Determinants of functional outcome in hip fracture: the role of comorbidity

Patients Residing in Areas of Increased Social Vulnerability Are at an Increased Risk for Prolonged Length of Stay and Mortality After Hip Fracture Surgery

INTRODUCTION

Patients undergoing hip fracture surgery face notable risks of postoperative morbidity and mortality, and racial and socioeconomic disparities in outcomes exist. This study examined the effect of social vulnerability on outcomes after hip fracture surgery using the CDC's Social Vulnerability Index (SVI).

METHODS

A retrospective study of 464 patients undergoing hip fracture surgery at a single institution from July 2020 to June 2023 was conducted. Demographics, comorbidities, time to surgery, length of stay (LOS), and postoperative outcomes were compared between patients with low versus high social vulnerability. SVI was calculated based on patient's zip code of residence. The 50th percentile of national SVI scores was used to divide patients into low and high vulnerability groups. Univariate and multivariable analyses were done to compare patient characteristics and outcomes between the groups. The primary outcome of interest was 1-year postoperative mortality.

RESULTS

No notable differences were observed in demographics, comorbidities, or procedure performed between the groups. Patients with increased social vulnerability had a higher rate of mortality within 1 year (low vulnerability: 12.2 vs. high vulnerability: 24.0%, P = 0.005) and a shorter time to mortality (340.7 vs. 138.9 days, P < 0.001). Patients with higher social vulnerability had longer LOS (β = 1.12, 95% CI: 0.35-1.88, P = 0.004), were 2.37 times more likely to experience mortality within 1 year (OR = 2.37, 95% CI: 1.30-4.27, P = 0.004), and 1.75 times more likely to experience mortality at any time (OR = 1.75, 95% CI: 1.01-2.99, P = 0.045).

CONCLUSION

Patients residing in areas of increased social vulnerability were more likely to experience a longer LOS, and more likely to die within 1 year, or at any time after undergoing hip fracture surgery, when compared with those living less socially vulnerable regions. These findings highlight the need for interventions aimed at addressing social factors within hip fracture care pathways to mitigate socioeconomic disparities in patient outcomes.

Functional outcome in patients with hip fracture from 2008 to 2018, and the significance of hand-grip strength - a cross-sectional comparative study

BACKGROUND

Incidence of hip fracture is estimated to rise, increasing demands on healthcare. Our objective was to compare patients with hip fracture, a decade apart, regarding surgical characteristics and functional outcome in relation to morbidity. A secondary aim was to analyse postoperative hand-grip strength (HGS) in relation to walking ability 4 months postoperatively.

METHODS

This is a cross-sectional comparative study of patients with hip fracture, included in 2008 (n = 78) and 2018 (n = 76) at Örebro University Hospital. Patient-data (age, gender, morbidity, fall-circumstances, fracture, surgical characteristics, and length of stay) were collected from medical records. HGS was measured postoperatively. Data on functional outcome in terms of housing, walking ability and need of walking aids at 4 months postoperatively was collected from the Swedish Hip Fracture Register RIKSHÖFT. Statistical analyses adapted were hypothesis tests and regression analysis.

RESULTS

Patients in 2018 presented a significantly higher morbidity than patients in 2008 and there were significant differences in adapted surgical methods. Functional outcome at 4-months postoperatively was analysed by logistic regression where Cohort 2018 was associated with higher odds of independent walking ability (OR 5.7; 95%CI 1.9-17.2) and not needing any walking aids (OR 5.1; 95%CI 1.9-17.2). Postoperative HGS was higher among patients in 2018 and a multiple regression analysis revealed a significant association between HGS and walking ability at 4 months postoperatively.

CONCLUSIONS

This study supports the since previously reported development in hip fracture surgery in Sweden while also presenting that functional outcome seems to have improved despite a concomitant increase in morbidity. Results suggest an improvement in postoperative HGS, predicting walking ability at 4 months postoperatively.

Comorbidity and functional outcomes after hip fracture: an umbrella review protocol

OBJECTIVE

The objective of the review is to examine the association between comorbidity and functional outcomes after hip fracture.

INTRODUCTION

Patients who have suffered a hip fracture are at risk of poor functional recovery, which may be influenced by factors such as age, functional status at baseline, and comorbid conditions. Patients recovering from a hip fracture seldom present without other comorbid conditions. This proposed review will lead to a better understanding of the association between comorbidity and functional recovery after hip fracture and will assist in the medical support of patients recovering from these injuries.

