In-hospital mortality risk of intertrochanteric hip fractures: a comprehensive review of the US Medicare database from 2005 to 2010

Immediate weight bearing as tolerated versus delayed weight bearing following intramedullary fixation for geriatric intertrochanteric fractures: a post hoc analysis

BACKGROUND

Early weight bearing is crucial for fracture healing after osteosynthesis for intertrochanteric fractures (ITFs). The optimal period to start weight bearing after surgery is still under debate. The aim of this study was to compare immediate weight bearing (IWB) as tolerated with delayed weight bearing (DWB) following intramedullary fixationin elderly ITF patients.

METHODS

This post hoc analysis included patients aged ≥ 65 years with X-ray-confirmed ITFs who were admitted within 21 days after injury and who underwent intramedullary fixation surgery. The primary outcome was the EQ-5D score at 120 days after surgery. The secondary outcomes included the EQ-5D score at 30 days and 365 days after surgery, the complication rate and the mortality rate.

RESULTS

Among 410 patients (190 IWB, 220 DWB), those in the IWB group had higher EQ-5D scores at 30 (P < 0.001) and 120 days (P = 0.002) but lower scores at 365 days (P = 0.012) than did those in the DWB group. There were no significant differences in the complication rates, reoperation rates, or one-year mortality rates between the groups.

CONCLUSIONS

Compared with delayed weight bearing, immediate weight bearing improves early functional outcomes without increasing the complication or mortality rates in elderly ITF patients.

Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission?

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.

In-Hospital Mortality Risk and Discharge Disposition Following Hip Fractures: An Analysis of the Texas Trauma Registry

Background

In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations.

Objective

Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures.

Methods

A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions.

Results

There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method.

Conclusion

Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.

Influencing factors on morbidity and mortality in intertrochanteric fractures

We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.

Primary Arthroplasty or Internal Fixation in Intertrochanteric Femur Fractures: A Survey of Surgical Attitudes of Orthopedic Surgeons in Turkey

This study aimed to examine the primary arthroplasty attitudes of Turkish orthopedics and traumatology specialists and residents to patients with intertrochanteric fractures, of various ages, comorbidity situations and fracture types, using an internet-based questionnaire. Between March and April 2021, a cross-sectional survey was conducted with a total of 159 orthopedics and traumatology specialists and residents in Turkey, using an online questionnaire that consisted of 16 different patient scenarios of varying intertrochanteric fracture types, ages, and comorbidity conditions. Respondents’ preference ratio for primary arthroplasty was 24.1% in the scenarios with patients over the age of 71, while it was 8.4% in the scenarios with patients aged between 50 and 70. The ratios of primary arthroplasty preference were 12.4%, 21% and 27.3% in 2-part, 3-part and 4-part fracture scenarios, respectively. The primary arthroplasty preferences of respondents with 10 years or more of professional experience were observed to be statistically significantly different to those of the respondents with 1 to 10 years of experience in the 4-part fracture scenario where the patient was aged 71 years and above with an ASA (American Society of Anesthesiologists) score of 3–4 (p < 0.05). Despite varying opinions in the literature in recent years, primary arthroplasty can be considered a valuable alternative approach for Turkish surgeons, and in older adult patients with unstable intertrochanteric fractures, particularly those who need early mobilization and have high ASA scores.

PFNA-II Internal Fixation Helps Hip Joint Recovery and Improves Quality of Life of Patients with Lateral-Wall Dangerous Type of Intertrochanteric Fracture

Objective

To analyze the effect of PFNA-II internal fixation on hip joint recovery and quality of life (QOL) in patients with lateral-wall dangerous type of intertrochanteric fracture.

Methods

One hundred and twelve patients with lateral-wall dangerous type of intertrochanteric fracture who underwent surgical treatment in our hospital from May 2017 to May 2019 were selected as the participants of the study. Based on the treatment method, all the enrolled patients were divided into two groups: proximal femoral nail antirotation (PFNA group; n = 59) who received closed reduction and minimally invasive PFNA internal fixation and dynamic hip screw group (DHS; n = 53) who received internal fixation. The clinical indicators, curative effect, hip function score, pain degree, postoperative QOL score, and complications were compared between the two groups.

Results

The operation time, intraoperative blood loss, postoperative drainage volume, and the incidence of postoperative complications in PFNA group were statistically lower than those in DHS group (P < 0.05). The curative effect in PFNA group was notably better than that in DHS group. There were no significant differences in scores of hip function, visual analogue scale (VAS), and QOL between the two groups before operation (P > 0.05). However, the hip function score and QOL score increased in both groups after surgery, and the increase was more significant in the PFNA group, while the VAS score decreased in both groups, and the decrease in PFNA group was more significant (P < 0.05).

