Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients

Excess Mortality for Femoral Intertrochanteric Fracture Patients Aged 50 Years and Older Treated Surgically and Conservatively in Tianjin, China: A Cohort Study

OBJECTIVE

Intertrochanteric fracture is one type of hip fracture, which is the most serious consequence of osteoporosis. Along with the growing elderly population, intertrochanteric fracture is expected to rise increasingly. The aim of this study was to assess excess mortality after intertrochanteric fractures and to identify the predictors of long-term mortality by therapy among patients aged 50 years and older in Tianjin.

METHODS

This is a retrospective cohort study on mortality for 3029 patients aged 50 years and older in Tianjin experiencing an intertrochanteric fracture between December 26, 2014 and December 31, 2018. Data were from Tianjin Hospital Hip Fracture (THHF) cohort. Follow-up period was until March 31, 2022. Mortality, excess mortality, and comorbidities were analyzed and stratified by therapy and gender. Time dependent Cox models were performed to estimate the effects of the variables.

RESULTS

Absolute mortality for all the patients was 5.90% at 3 months, 12.55% at 12 months, 19.92% at 24 months and 27.28% at 36 months. Absolute mortality for surgical group was 1.57% at 3 months, 4.77% at 12 months, 8.49% at 24 months and 12.07% at 36 months, significantly lower than conservative group: 10.50% at 3 months, 20.73% at 12 months, 31.96% at 24 months and 43.04% at 36 months. We found a substantially lower mortality (hazard ratio [HR] 0.34, 95% confidence internal, [CI]: 0.23-0.52, p = 0.000) among patients undergoing surgical therapy than those undergoing conservative therapy, even when controlled for gender, age, the length of hospital stay, and all the comorbidities. Female patients (HR 0.68, 95% CI: 0.58-0.79, p = 0.000) were less likely to die than male patients after an intertrochanteric fracture. Patients treated by the two methods were both found to have excess mortality rates compared to the general population, although in different levels. The excess mortality rates for patients in the conservative therapy group were 14.46% in males and 17.93% in females, while in the surgical therapy group, 2.78% in females and 4.37% in males. The comorbidities moderate or severe renal disease (HR 2.19, 95% CI: 1.61-2.98, p = 0.000), metastatic solid tumor (HR 6.35, 95% CI: 1.56-25.85, p = 0.010), hypoproteinemia (HR 1.22, 95% CI: 1.01-1.47, p = 0.034), and older age (HR 1.89, 95% CI: 1.73-2.08, p = 0.000) were also risk factors on mortality. A worse-case analysis for the primary outcome were performed as sensitivity analysis and it was consistent with the original conclusion.

CONCLUSION

Intertrochanteric factures for people aged 50 years older were found to have excess mortality compared to the general population in Tianjin city, and preventing the fractures in the hip for elderly people was imperative. After controlling tfor comorbidities and age, female gender and surgical therapy were protective factors for the death after fractures, which could provide strong evidence for patients and surgeons to make decisions.

Preoperative echocardiography in patients with hip fracture: a prospective cohort study

Introduction

Although clinical guidelines suggest echocardiography before surgery in patients with hip fracture, no prospective studies exist in the literature. The aim of the present investigation was to assess whether preoperative echocardiography affects time to surgery, length of hospital stay (LOS), and in hospital mortality in high-risk patients who need surgery for a hip fracture.

Material and methods

In the study entered 255 consecutive patients with hip fracture referred to a multidisciplinary hip fracture unit. Seven hundred seventeen patients referred before the implementation of routine echocardiographic examination were considered as control group. Echocardiography was performed in patients with systolic murmurs, unstable clinical conditions, recent decompensation of heart failure or hospital admission for coronary disease. Time to surgery, LOS, and in hospital mortality in patients who underwent preoperative echocardiography (high-risk group) were compared with patients who did not undergo echo (low-risk group) and with the control group.

Results

122/255 patients underwent echocardiography. The two groups did not differ for age, sex, type or fracture, and notably time to surgery and LOS. Coronary heart disease, atrial fibrillation, and two or more comorbidities were more frequent in the echo group. Overall clinical characteristics were not different from group of patients referred before the implementation of the echocardiographic protocol but in these last patients time to surgery and LOS were significantly longer. As well in hospital mortality was not significantly different in the two groups (1.9 in echo vs. 1.7% in nonecho) but lower than in the control group (4.1% ).

Conclusions

An echocardiographic guide may be useful in a high-risk group with a hip fracture to choose the proper anesthetic setting, referral for intensive care observation after surgery and, optimal medical treatment, including fluid management without delay in time to surgery.

Preoperative echocardiography for patients with hip fractures undergoing surgery in a low-resource setting: Asset or obstacle?

The aim of this study was to determine the rate of preoperative transthoracic echocardiography in hip fracture patients and to evaluate its effects on time to surgery and length of stay. We conducted a retrospective review of all patients with hip fractures treated at a tertiary referral hospital. Data examined included age, sex, comorbidities, time to surgery, length of stay, fracture type and transthoracic echocardiography findings. Forty-eight patients with hip fractures underwent surgery (men 41.7%; mean age 77.2 (49-95)). Nine patients (18.7%) had a preoperative transthoracic echocardiography. Preoperative transthoracic echocardiography was associated with a significantly longer time to surgery an abbreviation for days e.g dys should be added after the values to indicate what time frame is being measured (14.7 versus 6.8, p = 0.0051) and length of stay (23.6 versus 10.4, p = 0.0002). This study demonstrates a high rate of preoperative transthoracic echocardiography in hip fracture patients. The role of transthoracic echocardiography should be reassessed in view of its association with significant surgical delays.

