Mortality and cardiorespiratory complications in trochanteric femoral fractures: a ten year retrospective analysis

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

Consequences of anemia in geriatric hip fractures: how low is too low?

Background

The transfusion threshold for low hemoglobin (Hgb) in geriatric patients with hip fractures is widely debated. In certain populations, low Hgb is associated with poor outcomes. Our objective was to evaluate the relationship between lowest Hgb and outcome to identify the Hgb threshold where poor outcomes were more prevalent.

Methods

This retrospective cohort study included consecutive patients with hip fractures, aged ≥60 years, evaluated at two level 1 trauma centers from 2018 to 2021. Patients who did not undergo operative fixation or had a length of stay <1 day were excluded. The primary endpoint was adverse outcome defined as the composite of myocardial infarction, stroke, new-onset arrhythmia or death. We compared lowest Hgb and possible confounders between patients with and without adverse outcomes. Classification and regression tree (CART) analysis was performed to identify the threshold for Hgb where adverse outcomes were more prevalent. Multivariate analysis was performed.

Results

We evaluated 935 patients. Mean age was 80±10 years; admission Hgb was 12.5±1.7 g/dL. Diabetes was present in 20%, and 20% had coronary artery disease. Adverse outcomes were noted in 57 patients (6.1%). CART identified ≤7.1 g/dL as the Hgb threshold where adverse outcomes were more prevalent (15% vs. 4.1%, p<0.001). Additionally, a greater number of adverse outcomes were noted in the subgroup of patients having both a hemoglobin ≤7.1 g/dL and advanced age (age >79 years (22%)). After controlling for age, American Society of Anesthesiologist Physical Status Classification (ASA), antiplatelet medication, admission Hgb, time to operation and blood transfusions, lowest Hgb ≤7.1 g/dL remained a risk factor for adverse outcomes.

Conclusions

In geriatric patients with isolated hip fractures, Hgb ≤7.1 g/dL is associated with a significantly higher rate of adverse outcomes. This risk was most pronounced in patients older than 79 years; particular care should be taken in this demographic.

Level of evidence/study type

Level III/prognostic and epidemiological.

Orthogeriatric co-managements lower early mortality in long-lived elderly hip fracture: a post-hoc analysis of a prospective study

OBJECTIVE

To evaluate the clinical effectiveness of orthogeriatric co-management care in long-lived elderly hip fracture patients (age ≥ 90).

METHODS

Secondary analysis was conducted in long-lived hip fracture patients between 2018 to 2019 in 6 hospitals in Beijing, China. Patients were divided into the orthogeriatric co-management group (CM group) and traditional consultation mode group (TC group) depending on the management mode. With 30-day mortality as the primary outcome, multivariate regression analyses were performed after adjusting for potential covariates. 30-day mobility and quality of life were compared between groups.

RESULTS

A total of 233 patients were included, 223 of whom completed follow-up (125 in CM group, 98 in TC group). The average age was 92.4 ± 2.5 years old (range 90-102). The 30-day mortality in CM group was significantly lower than that in TC group after adjustments for (2.4% vs. 10.2%; OR = 0.231; 95% CI 0.059 ~ 0.896; P = 0.034). The proportion of patients undergoing surgery and surgery performed within 48 h also favored the CM group (97.6% vs. 85.7%, P = 0.002; 74.4% vs. 24.5%, P < 0.001; respectively). In addition, much more patients in CM group could walk with or without aids in postoperative 30 days than in the TC group (87.7% vs. 60.2%, P < 0.05), although differences were not found after 1-year follow-up. And there was no significant difference in total cost between the two groups (P > 0.05).

CONCLUSIONS

For long-lived elderly hip fracture patients, orthogeriatric co-management care lowered early mortality, improved early mobility and compared with the traditional consultation mode.

The Geriatrics at Risk Score (GeRi-Score) for mortality prediction in geriatric patients with proximal femur fracture - a development and validation study from the Registry for Geriatric Trauma (ATR-DGU)

This study developed an easy-to-use mortality prediction tool, which showed an acceptable discrimination and no significant lack of fit. The GeRi-Score was able to predict mortality and could distinguish between mild, moderate and high risk groups. Therefore, the GeRi-Score might have the potential to distribute the intensity of medical care.

PURPOSE

Several mortality-predicting tools for hip fracture patients are available, but all consist of a high number of variables, require a time-consuming evaluation and/or are difficult to calculate. The aim of this study was to develop and validate an easy-to-use score, which depends mostly on routine data.

METHODS

Patients from the Registry for Geriatric Trauma were divided into a development and a validation group. Logistic regression models were used to build a model for in-house mortality and to obtain a score. Candidate models were compared using Akaike information criteria (AIC) and likelihood ratio tests. The quality of the model was tested using the area under the curve (AUC) and the Hosmer-Lemeshow test.