Conclusion

PFNA internal fixation for the treatment of lateral-wall dangerous type of intertrochanteric fracture has the advantages of short operation time, less intraoperative blood loss, effective improvement of hip joint function, and fewer postoperative complications, which is worthy of clinical application.

Atrial Fibrillation and Mortality in the Oldest Old after Surgery for Hip Fractures

INTRODUCTION

One-year mortality following hip fractures increases steeply with age, from 2% in the 60- to 69-year-old population up to 28% in the oldest old (older than 90 years). Of the various factors that contribute to hip fractures, atrial fibrillation (AF) is an independent risk factor at any age.

OBJECTIVE

The objective of this study was to assess the association of AF with mortality among the oldest old with hip fractures.

METHOD

This is a retrospective cohort study of 701 persons above age 90 years who underwent orthopedic repair for a hip fracture during 2000-2018. Of them, 218 (31%) had AF at hospital admission. The primary outcome was survival following surgery. We compared patient characteristics and 30-day, 180-day, 1-year, and 3-year survival between patients with and without AF.

RESULTS

The adjusted odds ratio for 30-day postoperative mortality for those with AF versus without AF group was 1.03 (95% confidence interval [CI] 0.63-1.66). Survival estimates were higher among those without AF than with AF at 180 days postoperative: 0.85 (95% CI 0.82-0.89) versus 0.68 (95% CI 0.61-0.74), p < 0.001; at 1 year postoperative: 0.68 (95% CI 0.63-0.72) versus 0.48 (95% CI 0.42-0.55), p < 0.001; and at 3 years postoperative: 0.47 (95% CI 0.42-0.52) versus 0.28 (95% CI 0.27-0.34), p < 0.001.

CONCLUSIONS

Among individuals aged >90 years, operated for hip fractures, mortality was similar for those with and without AF at 30 days postoperative. However, the survival curves diverged sharply after 180 days. Our findings suggest that AF is not an immediate surgical risk factor, but rather confers increased long-term risk in this population.

[Injury of the profunda femoris artery with bleeding requiring transfusion due to secondary dislocation of the lesser trochanter after osteosynthesis of an intertrochanteric femoral fracture]

Ein 95-jähriger Patient erlitt eine transfusionspflichtige Blutung nach Osteosynthese einer pertrochantären Femurfraktur mittels proximalem Femurnagel. Das bei der Erstmobilisation sekundär dislozierte Fragment des Trochanter minor perforierte einen Seitenast der A. profunda femoris. Die Blutung konnte mittels Embolisation gestillt werden, und der Patient wurde wenige Tage später mit stabilem Hämoglobinwert entlassen. Wiederholt sinkende Hämoglobinwerte trotz mehrmaliger Bluttransfusion weisen auf eine aktive Blutung hin. Die genaue Identifikation der Blutungsquelle nach Osteosynthese proximaler Femurfrakturen ist entscheidend für die korrekte Therapie.

Revision surgery due to failed internal fixation of intertrochanteric femoral fracture: current state-of-the-art

Failed treatment of intertrochanteric (IT) femoral fractures leads to remarkable disability and pain, and revision surgery is frequently accompanied by higher complication and reoperation rates than primary internal fixation or primary hip arthroplasty. There is an urgent need to establish a profound strategy for the effective surgical management of these fragile patients. Salvage options are determined according to patient physiological age, functional level, life expectancy, nonunion anatomical site, fracture pattern, remaining bone quality, bone stock, and hip joint competency. In physiologically young patients, care should be taken to preserve the vitality of the femoral head with salvage internal fixation; however, for the elderly population, conversion arthroplasty can result in early weight bearing and ambulation and eliminates the risks of delayed fracture healing. Technical challenges include a difficult surgical exposure, removal of broken implants, deformity correction, critical bone defects, poor bone quality, high perioperative fracture risk, and prolonged immobilization. Overall, the salvage of failed internal fixations of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable surgical strategies and provide patients with satisfactory clinical outcomes.

Hip Fracture Trends in America Between 2009 and 2016

Background

Hip fractures are a common condition associated with high morbidity and mortality. In this study, we assess (1) yearly incidences, (2) demographic factors, (3) postoperative outcomes, (4) primary diagnoses, and (5) primary procedures.

Materials and Methods

The National Inpatient Sample was queried for patients admitted with hip fractures from 2009 to 2016 (n = 2 761 850). Variables analyzed were age, sex, race, obesity status, Charlson Comorbidity Index, smoking status, osteoporosis status, lengths of stay (LOS), discharge dispositions, charges, costs, mortalities, inpatient complications, primary and secondary diagnoses, and primary procedures.