INCLUSION CRITERIA

Systematic reviews that include cohort studies reporting on comorbidity and functional outcomes after hip fracture in adults (≥ 18 years old) published at any time will be included. Study protocols, papers that are not systematic reviews, papers not reporting on comorbidities or functional outcomes, and papers published in languages other than English will be excluded from the review.

METHODS

The JBI methodology for umbrella reviews will be followed. MEDLINE, Embase, and the Cochrane Database of Systematic Reviews will be searched. Two reviewers will screen the titles and abstracts against the eligibility criteria. Data extraction will be performed by 2 independent reviewers on the reviews selected for inclusion. Extracted study characteristics will include the author, year published, databases searched, number of studies/patients included, comorbidity measures, functional outcomes, presence of meta-analysis, and bias appraisal results. The quality of included studies will be reported using the JBI critical appraisal checklist for systematic reviews and research syntheses. A summary of the extracted data will be presented in tabular format and a narrative synthesis will be performed on the collected systematic reviews that meet the inclusion criteria.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021272502.

A screening test is not enough to define the prognostic role of cognitive impairment after hip fracture: a short-term prospective study

BACKGROUND

Cognitive impairment assessed by easy-to-administer tests successfully predicts function after hip fracture, whereas the prognostic role of additional cognitive evaluations is largely unknown.

AIMS

To investigate the capability of further assessments to discriminate cognitive impairment with prognostic relevance in hip-fracture women defined cognitively intact or mildly impaired on the Short Portable Mental Status Questionnaire (SPMSQ).

METHODS

We prospectively investigated women with subacute hip fracture admitted to our rehabilitation facility. The women who made ≤4 errors on the SPMSQ were further assessed by 4 tests: Montreal Cognitive Assessment, Rey Auditory Verbal Learning Test (immediate and delayed recall) and Frontal Assessment Battery. Activities of daily living (ADL) were measured by the Barthel index. Successful rehabilitation was defined with a Barthel index score ≥85.

RESULTS

Data from 127 women were available. Each of the 4 cognitive tests assessed at admission significantly predicted the Barthel index scores measured at discharge. The predictive role persisted after multiple adjustments. For a change in cognitive scores corresponding to the difference between 25° and 75° percentiles in their distribution in the sample, the adjusted odds ratio to achieve successful rehabilitation roughly ranged from 2 to 4, depending on which cognitive test was adopted.

DISCUSSION

The women with subacute hip fracture defined cognitively intact or mildly impaired on the SPMSQ could have cognitive impairment revealed by further examination, with prognostic disadvantages in ADL.

CONCLUSIONS

Assessing cognition by the SPMSQ seems not enough to exclude the presence of cognitive impairment with relevant prognostic disadvantage in hip-fracture women.

Prevalence and prognostic significance of depressive symptoms in a geriatric post-hip fracture assessment

OBJECTIVES

To investigate the prevalence and prognostic significance of post-hip fracture depressive symptoms.

METHODS

A naturalistic clinical cohort study. Data were collected on admission to hospital, geriatric assessment 4-6 months post-fracture and by telephone interview one-year post fracture. Depressive symptoms were assessed at the geriatric assessment using the 15-item Geriatric Depression Scale (GDS-15). Logistic regression analyses with multivariable models were conducted to examine the association of depressive symptoms with changes in mobility and living arrangements and Cox proportional hazards models for mortality between the geriatric assessment and one-year follow-up.

RESULTS

Of the 1070 patients, 22% (n = 238) had mild and 6% (n = 67) moderate to severe depressive symptoms. Patients with depressive symptoms had poorer nutritional status at baseline, lower scores on the cognitive and physical performance tests and poorer functional abilities in the geriatric assessment than those without. No association was observed between depressive symptoms and any of the outcomes at one-year follow-up. Poor nutritional status and physical functioning remained significant prognostic indicators.

CONCLUSION

Post-hip fracture depressive symptoms are common and deserve attention during post-hip fracture recovery and rehabilitation. Nonetheless, depressive symptoms have no impact on the change in mobility or living arrangements or mortality. These latter outcomes are mainly explained by poor nutritional status and functioning.