RESULTS

38,570 patients were included, almost equal distributed to the development and to the validation dataset. The AUC was 0.727 (95% CI 0.711 - 0.742) for the final model, AIC resulted in a significant reduction in deviance compared to the basic model, and the Hosmer-Lemeshow test showed no significant lack of fit (p = 0.07). The GeRi-Score predicted an in-house mortality of 5.3% vs. 5.3% observed mortality in the development dataset and 5.4% vs. 5.7% in the validation dataset. The GeRi-Score was able to distinguish between mild, moderate and high risk groups.

CONCLUSIONS

The GeRi-Score is an easy-to-use mortality-predicting tool with an acceptable discrimination and no significant lack of fit. The GeRi-Score might have the potential to distribute the intensity of perioperative medical care in hip fracture surgery and can be used in quality management programs as benchmark tool.

Age-Related changes in the morphological features of medial column of the proximal humerus in the Chinese population

Background

Age-related changes in the medial column (MC) of the proximal humerus have a major impact on fracture management; however, the changes in the morphological features remain unclear. This study aimed to investigate the age-related changes in the morphological features of MC and present the morphological grading.

Methods

One hundred computed tomography (CT) images of the proximal humerus of 100 individuals (19-95 years) were retrospectively obtained. The individuals were categorized into five age groups to quantify the differences among different ages; the youngest group (18-44 years) served as the baseline group. Parameters of the morphological features were measured on CT images with multiplanar reconstruction based on an explicit definition of MC, including length, thickness, width, oblique thickness (DSM), humeral head diameter (DHM), and ratio (RSM) of DSM to DHM. The morphological grading of MC was presented based on the value of RSM deviating different standard deviations (SD) from the mean value in the baseline group.

Results

Significant negative correlations were observed between age and the morphological parameters of MC (r ranged from -0.875 to -0.926; all P < 0.05), excluding DHM (r = 0.081, P = 0.422). Significant differences in the values of morphological feature parameters were detected among the five age groups (all P < 0.001). The highest mean values of morphological feature parameters were observed in the youngest group (18-44 years), which decreased gradually with increasing age until the lowest mean values were observed in the oldest group (≥90 years) (all P < 0.05). The morphological features of MC were categorized into three grades based on the value of RSM deviating 1.5 SD or 3 SD from the mean value in the baseline group.

Conclusion

Our study shows that the parameter values of morphological features of MC decreased with increasing age. The morphological features of MC could be categorized into three grades. Our findings may provide a more comprehensive insight into age-related changes in the morphological features of MC that facilitate risk stratification and optimize the management of proximal humeral fractures.

Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality

INTRODUCTION

Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.

PATIENTS AND METHODS

Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.

RESULTS

A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 ± 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.

CONCLUSION

Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.

Increased mortality after intramedullary nailing of trochanteric fractures: a comparison of sliding hip screws with nails in 19,935 patients

Background and purpose - Intramedullary nails (IMN) have become increasingly common as treatment for trochanteric hip fractures (THF) although they are costlier, and without proven superiority compared with sliding hip screws (SHS). We investigated whether the 2 methods differ in terms of short-term mortality when used in fractures where both methods are suitable. Patients and methods - We extracted data from the Swedish Fracture Register (SFR) on 19,935 patients ≥ 60 years with trochanteric fractures AO type 31-A1 or -A2 who had been treated with either SHS or IMN. We assessed absolute mortality rates and the relative risks (RR) of death after 7, 30, 90, and 365 days using generalized linear models, adjusting for age, sex, and fracture type. We performed a sensitivity analysis on a subgroup of 3,673 patients with information on comorbidity to address this potential confounder. Results - 69% of the patients were women and mean age was 84 years (60-107). IMN was used in 35% of A1 and in 71% of A2 fractures. The use of IMN was associated with a slightly increased adjusted risk of death within 30 days compared with SHS (RR = 1.1, 95% CI 1.0-1.2) with no difference at any other time point. Interpretation - The slightly increased risk of death up to 30 days postoperatively does not support the use of IMN instead of SHS in stable THF.

The Quality of Life, Patient Satisfaction and Rehabilitation in Patients With a Low Energy Fracture-Part III of an Observational Study

Introduction

Due to the aging population the incidence of Low Energy Fractures (LEF) increases. LEF have high mortality and morbidity rates and often cause elderly to lose independence. Patient-reported outcomes, such as Quality of Life (QoL) and patient satisfaction (PS) are needed to evaluate treatment, estimate cost-benefit analyses, and to improve clinical decision-making and patient-centered care.