Results

From 2009 to 2016, the overall gross number of hip fractures decreased (P < .001). At the conclusion of the study, more patients were male, obese, and smokers, while fewer had a diagnosis of osteoporosis (P < .001 for all). Mean LOS significantly decreased (P < .001), while charges and costs increased (P < .001 for both). Both mortality and the overall complication rate decreased (P < .001 for both). Specifically, complications that decreased included myocardial infarctions, deep vein thromboses, pulmonary emboli, pneumoniae, hematomas/seromas, urinary tract infections, and transfusions (P < .001 for all). Complications that increased included cardiac arrests, respiratory failures, mechanical complications, and sepsis (P < .001 for all). The most common diagnosis was "closed fracture of intertrochanteric section of neck of femur." The procedure performed most often was "open reduction of fracture with internal fixation, femur."

Conclusion

An increasing number of males and smokers have sustained hip fractures, although fewer patients with osteoporosis experienced these injuries. A decreasing overall complication rate may indicate improving perioperative courses for hip fracture patients. However, several shortcomings still exist and can be improved to further decrease negative outcomes.

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.

Cephalomedullary nailing versus sliding hip screws for Intertrochanteric and basicervical hip fractures: a propensity-matched study of short-term outcomes in over 17,000 patients

BACKGROUND

Hip fractures are associated with poor mortality and morbidity outcomes. Controversy exists over what the preferred treatment is between sliding hips screws (SHSs) and cephalomedullary nails (CMNs) for stable intertrochanteric (IT) and basicervical (BC) hip fractures. The purpose of this study was to compare early postoperative outcomes and complications in patients treated with SHS to those treated with CMN in IT and BC hip fractures.

METHODS

We used the National Surgical Quality Improvement Program database to identify IT and BC hip fractures, excluding subtrochanteric hip fractures treated with a SHS and CMN for 2008 to 2016. After propensity score matching, there were 8505 patients in the SHS cohort and 8505 in the CMN cohort. Propensity score-adjusted multivariate regression models assed SHS as an independent risk factor for the following 30-day outcomes: mortality, postoperative major and minor complications, discharge disposition, readmission and reoperation, length of hospital stay (LOS), and operative time.

RESULTS

No difference in mortality was encountered between SHS and CMN (p = 0.440). Compared to CMN, the SHS cohort had an 11.6% decreased likelihood of a minor complication (p < 0.001); however, no difference was found between CMN and SHS for major complications (p = 0.117). SHS patients were less likely to have transfusion (p < 0.001), DVT (p = 0.007), and MI (0.024). SHS patients were 12.5% more likely to go home (p = 0.002). No association was discovered between being treated with a SHS and reoperation (p = 0.449) and readmission (p = 0.588). SHS patients had almost a quarter of a day longer LOS (p = 0.041). Patients treated with SHS had a statistically significant (p < 0.001), but clinically irrelevant 2-min longer procedure.

LEVEL OF EVIDENCE

III.

Augmented reality fluoroscopy simulation of the guide-wire insertion in DHS surgery: A proof of concept study

BACKGROUND

Hip fractures contribute to a significant clinical burden globally with over 1.6 million cases per annum and up to 30% mortality rate within the first year. Insertion of a dynamic hip screw (DHS) is a frequently performed procedure to treat extracapsular neck of femur fractures. Poorly performed DHS fixation of extracapsular neck of femur fractures can result in poor mobilisation, chronic pain, and increased cut-out rate requiring revision surgery. A realistic, affordable, and portable fluoroscopic simulation system can improve performance metrics in trainees, including the tip-apex distance (the only clinically validated outcome), and improve outcomes.

METHOD

We developed a digital fluoroscopic imaging simulator using orthogonal cameras to track coloured markers attached to the guide-wire which created a virtual overlay on fluoroscopic images of the hip. To test the accuracy with which the augmented reality system could track a guide-wire, a standard workshop femur was used to calibrate the system with a positional marker fixed to indicate the apex; this allowed for comparison between guide-wire tip-apex distance (TAD) calculated by the system to be compared to that physically measured. Tests were undertaken to determine: (1) how well the apex could be targeted; (2) the accuracy of the calculated TAD. (3) The number of iterations through the algorithm giving the optimal accuracy-time relationship.

RESULTS

The calculated TAD was found to have an average root mean square error of 4.2 mm. The accuracy of the algorithm was shown to increase with the number of iterations up to 20 beyond which the error asymptotically converged to an error of 2 mm.

CONCLUSION

This work demonstrates a novel augmented reality simulation of guide-wire insertion in DHS surgery. To our knowledge this has not been previously achieved. In contrast to virtual reality, augmented reality is able to simulate fluoroscopy while allowing the trainee to interact with real instrumentation and performing the procedure on workshop bone models.