Prevalence of depression in older people with hip fracture: A systematic review and meta-analysis

INTRODUCTION

Hip fracture disrupts general health and is one of the most common physical injuries in the elderly. Depression is the most common mood disorder in older people and one of the main complications of hip fractures.

AIM AND METHODS

We conducted a meta-analysis to estimate the prevalence of depression in older people with hip fractures. Relevant literature published until July 2019 was obtained and screened according to established inclusion criteria. Two researchers independently carried out quality assessment and data extraction before the meta-analysis. We calculated proportions with 95% confidence intervals (CI). To investigate the sources of heterogeneity, we performed subgroup analyses based on study design, follow-up duration, type of fracture, and gender.

RESULTS

Twenty-seven studies with a combined sample size of 11958 were included. The overall prevalence of depression in older people with hip fracture was 23% (95% CI: 0.18 to 0.29). The lowest and highest prevalence of depression was in Asia (0.19) and America (0.27) respectively.

CONCLUSION

In this systematic review and meta-analysis the estimated prevalence of depression among older hip fracture patients was 23%. Further research is needed to identify strategies for preventing and treating mood disorders in this population.

Predictors of balance in older hip fracture patients undergoing standard motor rehabilitation

PURPOSE

Little is known about the factors predicting balance in hip fracture patients. The aim of this retrospective observational study was to assess balance before and after inpatient rehabilitation and, secondarily, to identify factors predicting the balance levels in older hip fracture patients after motor rehabilitation.

METHODS

Data were collected in 124 hip fracture patients over a 2-year period. All patients underwent a standard motor rehabilitation program. A modified version of Berg Balance Scale (BBS) score after rehabilitation, daily gain and percentage of improvement in BBS were the outcome measures. Multivariate regression analysis was performed to identify the predictors of balance.

RESULTS

The mean BBS score was 8.33 ± 7.23 at admission and 21.79 ± 12.15 at the end of rehabilitation (p < 0.001). The daily gain in BBS score was 0.39 ± 0.31 and the percent improvement was 32.28 ± 23.04%. Standing with one foot in front and standing on one foot were the BBS items with the lowest score at discharge and the lowest daily gain and percent improvement. The Cognitive-Functional Independence Measure (cognitive-FIM), hip muscles strength, and Katz index at discharge had moderate-to-strong relationships with final score, daily gain and percentage of improvement in BBS. Cognitive-FIM was a predictor of final BBS score (beta 0.49, p < 0.001), daily gain in BBS (beta 0.34, p < 0.001) and percent improvement in BBS (beta 0.44, p < 0.001). Conversely, hip muscles strength was a predictor of final BBS score (beta 0.32, p = 0.001), and Cumulative Illness Rating Scale severity, a predictor of daily gain in BBS (beta -0.29, p = 0.001). The R² value of the models were, respectively, 0.39, 0.23, and 0.19.

CONCLUSIONS

Cognitive function, comorbidities and hip muscles strength are important predictors of balance in hip fracture patients. Knowledge of these specific factors can be useful for physicians to identify patients needing specific rehabilitation programs for balance.

Simultaneous hip and upper-limb fractures are associated with lower Geriatric Nutritional Index scores than isolated hip fractures: a cross-sectional study of 858 women

BACKGROUND AND AIMS

Factors associated with simultaneous fractures at hip and upper limb have scarcely been investigated. Our aim was to assess the association between Geriatric Nutritional Risk Index (GNRI) scores and concurrent upper-limb fractures in women with a fall-related hip fracture.

METHODS

We investigated 858 of 907 women admitted to our Physical and Rehabilitation Medicine ward following a fall-related hip fracture.

RESULTS

GNRI scores were significantly lower in the 41 women with a simultaneous upper-limb fracture than in the 817 with an isolated hip fracture: median (interquartile range) were 85.9 (80.6-94.1) ad 90.3 (83.4-98.0), respectively, in the two groups (p = 0.021). After adjustment for age, height, body mass index, 25-hydroxyvitamin D, parathyroid hormone, femoral-neck bone mineral density, cognitive impairment, neurologic impairment and type of hip fracture we confirmed a significant association between GNRI scores and the concomitant upper-limb fractures (p = 0.001). The adjusted odds ratio for suffering a concomitant fracture was 7.53 (95% CI from 1.79 to 31.72; p = 0.006) for the 190 women of the GNRI lowest class (GNRI score < 82) versus the 213 women of the highest class (GNRI score > 98).