Objective

The primary goal was to evaluate QoL and PS in patients with LEF, and to compare QoL scores to the community dwelling population. Second, we observed the amount and type of physiotherapy (PT) sessions the patients conducted.

Methods

A single-center cohort study was conducted in Switzerland. Patients between 50 and 85 years, who were treated in the hospital for LEF, were followed 1 year after initial fracture. Data on QoL were obtained through the Euroqol-5-Dimension questionnaire-3-Level (EQ-5D-3L) and the EQ VAS (visual analog scale). PS was measured by a VAS on satisfaction with treatment outcome. Data on PT sessions, mobility and use of analgesics were collected by telephone interviews and written surveys. Results were compared between the different fracture locations and subgroup analyses were performed for age categories.

Results

411 patients were included for analysis. The median scores of the EQ-5D-3L index-VAS and PS were 0.90 (0.75-1.0), 90 (71.3-95) and 100 (90-100). Significant differences in all scores were found between fracture location (P < .05), with hip fracture patients and patients with a malleolar fracture scoring lowest in all measures. QoL index in hip fracture patients was 0.76 (0.70-1.00), QoL VAS 80 (70-90), and PS 95 (80-100). Median amount of PT sessions in all patients was 18 (9-27) and a significant difference was found between fracture locations. Patients with a fracture of the humerus received the highest amount of PT sessions 27 (18-36), hip fracture patients had a median of 18 (9-27) sessions.

Conclusion

At follow-up, QoL throughout all patients with a LEF was comparable to a normal population. Remarkably, though hip fracture patients seem to suffer from a clinically relevant loss of QoL, they received fewer PT sessions and performed fewer long-lasting home training than patients with a humerus fracture. Intensive, progressive rehabilitation with a high frequency of supervised training is recommended after hip fracture. The low frequency of PT sessions found in this study is unsatisfying. In hip fracture patients and in patients with a malleolar fracture, especially when aged over 75 years, more efforts are required to improve rehabilitation and subsequently QoL.

Red Blood Cell Transfusion and Postoperative Delirium in Hip Fracture Surgery Patients: A Retrospective Observational Cohort Study

Background

Patients having hip fracture surgery are at high risk for postoperative delirium. Red blood cell (RBC) transfusion may increase postoperative delirium risk by causing neuroinflammation. We hypothesized that RBC transfusion would be associated with postoperative delirium in patients having hip fracture surgery.

Methods

An observational cohort study was performed using the United States National Surgical Quality Improvement Program (NSQIP) participant use files for hip fracture from 2016 to 2018. Propensity score analysis and inverse probability of treatment weighting (IPTW) were used to reduce bias from confounding. An IPTW adjusted odds ratio for developing postoperative delirium was calculated for patients who received RBC transfusion during surgery or in the 72 hours after.

Results

There were 20,838 patients who had eligible current procedural terminology (CPT) codes for primary hip fracture surgery and complete study data. After employing strict exclusions to balance covariates and reduce bias, 3,715 patients remained in the IPTW cohort. Of these, 626 patients (16.9%) received RBC transfusion and 665 patients (17.9%) developed postoperative delirium. IPTW adjustment led to good covariate balance between patients who received RBC transfusion and those who did not. Patients who received RBC transfusion had significantly higher odds of postoperative delirium, IPTW adjusted odds ratio = 1.21, 95% CI = 1.03 to 1.43, and P = 0.02. Discharge location also differed significantly between patients who received RBC transfusion and those who did not (P < 0.001) with in-hospital mortality or referral to hospice occurring in 1.6% of patients who received RBC transfusion and 1.3% of patients who were not transfused.

Conclusion

RBC transfusion is associated with increased odds of postoperative delirium after hip fracture surgery and may be associated with worse clinical outcome.

Impact of concomitant injuries in geriatric patients with proximal femur fracture : an analysis of the Registry for Geriatric Trauma

AIMS

The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

METHODS

A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries.

RESULTS

A total of 22,602 patients met the inclusion criteria. The overall prevalence of a concomitant injury was 8.2% with a predominance of female patients (8.7% vs 6.9%; p < 0.001). Most common were fractures of the ipsilateral upper limb. Concomitant injuries resulted in prolonged time-to-surgery (by 3.4 hours (95 confidence interval (CI) 2.14 to 4.69)) and extended length of stay in hospital by 2.2 days (95% CI 1.74 to 2.61). Mortality during the admission was significantly higher in the concomitant injury group (7.4% vs 5.3%; p < 0.001). Additionally, walking ability and quality of life were reduced in these patients at discharge. More patients were discharged to a nursing home instead of their own home compared to patients without additional injuries (25.8% vs 30.3%; p < 0.001).

