Predicting mortality following hip fracture: an analysis of comorbidities and complications

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.

Predictors of one-year mortality following hip fracture surgery in elderly

Background

Understanding mortality risk factors is critical to reducing mortality among elderly hip fracture patients. To investigate the effects of admission and post-operative levels of distribution width of red blood cells (RDW), albumin, and RDW/albumin (RA) ratio on predicting 1-year mortality following hip fracture surgery.

Methods

A retrospective study was conducted on 275 elderly patients who underwent hip fracture surgery in a tertiary hospital between January 2018 and January 2022. Deaths within one year of hip fracture were defined as the deceased group. The survivors were defined as those who survived for at least one year. The relationship between admission and post-operative levels of RDW, albumin, RA, and mortality within one year after hip surgery was assessed statistically, including binary logistic regression analysis. The study also assessed other factors related to mortality.

Results

One-year mortality was 34.7%. There was a 3.03-year (95% CI [1.32-4.75]) difference between the deceased (79.55 ± 8.36 years) and survivors (82.58 ± 7.41 years) (p < 0.001). In the deceased group, the mean hemoglobin (HGB) values at admission (p = 0.022) and post-operative (p = 0.04) were significantly lower. RDW values at admission (p = 0.001) and post-op (p = 0.001) were significantly lower in the survivor group. The mean albumin values at admission (p < 0.001) and post-operative (p < 0.001) in the survivor group were significantly higher than in the deceased group. A significant difference was found between the survivor group and the deceased group in terms of mean RA ratio at admission and post-operative (p < 0.001). Based on binary logistic regression analysis, presence of chronic obstructive pulmonary disease (COPD) (OR 3.73, 95% CI [1.8-7.76]), RDW (OR 1.78, 95% CI [1.48-2.14]), and albumin (OR 0.81, 95% CI [0.75-0.87]), values at admission were found to be independent predictors of 1-year mortality in elderly patients with hip fracture.

Conclusion

Based on this study, presence of COPD, higher RDW, and lower albumin levels at admission were independent predictors of 1-year mortality following hip fracture surgery in the elderly.

Use of the Shizuoka Hip Fracture Prognostic Score (SHiPS) to Predict Long-Term Mortality in Patients With Hip Fracture in Japan: A Cohort Study Using the Shizuoka Kokuho Database

Hip fractures are common in patients of advanced age and are associated with excess mortality. Rapid and accurate prediction of the prognosis using information that can be easily obtained before surgery would be advantageous to clinical management. We performed a population-based retrospective cohort study using an 8.5-year Japanese claims database (April 2012-September 2020) to develop and validate a predictive model for long-term mortality after hip fracture. The study included 43,529 patients (34,499 [79.3%] women) aged ≥65 years with first-onset hip fracture. During the observation period, 43% of the patients died. Cox regression analysis identified the following prognostic predictors: sex, age, fracture site, nursing care certification, and several comorbidities (any malignancy, renal disease, congestive heart failure, chronic pulmonary disease, liver disease, metastatic solid tumor, and deficiency anemia). We then developed a scoring system called the Shizuoka Hip Fracture Prognostic Score (SHiPS); this system was established by scoring based on each hazard ratio and classifying the degree of mortality risk into four categories based on decision tree analysis. The area under the receiver operating characteristic (ROC) curve (AUC) (95% confidence interval [CI]) of 1-year, 3-year, and 5-year mortality based on the SHiPS was 0.718 (95% CI, 0.706-0.729), 0.736 (95% CI, 0.728-0.745), and 0.758 (95% CI, 0.747-0.769), respectively, indicating good predictive performance of the SHiPS for as long as 5 years after fracture onset. Even when the SHiPS was individually applied to patients with or without surgery after fracture, the prediction performance by the AUC was >0.7. These results indicate that the SHiPS can predict long-term mortality using preoperative information regardless of whether surgery is performed after hip fracture.

Should the early surgery threshold be moved to 72 h in over-85 patients with hip fracture? A single-center retrospective evaluation on 941 patients

AIM

Aim of the study was to assess whether early surgery and other clinical and orthogeriatric parameters could affect mortality rate in hip fracture patients aged > 85.

