlation was found for IL-6 values in patients undergoing IM, showing higher serum values than patients receiving DHSs in all postoperative blood sample collections. Conclusions: The results of this study reveal that the use of DHSs may have less biological impact than IM in frail elderly due to a more limited secretion of IL-6 cytokines deriving from the preservation of the femoral medullary canal, representing a possible guide for the choice of the surgical device.

Partial weight bearing and long-term survival outcomes in extracapsular hip fractures treated with trochanteric Gamma3 nails

BACKGROUND

Benefits of partial weight bearing (PWB) in operated extracapsular hip fractures (ECF) have not been proved. We have assessed influence of PWB on long-term survival and the final mobility achieved, dependence and mortality-related factors.

METHODS

Retrospective cohort study of osteoporotic ECF in ≥ 65-year-old patients who underwent surgery with trochanteric Gamma3 nails in 2014 (n = 218), followed in the long-term (consolidation or stabilisation). According to Baumgaertner-Fogagnolo classification (138 good, 71 acceptable and 9 poor) a postoperative protocol was applied. 116 cases bore weight before discharge (Immediate Partial Weight Bearing, IPWB = 116; Not-IPWB = 102), and 118 did it after a month (Early PWB, EPWB = 118; Not-EPWB = 100). Variables were collected from medical records and complementary studies. We used FMS (Fracture Mobility Score) and the National Mortality Database from the Spanish Ministry of Health at > 5 years. EPWB and Not-EPWB were comparable, except for hospital stay and dependence. We used the Cox method for mortality. < 0.05 p-values were significant.

RESULTS

Survival improved in IPWB earlier than in EPWB, although there was no statistical significance. The final FMS was significantly favourable only in EPWB. Not-EPWB showed greater dependence. Age (per year of increment), moderate Charlson comorbidity index (not age-modified) and greater immediate post-operative estimated blood loss were independent factors for mortality, but we did not find radiological factors implied.

CONCLUSIONS

Postoperative PWB in ECF may increase mid-term and long-term survival rates, but considerably delayed in EPWB. Only EPWB improved final mobility. Not-EPWB presented with greater dependence. Only clinical factors were independently related to mortality, but no radiological factors were.

Exploring the Efficacy of Computer-Assisted Navigation in Improving Lag Screw Placement and Preventing Cut-Out in Intramedullary Nail Fixation of Femoral Fractures: A Meta-Analysis

Femoral neck fractures are a common complication treated by orthopedic surgeons. Exploring the role of computer-assisted orthopedic programs in femoral fracture treatment is of particular interest given the technological advances in computer-assisted programs in the medical field. Notably, systems such as Stryker's Adaptive Positioning Technology (ADAPT) may allow for more precision in determining the tip-apex distance (TAD) when treating intertrochanter femur fractures. Such innovations hold the potential to reduce complication rates, including the incidence of lag screw cut-out, which could improve clinical outcomes in intertrochanter femur fracture treatment. This meta-analysis aims to evaluate the effectiveness of computer-assisted orthopedic systems in improving lag screw placement, as determined by the TAD and, ultimately, screw cut-out. Three studies were compared that reported continuous data for TAD in groups that did and did not use Stryker's ADAPT computer-assisted system. A random effects model was utilized to identify heterogeneity between studies. This was determined by variation and calculated through Cochran's Q-test, I2 statistic, and Tau2. Operative time was also reported in these studies and was evaluated as a secondary outcome. Each study analyzed showed that ADAPT had a statistically significant improvement in TAD with an overall effect size of -5.06. However, with an I2 value of 89% (p<0.01), there was notable heterogeneity between the three studies compared in this meta-analysis. While it is clear that there are benefits to using computer-assisted technology for internal femur fixation, more research is needed to understand the implications, including operative time and possible improvements in screw position.

Hemoglobin level, degree of mobilization, and pneumonia are associated with the development of postoperative delirium in cemented hemiarthroplasty after femoral neck fracture

PURPOSE

The aim of this retrospective study was to identify independent prognostic factors for developing a postoperative delirium (POD) in patients suffering from a proximal femoral neck fracture and treated by implantation of a hemiprosthesis.

METHODS

A retrospective study, including patients with hip hemiarthroplasty due to a femoral neck fracture between 2011 and 2020 was performed. Demographic data, preexisting conditions, intra-/postoperative complications, mobilization and laboratory results were extracted from the patients' charts. The different parameters were analyzed comparing patients with and without POD.

RESULTS

412 patients, mean age of 81 ± 9.58 years were included, 66.5% (n = 274) were female, 18.2% (n = 75) of them developed a POD. Significantly higher incidence of POD was associated with older age (p < 0.001), lower level of haemoglobin (p < 0.001), higher post-surgery interleukin 6 (IL 6) level (p = 0.008), higher postoperative level of leukocytes (p = 0.01). Patients with POD received more units of packed red blood cells (PRBC) (p = 0.007). Patients with no mobility limitations pre-operatively developed POD less frequently (p = 0.01), whereas suffering from pneumonia (p = 0.03) or limited mobility postoperatively increased the risk of POD (p < 0.001).

CONCLUSION

This study could help to identify patients with a risk for developing POD after a hemiarthroplasty in femoral neck fractures. As a consequence, frequent controls of Hb, IL 6 and leucocytes levels to avoid anemia and infections, as well as the well surgical treatment to guarantee a good postoperative outcome.