CONCLUSION

With a prevalence of 8.2%, the appearance of a concomitant injury is common in elderly patients with hip fracture. These patients are at a greater risk for death during the admission, longer hospital stays, and delayed surgery. This knowledge is clinically important for all who are involved in the treatment of proximal femur fractures. Cite this article: Bone Joint J 2021;103-B(9):1526-1533.

Fifteen years change in acute management of hip fracture patients: 1-year mortality calls for improvements

INTRODUCTION

Over the past two decades, the average age of hip fractured patients has increased, patients are increasingly fragile and their management is more complex. Most of the literature suggest that care improvement lowered short-term mortality but there is no clear evidence whether mid- and long-term mortality rates are improving. The aim of this study was to evaluate the variations in comorbidities in hip fractured patients over 15 years, the changes in mortality and identify the predictive factors for mortality for identifying the patients at higher risk.

MATERIALS AND METHODS

Hip fractured patients admitted in hospital in 2000-2001 (192 patients) and 2015-2016 (323 patients) were retrospectively reviewed. Demographic, clinical and management data from the two cohorts were compared. Thirty-day and 1-year mortality were calculated and compare between the two cohorts. A multivariate logistic regression model were performed to identify the most significant predictors of mortality.

RESULTS

After fifteen years, mean age of hip fracture patients increased by 2.6 years with a 31% increase in comorbidity. The most prevalent comorbidities were hypertension, COPD, diabetes, arrhythmia, renal impairment and dementia. In the 2015-2016 cohort, the age-adjusted mortality at 30 days significantly declined compared to the 2000-2001 cohort (respectively 6.9% vs. 12.5%) but the age-adjusted mortality at 1-year was equivalent. Older age, reduced mobility, higher comorbidity, lateral fractures and male sex were significant risk factors for reduced survival time CONCLUSIONS: After 15 years, there was a significant improvement in 30-days mortality in hip fractured patients despite their increase in comorbidities but this advantage was not observed in 1-year mortality. This suggests the need to implement targeted and longer-term care support for males, older patients and those with greater comorbidities which are at higher risk.

Care of Geriatric Patients with Lumbar Spine, Pelvic, and Acetabular Fractures before and after Certification as a Geriatric Trauma Center DGU®: A Retrospective Cohort Study

Background: More than 750,000 fragility fractures occur in Germany every year, with an expected increase in the following years. Interdisciplinary care pathways for geriatric patients are increasingly established to improve the treatment process and outcome, but there has been only limited evaluation of their use. Objectives: This study aimed to compare patient care before and after the implementation of a geriatric trauma center (GTC) in conformity with the German Society for Trauma Surgery (DGU^®). Patients and Methods: We performed a retrospective single-center cohort study, including 361 patients >70 years old with lumbar spine, pelvic, and acetabular fractures, admitted between January 2012 and September 2019. Patients were divided into a usual care cohort (UC, n = 137) before implementation and an ortho-geriatric care cohort (OGC, n = 224) after implementation of the GTC DGU^®. We recorded and compared demographic data, fracture type, geriatric assessment and management, therapy, complications, and various clinical parameters, e.g., length of stay, time to surgery, hours admitted to ICU, and change in walking ability. Results: The geriatric assessment revealed significant geriatric co-morbidities and a need for geriatric intervention in 75% of the patients. With orthogeriatric co-management, a significant increase in the detection of urological complications (UC: 25.5% vs. OGC: 37.5%; p = 0.021), earlier postoperative mobilization (UC: 57.1% vs. OGC: 86.3%; p < 0.001), an increased prescription of anti-osteoporotic treatment at discharge (UC: 13.1% vs. OGC: 46.8%; p < 0.001), and lower rates of revision surgery (UC: 5.8% vs. OGC: 3.1%; p = 0.012) could be seen. Conclusions: Our results emphasize the improvement in patient care and clinical outcome by implementing a GTC DGU^® and provide opportunities for future improvement in ortho-geriatric patient care.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications

Backgroundand Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialisand Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017-2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81-89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction-3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Efficacy of two integrated geriatric care pathways for the treatment of hip fractures: a cross-cultural comparison

INTRODUCTION

Many studies have focussed on the implementation and outcomes of geriatric care pathways (GCPs); however, little is known about the possible impact of clinical practices on these pathways. A comparison was made between two traumageriatric care models, one Swiss (CH) and one Dutch (NL), to assess whether these models would perform similarly despite the possible differences in local clinical practices.

MATERIALS AND METHODS

This cohort study included all patients aged 70 years or older with a unilateral hip fracture who underwent surgery in 2014 and 2015. The primary outcomes were mortality and complications. Secondary outcomes were time to surgical intervention, hospital length of stay (HLOS), differences in surgical treatment and the number of patients who needed secondary surgical intervention.