MATERIALS AND METHODS

Data regarding a 42-month period were retrospectively obtained from the institutional medical records and registry data. Gender, age, fracture pattern, surgical technique, type of anesthesia, timing of surgical intervention (within 24, 48 or 72 h from admission), days of hospitalization, mortality rate divided in intra-hospital, at 30 days and at 1 year were collected for the whole population. Some additional data were collected for an orthogeriatric subgroup.

RESULTS

941 patients were considered, with a mean age of 89 years. Surgery was performed within 24, 48 and 72 h in 24.4%, 54.5% and 66.1% of cases, respectively. Intra-hospital mortality rate resulted to be 3.4%, while mortality at 30 days and 1 year resulted to be 4.5% and 31%, respectively. Early surgery within 48 and 72 h were significantly associated with a lower intra-hospital and 30-day mortality rate. In the orthogeriatric subgroup (394 patients), a significant association with a higher mortality rate was found for general anesthesia, number of comorbidities, ADL (Activities of Daily Living) < 3, transfer to other departments.

CONCLUSIONS

In over-85 hip fracture patients, the threshold for early surgery might be moved to 72 h to allow patients pre-operative stabilization and medical optimization as intra-hospital and 30-day mortality rates remain significantly lower. Advanced age, male sex, number of comorbidities, pre-operative dependency in ADL, general anesthesia, length of hospitalization and transfer to other departments were significantly related to mortality rate.

Analysis of the risk factors of mortality in elderly patients with hip fracture using a combined database of medical and long-term care insurance claims data

BACKGROUND

The present study evaluated the risk of mortality in elderly hip fracture, focusing on comorbidities and nursing care levels.

METHODS

The present study was an observational cohort study that used a combined database of medical and long-term care insurance (LTCI) claims data from one prefecture in Japan between 2011 and 2016. In total, 6125 patients aged 65 years and older were selected from acute care hospitals with a diagnosis of "hip fracture" between March 2011 and March 2012. The impact of long-term care insurance claim evaluation levels and comorbidities at recruitment time was investigated using this dataset. These patients were followed up monthly until March 2016. Based on this person-month dataset, survival analysis was performed with death as the endpoint. Cases in which receipt data were missing during the middle of the observation period and cases in which the patient survived at the end of the observation period were censored.

RESULTS

The number of deaths during the observation period was 635 (10.4%). The impact of comorbidities and nursing care level on mortality were both significant as follows: high nursing care level before the fracture (hazard ratio: 1.09, P < 0.001), comorbidities of malignant diseases (HR: 1.45, P < 0.001), heart disease (hazard ratio: 1.20, P = 0.037), pneumonia (hazard ratio: 1.27, P < 0.001), chronic obstructive pulmonary disease (hazard ratio: 1.28, P = 0.026), renal failure (hazard ratio: 1.44, P < 0.001), and dementia (hazard ratio: 1.27, P = 0.013).

CONCLUSION

The results of this study showed that a high level of nursing care and presence of comorbidities such as malignant diseases, heart diseases, pneumonia, chronic obstructive pulmonary disease, renal failure, and dementia increased mortality in elderly patients with hip fracture. Furthermore, this study showed the usefulness of a combined database of medical and LTCI claims data for clinical and health service-related research in the field of orthopedics.

Long-term outcomes after hip fracture in Ireland: a protocol for a systematic review of traditional and grey literature

Background: Hip fracture is experienced by almost 3,500 older people in Ireland annually. The Irish Hip Fracture Database (IHFD), which drives clinical improvements in acute hospitals, aims to allow recording of longer-term outcomes. Feasible and robust methods of data collection need to be identified to inform this activity. The aim of this systematic review is to identify, describe and appraise studies that have collected long-term outcomes after hip fracture in Ireland in the last 15 years and to generate pooled estimates of outcomes if appropriate. Methods: A search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) and grey literature sources will be conducted for journal articles, conference abstracts, academic theses, and reports. Search terms related to hip fracture and Ireland will be included for most sources. The search will be supplemented by email contact with relevant professionals. Observational and interventional studies published between 2005 and 2021 will be included if outcome data were collected in the Republic of Ireland in patients with hip fracture. Outcomes of interest will include data collected after discharge from an inpatient setting or at a fixed time-point greater than 30 days after fracture, hospital admission or surgery. Information relating to study characteristics, description of researchers, data collection methods, patient characteristics and long-term outcomes will be extracted from each study and summarised in tables. Studies will be assessed for risk of bias by two review authors. Where outcomes are sufficiently homogeneous, meta-analyses of estimates will be conducted. Conclusion: Results from this study will inform the planning of further qualitative research to explore barriers and facilitators of long-term outcome collection in Ireland. It will form the basis of education and training for future data collectors in this setting.