Unnecessary Preoperative Cardiology Evaluation and Transthoracic Echocardiogram Delays Time to Surgery for Geriatric Hip Fractures

OBJECTIVE

Delays to surgery for patients with geriatric hip fracture are associated with increased morbidity and mortality. The American Heart Association (AHA) and American College of Cardiology (ACC) Clinical Practice Guidelines (CPG) were created to standardize preoperative cardiology consultation and transthoracic echocardiogram (TTE). This study's purpose is to determine if these practices are over used and delay time to surgery at a safety net hospital.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center and safety net hospital.

PATIENTS

Charts were reviewed for indications of preoperative cardiology consultation or TTE per AHA and ACC CPG in 412 patients admitted with geriatric hip fracture.

INTERVENTION

Criteria meeting the AHA/ACC guidelines for preoperative TTE and cardiac consultations.

MAIN OUTCOME MEASUREMENTS

Time to surgical intervention.

RESULTS

Despite 17.7% of patients meeting criteria, 44.4% of patients received cardiology consultation. Of those patients, 33.8% met criteria for receiving preoperative TTE but 89.4% received one. Time to surgery was greater for patients receiving cardiology consultation (25.42 ± 14.54 hours, P-value <0.001) versus those who did not (19.27 ± 13.76, P-value <0.001) and for those receiving preoperative TTE (26.00 ± 15.33 hours, P-value <0.001) versus those who did not (18.94 ± 12.92, P-value <0.001).

CONCLUSIONS

Cardiology consultation and TTE are frequently used against AHA/ACC CPG. These measures are expensive and delay surgery, which can increase morbidity and mortality. These findings persisted despite limited resources available in a safety net hospital. Hospitals should improve adherence to CPG, or modify protocols.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture

AIMS

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms.

METHODS

A population-based, matched cohort study of all hip fracture patients (aged over 45 years) in Ontario, Canada between 2009 and 2014 was conducted. The primary exposure was preoperative echocardiography (occurring between hospital admission and surgery). Mortality rates, surgical wait times, postoperative LOS, and medical costs (expressed as 2013$ CAN) up to one year postoperatively were assessed after propensity-score matching.

RESULTS

A total of 2,354 of 42,230 (5.6%) eligible hip fracture patients received a preoperative echocardiogram during the study period. Echocardiography ordering practices varied among hospitals, ranging from 0% to 23.0% of hip fracture patients at different hospital sites. After successfully matching 2,298 (97.6%) patients, echocardiography was associated with significantly increased risks of mortality at 90 days (20.1% vs 16.8%; p = 0.004) and one year (32.9% vs 27.8%; p < 0.001), but not at 30 days (11.4% vs 9.8%; p = 0.084). Patients with echocardiography also had a mean increased delay from presentation to surgery (68.80 hours (SD 44.23) vs 39.69 hours (SD 27.09); p < 0.001), total LOS (19.49 days (SD 25.39) vs 15.94 days (SD 22.48); p < 0.001), and total healthcare costs at one year ($51,714.69 (SD 54,675.28) vs $41,861.47 (SD 50,854.12); p < 0.001).

CONCLUSION

Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality at 90 days and one year but not at 30 days. Preoperative echocardiography is also associated with increased surgical delay, postoperative LOS, and total healthcare costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay. Cite this article: Bone Joint J 2021;103-B(2):271-278.

Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study

BACKGROUND/OBJECTIVES

For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture.

DESIGN

Retrospective chart review.

SETTING

Seven hospitals (three tertiary, four community) within a large health system.

PARTICIPANTS

Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married).

MEASUREMENTS

Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality.

RESULTS

Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE.

CONCLUSION

This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.

Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report

INTRODUCTION

Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients.

PATIENTS AND METHODS

From January 2014 to January 2019, the medical records of all surgically treated elderly patients (>65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure >25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) <50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality.

RESULTS

There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332-8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869-17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047-1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002-185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988-51.413, p=0.040) and LVEF <50% (OR:8.803, 95% CI: 1.115-69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality.

CONCLUSION

Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF <50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.

Preoperative Mild Pericardial Effusion Is Associated With Perioperative Complications In Elderly Patients Following Hip Fracture Surgery

Background: The prevalence and prognostic value of mild pericardial effusion (MPE) has not been examined in patients undergoing non-cardiac surgery. Our study aimed to assess the frequency and prognostic value of MPE in elderly patients undergoing surgery for hip fracture. Methods: This is a single center, and retrospective study including elderly patients who underwent hip fracture surgery. The medical records of all patients, aged ≥65 years with femoral neck, intertrochanteric or subtrochanteric hip fracture undergoing surgery (intramedullary hip screw, sliding compression hip screw, hemiarthroplasty, or total hip arthroplasty) from June 2014 to June 2019 were analyzed. Patients with of multiple trauma and accidents were excluded. The MPE was defined as the presence of <10 mm pericardial effusion. The primary outcomes of the study were perioperative adverse medical events and length of stay in hospital. Results: A total of 462 patients (mean age 75.2 ± 11.7 years, and 53.5% female) were enrolled. MPE was detected in 72 patients (15.6%), and 62 patients (13.4%) experienced perioperative adverse medical events. Patients with MPE were older, had higher prevalence of diabetes, coronary artery disease, and heart failure, and had longer length of stay compared to patients without MPE. Univariate analysis showed a significant association between age, diabetes, coronary artery disease, American Society of Anesthesiologists status, MPE, and perioperative adverse events. After adjustment for age, demographics, and medical history, the presence of MPE remained as significant variable associated with perioperative complications (OR: 2.543, 95% CI: 1.173-3.469, p = 0.003). Conclusion: Our study is the first to demonstrate that the presence of MPE is associated with perioperative adverse events in elderly patients undergoing hip fracture surgery.