RESULTS

A total of 752 patients were included. No differences were seen in mortality at 30 days, 90 days and 1 year post-operatively. In CH, fewer patients had a complicated course (43.5% vs. 51.3%; p = 0.048) and fewer patients were diagnosed with delirium (7.9% vs. 18.3%; p < 0.01). More myocardial infarctions (3.8% vs. 0.4%; p < 0.01) and red blood cell transfusions (27.2% vs. 13.3%; p < 0.01) were observed in CH and HLOS in CH was longer (Mdn difference: - 2; 95% CI - 3 to - 2). Furthermore, a difference in anaesthetic technique was found, CH performed more open reductions and augmentations than NL and surgeons in CH operated more often during out-of-office hours. Also, surgery time was significantly longer in CH (Mdn difference: - 62; 95% CI - 67 to - 58). No differences were seen in the number of patients who needed secondary surgical interventions.

CONCLUSIONS

This cross-cultural comparison of GCPs for geriatric hip fracture patients showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. These clinical practices did not influence the outcome.

Type of underlying fracture after the surgical treatment of geriatric trauma patients has no effect on mortality during intensive care treatment

AIM

Due to demographic change, the number of geriatric patients is still rising. Although hip fractures are the subject of current research, little is known about the remaining geriatric trauma entities. The aim of this study was to collect data of the age-related traumatological intensive care unit (ICU) population, its underlying diagnosis, and the influence on mortality and length of stay in the ICU.

METHODS

Geriatric trauma patients (aged ≥65 years) treated postoperatively in our surgical ICU were included in this retrospective observational study covering the period 2013-2017. In addition to the underlying fracture entities, patient characteristics, such as age, sex, Charlson Comorbidity Index, length of stay and mortality, were collected to identify possible independent predictive factors for mortality in the ICU using multivariate analysis.

RESULTS

During the observation period, 805 (60.5%) patients met the inclusion criteria. 47.6% of the patients suffered from a proximal femoral fracture. The total mortality rate during the stay in the ICU was 7.5%. Significant predictive factors for mortality in the ICU were Charlson Comorbidity Index (P < 0.001) and length of stay (P < 0.001). The different fracture types themselves were not a significant risk factor for mortality (P = 0.862).

CONCLUSION

Patients with proximal femoral fractures account for approximately half of the patients in intensive care. The mortality rate of these patients is no higher than that in geriatric trauma patients with other fractures. The progression is essentially influenced by the patient's comorbidities. Nowadays, the focus shifts from trauma care to the therapy of concomitant diseases. Nevertheless, this cohort, when adequately treated, shows a comparatively low mortality rate. Geriatr Gerontol Int 2020; 20: 1120-1125.

Orthogeriatric co-management for proximal femoral fractures. Can two additions make a big difference?

BACKGROUND

Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated.

METHODS

This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one "elective" operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone.

RESULTS

Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573).

CONCLUSION

We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.

Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study

Background

With an increase in the elderly population, the occurrence of hip fractures, femoral neck fractures, and intertrochanteric fractures (ITFs) is also increasing. It is important to establish effective perioperative methods that would help reduce the morbidity and mortality rates associated with ITFs. The purpose of this study was to determine the effects of ITFs according to the AO classification for perioperative hemoglobin drop.

Methods

Seventy-six patients with ITFs classified as AO 31-A1 or A2 and fixated with intramedullary nails participated in this retrospective cohort study. Medical records of these patients were retrospectively reviewed from September 2016 to August 2018. The perioperative hemoglobin drop was chosen as the main outcome measure and calculated as the difference between pre- and postoperative hemoglobin levels. Multivariate linear regression analysis was performed and included the following variables: AO classification (A1.1-A2.1 [stable] vs. A2.2-A2.3 [unstable]), time interval between injury and surgery, age, body mass index, and the use of anticoagulants.

Results

Among the 76 patients who met the inclusion criteria, a significantly higher hemoglobin drop was observed in the AO 31 A2.2-A2.3 (unstable) group than in the AO 31 A1.1-A2.1 (stable) group (p = 0.04). The multivariate analysis also showed a greater hemoglobin drop in the unstable group (p < 0.05).

Conclusions

Patients with unstable ITFs exhibited a greater hemoglobin drop and a hidden blood loss was suspected around the fracture site. We believe that this should be taken into consideration when presurgical blood transfusion is being planned for patients with unstable ITFs, to reduce associated postoperative complications, especially in patients with severe anemia or high risk of mortality.

Medical and economic consequences of perioperative complications in older hip fracture patients

Patients suffering from complications during inpatient treatment after hip fracture surgery are associated with a worse mid-term outcome. While surgically treatable complications only delay the healing process, internal complications seem to worsen the outcome in the long run. All complications come with significant increased costs during the hospital stay.