Factors Associated with Recovered Functionality After Hip Fracture in Non-Institutionalized Older Adults: A Case-Control Study Nested in a Cohort

Purpose

To identify factors associated with recovered functionality after a hip fracture in a sample of older adult patients.

Patients and Methods

Nested case-control study in a cohort. Older adults (60 years or older) with a hip fracture were recruited between May 2017 and October 2018. The Barthel scale was used to measure performance in activities of daily living (ADL). A questionnaire was applied to collect information about demographic, clinic, psychological and social variables, and anthropometric measurements were taken. A logistic regression model was built to analyze various factors related to recovered functionality.

Results

A total of 346 older adults with a hip fracture were studied (n=173 cases and n=173 controls); 69.4% (n=240) women and 30.6% (n=140) men. Mean age was 79.4 years (±8.7) overall; for cases, 77.4 (±7.9) years and for controls, 81.4 (±9.0). Mean schooling was 6.3 (± 4.3) years. Recovered functionality was associated with normal nutritional status (OR 4.81, 95% CI = 2.54–9.12), absence of heart disease (OR 4.08, 95% CI = 1.48–11.20), self-efficacy for ADL (OR 4.07, 95% CI = 2.15–7.72), absence of depressive symptoms (OR 2.99, 95% CI = 1.69–5.28), prior functionality (OR 2.83, 95% CI = 1.51–5.31), high socioeconomic level (OR 2.41, 95% CI = 1.24–4.65) and transcervical fracture (OR 2.34, 95% CI = 1.05–5.22).

Conclusion

In older adults who have suffered a hip fracture, clinical, psychological, and demographic characteristics are associated with recovered functionality. These factors should be considered as a priority in the care of older adults who have experienced hip fractures.

Higher Charlson Comorbidity Index Increases 90-Day Readmission Rate with Poorer Functional Outcomes in Surgically Treated Hip Fracture Patients

Introduction

The associated mortality and morbidity in hip fracture patients pose a major healthcare burden for ageing populations worldwide. We aim to analyse how an individual’s comorbidity profile based on age-adjusted Charlson Comorbidity Index (CCI) may impact on functional outcomes and 90-day readmission rates after hip fracture surgery.

Materials and Methods

Surgically treated hip fracture patients between 2013 and 2016 were followed up for 1-year and assessed using Parker Mobility Score (PMS), EuroQol-5D (EQ-5D) and Physical and Mental Component Scores (PCS and MCS, respectively) of Short Form-36 (SF-36). Statistical analysis was done by categorising 444 patients into three groups based on their CCI: (1) CCI 0–3, (2) CCI 4–5 and (3) CCI ≥ 6.

Results

PMS, EQ-5D and SF-36 PCS were significantly different amongst the CCI groups pre-operatively and post-operatively at 3, 6 and 12 months (all P < 0.05), with CCI ≥ 6 predicting for poorer outcomes. In terms of 90-day readmission rates, patients who have been readmitted have poorer outcome scores. Multivariate analysis showed that high CCI scores and 90-day readmission rate both remained independent predictors of worse outcomes for SF-36 PCS, PMS and EQ-5D.

Discussion

CCI scores ≥6 predict for higher 90-day readmission rates, poorer quality of life and show poor potential for functional recovery 1-year post-operation in hip fracture patients. 90-day readmission rates are also independently associated with poorer functional outcomes. Peri-operatively, surgical teams should liaise with medical specialists to optimise patients’ comorbidities and ensure their comorbidities remain well managed beyond hospital discharge to reduce readmission rates. With earlier identification of patient groups at risk of poorer functional outcomes, more planning can be directed towards appropriate management and subsequent rehabilitation.