Loss of Independence after Index Hospitalization Following Proximal Femur Fracture

Purpose: Proximal femur fractures (PFFs) in elderly patients lead to decreased productivity. Skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) are non-home destinations for post-discharge disposition. This study aims to evaluate the loss of independence (LOI) following PFFs and examine the economic impact it entails. Method: The literature from various databases was collected and analyzed retrospectively. The inclusion criteria included patients age > 18 years and articles published after 1990. All studies were screened, a PRISMA chart was used to demonstrate the search process, and 24 studies were finally used for review. Results: LOI following PFFs significantly increases with age. Fractures in geriatrics avail a significant amount of post-care resources and had longer lengths of stay. Furthermore, six pre-operative risk factors were identified for non-home disposition, including age > 75, female, non-Caucasian race, Medicare status, prior depression, and Charlson Comorbidity Index. Patients discharged directly to home have lower total costs compared to those discharged to rehabilitation units. Loss of independence increases with advancing age. Conclusions: PFFs can lead to a serious loss of independence among elderly patients. Female gender, advancing age, white population, co-existing morbidities, lack of proper care, post-operative infections, limitation in mobility following surgery, and impaired cognitive function following surgery are the factors that contribute to the decline in the rate of appropriate recovery following surgery. Therefore, these factors could necessitate permanent residence in a nursing facility (IRFs and SNFs), with a direct impact on economic, social, psychological aspects and the healthcare system.

Mechanical Complications of Proximal Femur Fractures Treated with Intramedullary Nailing: A Retrospective Study

Background and Objectives: This retrospective cohort study analyzes mechanical complications in hip fracture surgery using the Trochanteric Fixation Nail-Advanced (TFNA) implant. It investigates the correlation of these complications with demographic, intraoperative, and radiological factors, aiming to identify associated risk factors and suggest improvements in clinical surveillance and treatment strategies. Materials and Methods: We enrolled 253 patients diagnosed with pertrochanteric hip fractures treated between 2017 and 2021, with 126 meeting the criteria for a minimum 6-month follow-up. Data on demographics, American Anesthesia Association Classification (ASA), comorbidities, AO/OTA [AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopedic Trauma Association)] fracture classification, procedural details, and time to failure were collected. Radiographs were evaluated for reduction quality, the tip-apex distance (TAD), progressive varus deviation, and identification of mechanical complications. Statistical analysis was performed using SPSS software. Results: The predominant AO/OTA fracture classification was 31A2 in 67 cases (52.7%). Reduction quality was deemed good or acceptable in 123 cases (97.6%). The mean time to failure was 4.5 months (range: 2.2-6). The average TAD was 18 mm (range: 1.2-36), with a mean progressive varus deviation of 2.44° (range: 1.30-4.14). A good or acceptable reduction quality was observed in 97.6% of cases. Mechanical complications occurred in 21.4% of patients, with significant associations found with the lateral cortex fracture, use of a TFNA implant with a 130° angle, open reduction, and absence of prior osteoporosis treatment. Conclusions: The study provides insights into mechanical complications in proximal femur fractures treated with the TFNA nail, emphasizing the need for enhanced clinical and radiographic surveillance, especially in patients without osteoporosis treatment. Our findings support the necessity for further clinical studies comparing these outcomes with other implant designs and underscore the importance of personalized treatment strategies to reduce complication rates.

Patients risk for mortality at 90 days after proximal femur fracture - a retrospective study in a tertiary care hospital

BACKGROUND

Despite improving the management of proximal femur fractures (PFF) with legal requirements of timing the surgery within 24 h, mortality rates in these patients remain still high. The objective of our study was to analyze potential cofactors which might influence the mortality rate within 90 days after surgery in PFF to avoid adverse events, loss of quality of life and high rates of mortality.

METHODS

In this retrospective, single-center study all patients with PFF aged 65 years and older were included. We recorded gender, age, type of fracture, surgery and anesthesia, time, comorbidities and medication as well as complications and mortality rate at 90 days. Separate logistic regression models were used to assess which parameters were associated with patients' mortality. The mortality rate was neither associated with timing, time and type of surgery nor time and type of anesthesia, but with higher age (OR 1.08 per year; 95% CI 1.034-1.128), lower BMI (OR 0.915 per kg/m2; 95% CI 0.857-0.978), higher CCI (OR 1.170 per point; 95% CI 1.018-1.345), dementia (OR 2.805; 95% CI 1.616-4.869), non-surgical complications (OR 2.276; 95% CI 1.269-4.083) and if mobilization was impossible (OR 10.493; 95% CI 3.612-30.479).

RESULTS

We analyzed a total of 734 patients (age ≥ 65 years) who had a PFF in 2019 and 2020 and received surgery. 129 patients (17.6%) died until 90 days at an median age of 89.7 years (range 65-101 years).

CONCLUSION

The proportion of patients who died until 90 days after surgery is still high. It is less extend influenced by surgical and anaesthesiologic factors than by patient-related factors like age or lower BMI. Physicians should be aware of the importance of avoiding adverse events and the importance of patients' mobilization to reduce mortality and improve patients' outcome.

Malnutrition in Older Adults—Effect on Falls and Fractures: A Narrative Review

Malnutrition in older adults impacts health status, increased mortality, and morbidity. Malnutrition may increase the development of geriatric syndromes and contribute to a higher prevalence of falls and osteoporotic fractures that lead to loss of independence and an increased rate of institutionalization. The role of malnutrition in the pathogenesis of other geriatric syndromes seems to be well established. However, the data concerning nutritional interventions are confounding. Moreover, long-term undernutrition seems to be one of the factors that strongly influences the efficacy of interventions. This review outlines the current literature on this topic, and aims to guide physicians to make proper decisions to prevent the vicious cycle of falls, fractures, and their negative outcomes in patients with malnutrition.