PURPOSE

Due to the demographic changes, the importance of hip fractures is still increasing nowadays. Not only surgical but also medical complications represent a major challenge in the treatment of those patients. Nevertheless, only few is known about the functional, medical, and economic consequences of complications.

METHODS

A total of 402 hip fracture patients ≥ 60 years were observed prospectively at a German university hospital. Complications were assessed during the inpatient stay and classified by Clavien and Dindo. Afterwards their influence on acute care costs was examined as well as their influence on the mortality, health-related quality of life (HRQL) (EQ5D), functional capacities (Barthel index), and mobility (Tinetti score) in the follow-up periods of 6 and 12 months.

RESULTS

Complications that required surgical revision/treatment (type III) were associated with an increased 6 months' mortality, while type II and IV complications did not influence mortality after 6 and 12 months. Six months after surgery, HRQL, Barthel score, and Tinetti score were reduced in patients suffering from all different types of complications. After 12 months however, HRQL, Barthel score, and Tinetti score following type II and IV complications remained reduced, while the scores improved in patients suffering from type III complication. All types of complications led to significantly increased acute care costs.

CONCLUSIONS

The results of the present study emphasize the crucial role of perioperative complications in older patients with hip fractures. Therefore, special attention has to be given to the prevention of those complications, e.g., with orthogeriatric treatment models, which have been shown to be effective in the reduction of complications.

Predictors of 30-day mortality in orthogeriatric fracture patients aged 85 years or above admitted from the emergency department

Purpose

Orthogeriatric trauma patients are at risk for functional decline and mortality. It is important to identify high-risk patients in an early stage, to improve outcomes and make better informed treatment decisions. The aim of this study was to identify independent risk factors for 30-day mortality in patients aged 85 years or above admitted from the emergency department with a fracture.

Methods

All orthopaedic trauma patients 85 years or above admitted from the emergency department were included. After a 30-day follow-up, mortality was determined by consulting the patient records. Multivariable logistics regression analysis generated odd ratios for mortality risk factors. A subgroup analysis was performed for patients undergoing hip fracture surgery.

Results

The 30-day mortality in geriatric fracture patients admitted to the hospital was 12%. Risk factors for 30-day mortality were: increased age, male sex, decreased hemoglobin levels, living in an institutional care facility and a decreased BMI. For geriatric patients undergoing hip fracture surgery 30-day mortality was 11%. Independent risk factors for this group were: increased age, male sex, and a decreased BMI.

Conclusion

Orthopaedic trauma patients aged 85 years or above who are admitted to the hospital with a fracture are at high risk for mortality. This study identified older age, male sex, and decreased BMI as predictors of 30-day mortality in admitted geriatric fracture patients and in geriatric hip fracture patients undergoing surgery.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures

INTRODUCTION

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population.

METHODS

In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation.

RESULTS

After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival.

DISCUSSION

A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

[Evaluation of a simple screening tool for ambulant fall prevention]

BACKGROUND

An individual's risk of falling is generally difficult to detect and it is likely to be underestimated. Thus, preventive measures are challenging and they demand sufficient integration and implementation into aftercare and outpatient management. The Aachen Falls Prevention Scale (AFPS) is a quick and easy tool for patient-driven fall risk assessment. Older adults' risk of falling is identified in a suitable manner and they then have the opportunity to independently assess and monitor their risk of falling.

OBJECTIVES

The aim of the current study was to evaluate the AFPS as a simple screening tool in geriatric trauma patients via the identification of influencing factors, e.g. objective or subjective fall risk, fear of falling (FOF) and demographic data. In this context, we investigated older adults' willingness to take part in special activities concerning fall prevention.

METHODS

Retrospectively, all patients over 70 years of age who received in-hospital fracture treatment between July 2014 and April 2016 were analyzed at a level I trauma center. After identification of 884 patients, participants completed a short questionnaire (47 questions, yes/no, Likert scale) comprising the AFPS. A history of falls in the past year was considered an indicator of a balance disorder. In addition, ambulant patients were invited to participate between July and August 2016.

RESULTS

In total, 201 patients (mean 80.4 years, range 63-97 years) performed a self-assessment based on the AFPS. After steps 1 and 2 of the AFPS had been completed, 95 (47%) participants rated their subjective risk of falling as high (more than 5 points). Of the participants 84 (42%) were objectively classified as "fallers" with significant effects on their AFPS evaluation and rating of their subjective risk of falling. Furthermore, 67% of the participants identified a general practitioner as their main contact person, and 43% of the respondents viewed the AFPS as a beneficial screening tool in fall risk evaluation (8% negative attitudes). Only 12% of the participants could imagine using the AFPS app version as a feasible option.