Conclusion

Further research should focus on development of a stratified, peri-operative multidisciplinary, hip-fracture care pathway treatment regime based on CCI scores to determine its effectiveness in improving functional outcomes.

A Bibliometric Analysis of Fragility Fractures: Top 50

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.

Peripheral IL-6 Levels but not Sarcopenia Are Predictive of 1-Year Mortality After Hip Fracture in Older Patients

BACKGROUND

Sarcopenic patients may have an increased risk of poor outcomes after a hip fracture. The objective of this study was to determine whether sarcopenia and a set of biomarkers were potential predictors of 1-year-mortality in older patients after a hip fracture.

METHODS

About 150 patients at least 80 years old were hospitalized for the surgical treatment of a hip fracture. The primary outcome measure was the death in the first year after the hip fracture. Sarcopenia was defined at baseline by having both low muscle mass (bioimpedance analysis) and handgrip and using the updated European Working Group on Sarcopenia in Older People (EWGSOP2) definition of probable sarcopenia. Janssen's (J) and Masanés (M) cutoff points were used to define low muscle mass.

RESULTS

Mortality 1 year after the hip fracture was 11.5%. In univariate analyses, baseline sarcopenia was not associated with mortality, using neither of the muscle mass cutoff points: 5.9% in sarcopenic (J) versus 12.4% in non-sarcopenic participants (p = .694) and 16% in sarcopenic (M) versus 9.6% in non-sarcopenic participants (p = .285). Probable sarcopenia (EWGSOP2) was not associated with mortality. Peripheral levels of IL-6 at baseline were significantly higher in the group of participants who died in the year after the hip fracture (17.14 ± 16.74 vs 11.42 ± 7.99 pg/mL, p = .026). TNF-α peripheral levels had a nonsignificant trend to be higher in participants who died. No other biomarker was associated with mortality.

CONCLUSIONS

Sarcopenia at baseline was not a predictor of 1-year mortality in older patients after a hip fracture. IL-6 was associated with a higher risk of mortality in these patients, regardless of sarcopenia status.

Mortality and Medical Complications of Subtrochanteric Fracture Fixation

The aim of this study was to define the incidence and investigate the associations with mortality and medical complications, in patients presenting with subtrochanteric femoral fractures subsequently treated with an intramedullary nail, with a special reference to advancement of age. Materials and Methods: A retrospective review, covering an 8-year period, of all patients admitted to a Level 1 Trauma Centre with the diagnosis of subtrochanteric fractures was conducted. Normality was assessed for the data variables to determine the further use of parametric or non-parametric tests. Logistic regression analysis was then performed to identify the most important associations for each event. A p-value < 0.05 was considered significant. Results: A total of 519 patients were included in our study (age at time of injury: 73.26 ± 19.47 years; 318 female). The average length of hospital stay was 21.4 ± 19.45 days. Mortality was 5.4% and 17.3% for 30 days and one year, respectively. Risk factors for one-year mortality included: Low albumin on admission (Odds ratio (OR) 4.82; 95% Confidence interval (95%CI) 2.08-11.19), dementia (OR 3.99; 95%CI 2.27-7.01), presence of pneumonia during hospital stay (OR 3.18; 95%CI 1.76-5.77) and Charlson comorbidity score (CCS) > 6 (OR 2.94; 95%CI 1.62-5.35). Regarding the medical complications following the operative management of subtrochanteric fractures, the overall incidence of hospital acquired pneumonia (HAP) was 18.3%. Patients with increasing CCS (CCS 6-8: OR 1.69; 95%CI 1.00-2.84/CCS > 8: OR 2.02; 95%CI 1.03-3.95), presence of asthma/chronic obstructive pulmonary disease (COPD) (OR 2.29; 95%CI 1.37-3.82), intensive care unit (ICU)/high dependency unit (HDU) stay (OR 3.25; 95%CI 1.77-5.96) and a length of stay of more than 21 days (OR 8.82; 95%CI 1.18-65.80) were at increased risk of this outcome. The incidence of post-operative delirium was found to be 10.2%. This was associated with pre-existing dementia (OR 4.03; 95%CI 0.34-4.16), urinary tract infection (UTI) (OR 3.85; 95%CI 1.96-7.56), need for an increased level of care (OR 3.16; 95%CI 1.38-7.25), pneumonia (OR 2.29; 95%CI 1.14-4.62) and post-operative deterioration of renal function (OR 2.21; 95%CI 1.18-4.15). The incidence of venous thromboembolism (VTE) was 3.7% (pulmonary embolism (PE): 8 patients; deep venous thrombosis (DVT): 11 patients), whilst the incidence of myocardial infarction (MI)/cerebrovascular accidents (CVA) was 4.0%. No evidence of the so called "weekend effect" was identified on both morbidity and mortality. Regression analysis of these complications did not reveal any significant associations. Conclusions: Our study has opened the field for the investigation of medical complications within the subtrochanteric fracture population. Early identification of the associations of these complications could help prognostication for those who are at risk of a poor outcome. Furthermore, these could be potential "warning shots" for clinicians to act early to manage and in some cases prevent these devastating complications that could potentially lead to an increased risk of mortality.

Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study

Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world's population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005-1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052-2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007-1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort.

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

INTRODUCTION

We conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD.

METHODS

This study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality.

RESULTS

The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD.

CONCLUSIONS

In elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.

Epidemiological and clinical study of hip fracture in hospitalized elderly patients in Shanghai, China

In this study, we attempted to determine the epidemiology and clinical characteristics of hip fracture in the elderly. We find that elderly people with hip fracture have multiple comorbidities and suffer numerous complications.

INTRODUCTION

We attempted to explore the epidemiology and clinical characteristics of hip fracture in the elderly.

METHODS

One thousand five hundred thirty-nine patients aged over 65 years were included in the retrospective study. From the medical records, information was gathered about pre-fracture conditions, as well as fracture type, surgical details, laboratory indicators, postoperative complications, length of stay, outcomes, and costs of hospitalization. Binary logistic regression was used to screen for potential risk factors for perioperative complications and postoperative death, and general linear models were used to determine factors that influenced the cost of surgical treatment.

RESULTS

The average age of hip fracture patients in our study was 82.20 ± 6.82 years old, and the male-to-female ratio was 1:2.82. In 1356 patients who underwent hip surgery, the incidence of perioperative complications was 6.71% (91/1356), and the postoperative mortality rate was 1.11% (15/1356). Factors associated with perioperative complications were male sex, heart function class III or higher, serum albumin < 35 g/L, respiratory diseases, and perioperative blood transfusion (P < 0.05). Perioperative blood transfusion was an independent risk factor for postoperative death after hip fracture in the elderly (P < 0.05). The main factors that influenced hospitalization expenses related to elderly hip fracture patients were type of surgery, method of anesthesia, length of stay, perioperative complications, and outcomes (P < 0.05).

CONCLUSIONS

Elderly people with hip fracture have multiple comorbidities and suffer numerous complications. Thus, randomized intervention studies should focus on prevention of complications that might be avoidable.

Preoperative Hypoalbuminemia Predicts Poor Short-term Outcomes for Hip Fracture Surgery

Hip fractures are common in elderly patients, and which surgical modality to pursue is often debated. Malnutrition, which cannot be corrected preoperatively in this population, is often not considered. Therefore, the authors sought to investigate the association between hypoalbuminemia and postoperative outcomes based on surgical intervention. Patients undergoing arthroplasty (hemiarthroplasty or total hip arthroplasty), open reduction and internal fixation, and intramedullary nailing placement for treatment of hip fractures were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by preoperative albumin level, with less than 3.5 g/dL indicating hypoalbuminemia. Albumin's association with postoperative complications was evaluated with multivariate logistic regression controlling for patient age, body mass index, American Society of Anesthesiologists score, and functional independence. A total of 20,278 patients with hip fractures and available albumin levels were included. Multivariate analysis revealed hypoalbuminemia was predictive of readmission, reintubation, mortality, and length of stay for all surgeries performed. When analyzing across surgical modalities, unique complications were identified for patients with hypoalbuminemia undergoing open reduction and internal fixation/prosthetic replacement (reoperation, P<.001) and arthroplasty (any infection, P=.028) compared with other treatment options. Hypoalbuminemia can predict postoperative complications for patients with hip fractures and should be considered preoperatively to guide surgical decision making in equivocal cases where multiple modalities may be used based on fracture pattern. This study supports that, compared with other interventions, intramedullary nailing is associated with fewer postoperative complications in patients with hypoalbuminemia. [Orthopedics. 2018; 41(6):e789-e796.].

Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture

Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated.

INTRODUCTION

Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers.

PURPOSE

The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase.

METHODS

All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period.

RESULTS

One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance.

CONCLUSION

Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.

[Assessment of clinical complications and their associated factors in hip-fracture patients in an Acute Geriatric Orthopaedic Unit]

INTRODUCTION

The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly.

MATERIAL AND METHODS

A prospective, observational and analytical study was conducted on 383 consecutive patients admitted to the unit during the years 2013 and 2014. Clinical complications were defined according to recommendations supported by the AOTrauma Network (International Network of Traumatologists for the Study of Osteosynthesis).

RESULTS

A total of 273 patients (71.28%) showed some clinical complication. The main ones were, delirium (55.4%), renal failure (15.4%), and cardiac complications (12.3%). An ASA III-IV score of OR = 1.962 (95% CI; 1.040-3.704, P=.038), lower Barthel index at discharge (b = -3.572, 95% CI -0.866 to -0.104, P=.01), the increase in pre-operative stay (OR = 1.165, 95% CI 1.050-1.294, P=.004) and an increased length of stay (b = 2.663, 95% CI 3.522-0.325; P<.001) were factors associated with clinical complications.

CONCLUSIONS

Delirium, renal failure, and cardiac complications were the most frequent complications according the new recommendations. An ASA III-IV score, worse functional status at discharge, prolonged pre-operative period, and increased length of stay, were risk factors associated with clinical complications. Cardiac, pulmonary, and gastrointestinal complications were the main causes of mortality in the unit.

Association of orthogeriatric services with long-term mortality in patients with hip fracture

PURPOSE

To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture.

METHODS

Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression.

RESULTS

First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1.

CONCLUSIONS

Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.

Baseline and pre-operative 1-year mortality risk factors in a cohort of 509 hip fracture patients consecutively admitted to a co-managed orthogeriatric unit (FONDA Cohort)

INTRODUCTION

The aim of this study was to determine the patient characteristics that predict 1-year mortality after a hip fracture (HF).

METHODS

All patients admitted consecutively with fragility HF during 1 year in a co-managed orthogeriatric unit of a university hospital (FONDA cohort) were assesed. Baseline and admission demographic, clinical, functional, analytical and body-composition variables were collected in the first 72 h after admission. A protocol designed to minimize the consequences of the HF was applied. One year after the fracture patients or their carers were contacted by telephone to ascertain their vital status.

RESULTS

A total of 509 patients with a mean age of 85.6 years were included. One-year mortality was 23.2%. The final multivariate model included 8 independent mortality risk factors: age >85 years, baseline functional impairment in basic activities of daily living, low body mass index, cognitive impairment, heart disease, low hand-grip strength, anaemia at admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The association of several of these factors greatly increased mortality risk, with an OR (95% confidence interval [CI]) of 5.372 (3.227-8.806) in patients with 4 to 5 factors, and an OR (95% CI) of 11.097 (6.432-19.144) in those with 6 or more factors.

CONCLUSIONS

In addition to previously known factors (such as age, impairment in basic activities of daily living, cognitive impairment, malnutrition and anaemia at admission), other factors, such as muscle strength and hyperparathyroidism associated with vitamin D deficiency, are associated with greater 1-year mortality after a HF.

Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results

Introduction: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient’s quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. Methods: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the “Minimum Basic Data Set (CMBD)” was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. Results: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). Conclusions: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.

Comparison of regional with general anaesthesia on postoperative delirium (RAGA-delirium) in the older patients undergoing hip fracture surgery: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is a common serious postoperative complication especially in older people and is associated with increased mortality, morbidity and healthcare costs. There is no clear consensus which anaesthesia is associated with less incidence of POD for older patients. We aim to assess whether regional anaesthesia results in lower incidence of POD comparing with general anaesthesia (GA) among older patients undergoing hip fracture surgery.