CONCLUSIONS

Data show that GNRI scores were significantly lower in the subgroup of women with hip fracture and concurrent upper-extremity fracture than in the controls with isolated hip fracture. Although caution is needed in interpreting our results due to the cross-sectional design of the study, we suggest that low GNRI scores may have a role in the genesis of the concurrent fractures.

Geriatric patients with dementia show increased mortality and lack of functional recovery after hip fracture treated with hemiprosthesis

PURPOSE

Operative timing, perioperative management and postoperative rehabilitation are rising challenges in orthopedic geriatric trauma. The aim of this study was to determine the outcome of patients with dementia or with a high number of comorbidities treated with hemiprosthesis after hip fracture. Literature regarding patients with high comorbidities is scarce, leaving nothing but endoprosthetic treatment for even the sickest, immobile patients.

METHODS

A retrospective chart review of 326 patients (mean age 81 ± 9 years; 230 women and 96 men) with hip fractures treated between 2012 and 2017 with a hemiprosthesis was performed. Primary outcome measures were surgical and nonsurgical complication rates, best achievable mobilisation during the hospital stay and mortality.

RESULTS

Patients with dementia had 20-fold increased risk to be bedridden after surgery and ninefold increased risk of dying (p < 0.005). Furthermore, they needed significantly more revision surgeries because of surgical complications. Patients classified ASA IV and V had significantly lower postoperative mobilization levels with only 10% able to walk with crutches and 53% bedridden. They also had significantly more non-surgical complications while dementia had no effect on non-surgical complication rate.

CONCLUSION

Patients classified ASA IV and V or suffering dementia show poor outcome after hip fracture treated with hemiprosthesis. Multidisciplinary approaches including surgeons, geriatricians, physiotherapists and psychiatrists are needed to improve the outcome of these patients. Especially in a subgroup of patients, where no mobilization is expected, alternative treatment options may be considered.

The influence of depression on patient-reported outcomes for hip-fracture patients 1 year after surgery: a prospective cohort study

BACKGROUND

Depression is common in elderly hip-fracture patients and together with cognitive impairment is associated with increased risk of mortality.

AIM

We aimed to examine the influence depression has on patient-reported outcome up to 1 year after acute hip fracture.

METHODS

162 hip-fracture patients participated in the prospective observational cohort study and were followed up at baseline, and 3 and 12 months using patient-reported outcome scores. Patients with cognitive impairment were excluded. Depression was defined as a score ≥ 8 on the depression subscale of the Hospital Anxiety Depression Scale (HADS D), having a diagnosis of depression or being treated with anti-depressant medication. Hip function was assessed using Harris Hip Score (HHS), EQ-5D was used to assess health status and Quality of life, and the Pain Numerical Rating Scale (PRNS) was used to assess pain levels. A linear regression model adjusted for group, age, sex, and ASA class was used to identify risk factors for functional outcome 12 months after fracture.

RESULTS

35 patients were included in the depression group versus 127 in the control group. No statistical differences were found in the demographic data (age, sex, ASA class, fracture type, operation method, living situation, activities of daily living ADL and clinical pathway) between the groups. In the regression model, we found no correlation between depression and the patient-reported outcome.

CONCLUSION

In young elderly hip fracture patients without cognitive dysfunction, depression may not be of major importance for the rehabilitation of hip function in the short term.

Functional recovery in hip fracture patients: the role of pharmacotherapy

BACKGROUND AND AIM

The aim of this prospective observational cohort study was to verify the relationship between number of drugs used and functional outcome in hip fracture patients undergoing rehabilitation.

METHODS

This study was conducted on 139 patients with hip fracture who underwent a rehabilitation program. Efficiency rate in the Functional Independence Measure (FIM) and Berg Balance Scale (BBS), and length of stay (LOS) were the outcome measures.