CONCLUSION

It would be advantageous to pretest at-risk individuals in their environment using a simple self-assessment approach, with the main purpose of identifying potential balance problems. With this approach, cost savings in the healthcare system are possible, combined with a higher health-related quality of life in the geriatric population.

Different approaches towards geriatric trauma care for hip fracture patients: an inter-hospital comparison

PURPOSE

Hip fractures in geriatric patients have high morbidity and mortality rates. The implementation of a multidisciplinary geriatric care pathway (GCP) may improve treatment for this patient population. This study focusses on two level II hospitals with a different treatment protocols. A comparison was made between a multidisciplinary GCP and extensive standard care with a focus on geriatric hip fracture patients to assess if a multidisciplinary GCP leads to lower mortality and morbidity.

METHODS

This retrospective cohort study included patients aged 70 years or older with a unilateral proximal hip fracture who underwent surgery between January 2014 and December 2015. The primary outcome measures complications and 30-day mortality. Secondary outcome measures were time to surgery, hospital length of stay (HLOS) and secondary surgical interventions.

RESULTS

This study included a total of 898 patients. No differences were found between major postoperative complications, 30-day mortality, HLOS or the amount of secondary surgical interventions.

CONCLUSIONS

Mortality, major complications, HLOS and the amount of secondary surgical interventions showed no differences between both hospitals. This inter-hospital comparison of two types of geriatric care models showed no outcome that favours one specific geriatric care model over another. This provides opportunities for future studies to get a better understanding of what specific factors of geriatric care models contribute most to an improvement in the treatment of this patient population and decide which approach is most cost effective.

Microcirculation After Trochanteric Femur Fractures: A Prospective Cohort Study Using Non-invasive Laser-Doppler Spectrophotometry

Proximal femur fractures represent a major healthcare problem in the aging society. High rates of post-operative infections are linked to risk factors that seem to affect local microcirculation. Patterns and time courses of alterations in microcirculation have, however, not been previously investigated. The aim of this prospective cohort study was to evaluate perioperative changes in microcirculation after trochanteric femur fractures using non-invasive laser-Doppler spectrophotometry to analyze how oxygen saturation (SO₂), hemoglobin content (Hb) and blood flow changed before and after surgery, and how these parameters were altered by implant type, gender, smoking, diabetes and age. Measurements were separately recorded for nine locations around the greater trochanter in 2, 8, and 15 mm depths, before surgery and 8, 24, 48 h, 4, 7, and 12 days after surgery in 48 patients. Three implants were compared: Dynamic Hip Screw, Gamma3 Nail, and Percutaneous Compression Plate. Surgery resulted in significant differences between the healthy and injured leg in SO₂, Hb and flow. Each parameter showed comparable values for both legs prior to surgery. Significantly higher values in SO₂ and flow were registered in women compared to men before and after surgery. Smoking caused significant increases in SO₂, Hb, and flow only in the superficial layer of the skin after surgery. Diabetes decreased blood flow at 2 and 8 mm depth and increased SO₂ at 8 and 15 mm depth after surgery. Age revealed a significant negative correlation with flow. The ability to increase the flow rate after surgery decreased with age. Comparison of implants indicated the minimally invasive implant PCCP altered microcirculation less than the DHS or the Gamma3 nail. Overall, the proximal femur fracture alone did not alter local skin microcirculation significantly in a way comparable to the effect caused by surgery. In conclusion, microcirculation after proximal femur fractures is highly affected by surgery, gender, smoking, diabetes, age and implant in ways specified in this study.

Comorbidity and mortality after hip fracture in nineteen thousand six hundred and eighty two patients aged eighteen to sixty five years in Denmark from 1996 to 2012

PURPOSE

This nationwide study assessed associations between comorbidity and mortality after hip fracture in young and middle-aged patients.

METHODS

Data on 19,682 patients aged 18 to 65 years were extracted from Danish registries out of 154,047 patients who experienced a hip fracture between 1996 and 2012. Mortality and comorbidity were assessed using information on vital status, hospital admissions, and prescriptions.

RESULTS

Of the 19,682 patients 17,722 (90.0%) were middle-aged (40-65 years) and 1960 (10.0%) were young (18-39 years). The 30-day mortality rates were 3.2% (n = 570) and 1.6% (n = 32), respectively. Indicators of multi-trauma (hazard ratio (HR), 3.5 95% confidence interval (CI) [1.6-7.8], n = 2056) and having diabetes (HR, 4.4 [1.2-11.3], n = 59) and heart disease (HR, 4.4[1.3-14.8], n = 57) increased 30-day mortality in the young patients, while having cancer (HR, 5.0 [4.2-5.9], n = 1958) increased 30-day mortality in the middle-aged patients.