METHODS AND ANALYSIS

RAGA-delirium is a pragmatic, multicentre, prospective, parallel grouped, randomised controlled clinical trial comparing RA or GA for hip fracture surgery. A total of 1000 patients who are 65 years or over and who are having planned hip fracture surgery in nine clinical trial centres of China will be randomised in a 1:1 ratio to receive either anaesthesia for the surgery. The primary endpoint will be the incidence of POD at day 7. The secondary endpoints will be the subtype, severity and duration of delirium, postoperative acute pain score, incidence of other postoperative non-delirium complications, quality of life and cost-effective outcomes. Randomisation will be performed at the patient level using computer-generated assignment. Outcome assessors will be blinded from intervention assignment. Assessments will be conducted before surgery, intraoperatively, postoperatively, during the hospital stay, at 30-day, 6-month and 1-year postoperative intervals.

POTENTIAL IMPACT OF STUDY

This study will provide clinical evidence with a more robust methodology to help anaesthetists in selecting appropriate anaesthesia for older patients with high risk for POD. At the era of increasing emphasis on delirium prevention, this trial has the potential to inform the future national guideline to reduce POD.

ETHICS AND DISSEMINATION

Ethical approved by the local institutional review board. Trial results will be presented at national and international academic conferences, and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT02213380); pre-results.

Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment

INTRODUCTION

This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course.

METHODS

We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥, n = 341) and low-risk (LR, ASA 1-2, n = 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course.

RESULTS

The analysis demonstrated that 49.6% (n = 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (n = 17). In 57.5% (n = 196) of the HR patients, a complicated course was seen compared to 25.2% (n = 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%, p ≤ 0.001), anemia (HR 19.4% vs. LR 6.3%, p = 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%, p = 0.301) and pneumonia (HR 10.9% vs. LR 5.4%, p = 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01-1.07, p = 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04-2.37, p = 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22-5.91, p ≤ 0.001).

CONCLUSIONS

After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.

Outcome parameters in orthogeriatric co‑management - a mini-review

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12 outcome parameters published by the Experts' Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies.

Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients

Background

Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery.

Materials and methods

56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients.

Results

There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016).

Conclusions

There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively.

Level of evidence Level III.

Consenting patients with femoral neck fractures--how well are we involving the patient's relatives?

The consent process is a vital part of the in-patient journey for patients admitted with a fractured neck of femur. However, an aspect that is frequently over-looked is the involvement of a patient's next of kin. We organised a pilot study in our institution to see what steps we could take to make improvements in the way that next of kin involvement was managed, in line with widespread national guidelines.

Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications?

BACKGROUND

Low energy distal femur fractures often occur in a fragile elderly population that is prone to local and systemic complications following operative treatment of extremity fractures. The nonunion rate and early complication rate following laterally based locked plating in this specific fracture are not well described.

METHODS

We conducted a retrospective cohort study conducted at three affiliated tertiary care hospitals to evaluate nonunion, early post operative complications, discharge disposition, length of stay, and mortality in patients over 60 years old undergoing laterally based locked plating of a low energy distal femur fracture.

RESULTS

Forty-four out of 176 patients were deceased at one year (25%). Predictors of one year mortality included older age, higher Charlson Comorbidity Index (CCI), and delay to surgery greater than 2days (p<0.001). Of 99 patients alive and with follow up at one year, 24 (24%) developed a nonunion and 21 of 24 required nonunion surgery. Development of a surgical site infection was statistically significantly correlated with development of nonunion. Age and CCI did not predict development of nonunion. Average length of stay was 10days and 82% of patients were discharged to a skilled nursing facility. Thirty eight percent of patients experienced at least one postoperative systemic complication.

CONCLUSIONS

Laterally based locked plating of the low energy geriatric distal femur fracture is most often followed by a tumultuous post-operative course with a high rate of local and systemic complications including death, nonunion, and extended hospital stays.

LEVEL OF EVIDENCE

Level III prognostic.

Orthogeriatric care: improving patient outcomes

Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.