RESULTS

At the end of rehabilitation, 66.1% of patients showed an increase in number of drugs used, while 33.9% used the same or lower number of drugs than at admission. At the end of rehabilitation patients with increased pharmacotherapy took a higher total number of drug classes (p = 0.001), had longer LOS (p = 0.009) and lower Berg efficiency (p = 0.048) than patients with the same or lower pharmacotherapy. The number of drugs used at discharge was an independent determinant of LOS (beta = 0.19, p = 0.022) and FIM efficiency (beta = - 0.20, p = 0.025). Age was a determinant of LOS (beta = 0.17, p = 0.044) and BBS efficiency (beta = - 0.23, p = 0.009), while CIRS severity was a determinant of BBS efficiency only (beta = - 0.22, p = 0.016).

DISCUSSION

Findings of study indicate that in hip fracture patients, the number of drugs prescribed at discharge is an important indicator of LOS and rehabilitation efficiency.

CONCLUSIONS

These findings can help the physician to better plan the rehabilitation of hip fracture patients who require polypharmacy.

Factors affecting recovery during the first 6 months after hip fracture, using the decision tree model

Pelvic fractures are one of the most common orthopedic problems that can reduce the quality of life in the elderly. In this prospective study, we found that osteoporosis, depression, and socioeconomic status were the most important factors associated with patients' recovery during the first 6 months after pelvic fracture.

PURPOSE

Hip fractures are one of the most common orthopedic problems that can reduce the quality of life in the elderly. Considering that, we aimed to provide a comprehensive assessment of the factors affecting recovery during the first 6 months after hip fracture.

METHODS

All patients with hip fracture admitted to any of the orthopedic hospitals during July 10, 2011 to July 9, 2012 in Shiraz, Iran were included in this prospective cohort study. Patients' demographic data and also information regarding their performance and mobility after hip fracture was collected in two interviews at intervals of 6 months. All analyses were done in R software and mostly by party packages and PCAmixdata package. Tree and forest models of conditional inference were used to evaluate the factors affecting the recovery after hip fracture.

RESULTS

Two hundred sixty-six out of 514 patients (51.75%) with hip fracture recovered completely after a 6-month follow-up period. Osteoporosis, new-onset depression after hip fracture, and socioeconomic status (SES) were the most important predictors of patients' mobility status 6 months after hip fracture. In identifying predictor variables, the conditional inference forest method provided a more appropriate fit for the data than the conditional inference tree.

CONCLUSIONS

Awareness of the factors that affect patients' recovery can be helpful in improving the patients' health, as well as improving care services, thereby increasing the success of treatment. Osteoporosis, new-onset depression after hip fracture, and SES were the most important factors associated with patients' recovery. Therefore, focusing on these variables is essential.

Predictors of recovering ambulation after hip fracture inpatient rehabilitation

Background

Despite progress in surgery and care, hip fracture (HF) remains a catastrophic event, burdened with high risk of mortality and disability. This study aims at identifying predictors of recovering ambulation after intensive inpatient rehabilitation within the Tuscany Region HF rehabilitation pathway.

Methods

All HF patients referred from acute care to the two Massa-Carrara Rehabilitation facilities January 2015–June 2017 were enrolled. Comorbidity Total Score (CIRS) defined high- or low-care setting referral. Recovery of ambulation, with or without aid, (assessed by SAHFE) was the primary outcome. Personal data, comorbidity, cognitive (MMSe) and pre-fracture function (mRANKIN) were recorded on admission. Outcomes included hospital readmission, length of stay (LOS) and home discharge. Urinary catheter, bedsores, disability (modified Barthel Index-mBI), communication disability (CDS), trunk control (TCT), pain (NRS), and ambulation were recorded (admission-discharge).

Results

Of 352 patients enrolled (age 83.9 ± 7.1; 80% women), 1 died and 6 were readmitted to acute-care hospital; 97% patients referred to high-care, and 64% referred to low-care, presented moderate-high comorbidity on admission. Median LOS was 22 days; 95% patients were discharged back home; daily functional gain (mBIscore/LOS) was 1.3 ± 0.7. Patients who recovered ambulation on discharge were 84%. Older age, higher comorbidity, bladder catheter, impaired trunk control, worse cognitive and functional status on admission, and pre-fracture disability were associated to poor outcome, but only higher comorbidity and impaired communication on admission predicted failure to recover ambulation on discharge.

Conclusion

In HF patients entitled to intensive inpatient rehabilitation, moderate-high comorbidity and impaired communication are frequent findings and predict rehabilitation failure.