CONCLUSION

Heart disease and diabetes were associated with high mortality in the young patients while having cancer was associated with high mortality in the middle-aged patients.

Functional outcomes and mortality in geriatric and fragility hip fractures-results of an integrated, multidisciplinary model experienced by the "Florence hip fracture unit"

PURPOSE

The aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs.

METHODS

Six hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated.

RESULTS

88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture.

CONCLUSIONS

An integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia

INTRODUCTION

Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.

METHODS AND ANALYSIS

The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. ETHICS AND DISSEMINATION: iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00013644; Pre-results.

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register

BACKGROUND

Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study.

METHODS

A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register.

RESULTS

A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients' accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h.

CONCLUSION

Safety measures to prevent fall at elderly patient's accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.

Patients with Clinically Suspected but Unproven Hip Fractures, Who Require Cross-Sectional Imaging, Are Best Initially Admitted under Geriatrician-Led Care-A Retrospective Review

Patients with suspected hip fractures who require further imaging to confirm or disprove the diagnosis may be admitted to orthopaedic or medical departments. We aim to provide evidence regarding the appropriate admission pathway for such patients. This is a retrospective study of all suspected hip fracture patients receiving second-line imaging between 1 January 2015 to 30 June 2016 in one hospital trust. Information was gained from hospital records to determine indication and result of imaging, eventual diagnoses, length of stay, and inpatient mortality. During the study period, 126 patients underwent cross-sectional imaging for clinically suspected but unproven hip fractures. Of these, 27% were positive for hip fractures (n = 34, 3.2% of hip fracture admissions) whilst the remainder were negative. Of the patients without hip fractures, 50 (54%) had a concomitant medical discharge diagnosis. Thirty-one different diagnoses were found in this cohort. This research provides evidence for geriatrician-led admission of patients with suspected but unproven hip fracture, due to the frailty and medical requirements of this patient group.

Major emergency orthopaedic surgery in patients with a concomitant acute coronary event following trauma

INTRODUCTION

This paper is a short series description of our experience with five cases managed surgically for orthopaedic trauma and who suffered meanwhile an acute coronary event.

MATERIALS AND METHODS

Five polytrauma, multiply fractured patients were treated in our institution for various lesions, including an open femur and knee articular fractures, major fractures around the pelvis and hips. They had suffered around the same time an acute coronary event complicating the orthopaedic management. One patient was treated for the orthopaedic condition as a delayed emergency, with a five day retard due to pre-operative pulmonary oedema. Four patients had cardiac evaluation, angiogram or echocardiogram. The patients were managed by a multi-disciplinary team.

RESULTS

One patient died post-operatively due to multiple complications, and four patients survived with a good functional outcome.

CONCLUSIONS

Patients with acute orthopaedic polytrauma presenting concomitant acute coronary events should be treated by multi-disciplinary teams, allowing early surgical management in a safe cardio-vascular and stable haemodynamic status.

Re-admissions treble the risk of late mortality after primary total hip arthroplasty

BACKGROUND

Following a total hip arthroplasty (THA), early hospital re-admission rates of 3-11% are considered as 'acceptable' in terms of medical care cost policies. Surprisingly, the impact of re-admissions on mortality has not been priorly portrayed. Therefore, we sought to determine the mortality rate after 90-day re-admissions following a THA in a series of patients from a captive medical care program.

PATIENTS AND METHODS

We prospectively analysed 90-day readmissions of 815 unilateral, elective THA patients operated upon between 2010 and 2014 whose medical care was the one offered by our institution. We stratified our sample into readmitted and non-readmitted cohorts. Through a Cox proportional hazards model, we compared demographic characteristics, clinical comorbidities, surgical outcomes and laboratory values between both groups in order to determine association with early and late mortality.

RESULTS

We found 37 (4.53%) re-admissions at a median time of 40.44 days (IQR 17.46-60.69). Factors associated with re-admission were hospital stay (p = 0.00); surgical time (p = 0.01); chronic renal insufficiency (p = 0.03); ASA class 4 (p = 0.00); morbid obesity (p = 0.006); diabetes (p = 0.04) and a high Charlson index (p = 0.00). Overall mortality rate of the series was 3.31% (27/815). Median time to mortality was 455.5 days (IQR 297.58-1170.65). One-third (11/37) of the re-admitted patients died, being sepsis non-related to the THA the most common cause of death. After adjusting for confounders, 90-day re-admissions remained associated with mortality with an adjusted HR of 3.14 (CI95% 1.05-9.36, p = 0.04).

CONCLUSIONS

Unplanned re-admissions were an independent risk factor for future mortality, increasing three times the risk of mortality.

Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures

PURPOSE

Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture.

METHODS

Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression.

RESULTS

A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867).

CONCLUSION

Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.