Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study

Gigantomastia: Advancing a Preference Score System to Enhance Care Quality and Life Standards

BACKGROUND

This study introduces a new Gigantomastia Preference Score (GPS) to prioritize surgical candidates based on clinical severity and quality of life impact.

METHODS

This retrospective study applied the newly developed GPS to the existing surgery waiting list of 213 patients at our center. The GPS was developed from evidence-based clinical practice indicators and a thorough literature review, selecting nine variables. The GPS was then used to reorder the waiting list, and comparisons were made between the original and reordered lists.

RESULTS

Implementation of the GPS significantly reordered the waiting list. The Spearman's Rank Correlation coefficient between the original and new rankings was 0.5679 (p-value = 1.38e-19), indicating a moderate to strong positive correlation. The Wilcoxon Signed-Rank Test yielded a statistic of 3485.0 (p-value = 8.44e-21), showing significant changes in patient positions. ANOVA results highlighted significant differences in BMI and largest breast weight across priority levels. Chi-Square tests revealed significant associations between priority levels and Trauma and Psychiatry reports.

CONCLUSIONS

The GPS significantly improved the prioritization of patients with gigantomastia by incorporating multiple clinically relevant factors. This led to a more equitable and informed ordering of the surgical waiting list, potentially improving patient outcomes and optimizing healthcare resource allocation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Periprosthetic and peri-implant femoral fractures and timeliness to surgery: A retrospective matched cohort study

Purpose

Periprosthetic (PPFF) and peri-implant femoral fractures (PIFFs) are troublesome complications of prosthetic and implant surgery, the prior being described to have a greater delay to surgery when compared with standard hip fractures. The implications of PPFF delay being disputed in the current literature and those of PIFF have not been investigated. The aim of this study was to determine whether the time from radiological examination to surgery differs between hip fractures and PPFF/PIFF, and the possible consequences of delay and group affiliation on morbidity, mortality, and readmissions.

Methods

One hundred and thirty-six participants were admitted to Danderyd hospital during 2020, cases exposed to PPFF or PIFF (n = 35) and hip fracture controls (n = 101) matched at 1:3 with respect to age and sex. Timestamps from radiology, surgery, and death were retrieved from the Swedish fracture registry, data on adverse events (AEs), and readmissions were collected through retrospective medical record review for 90-days postsurgery.

Results

Linear regression showed that time to surgery differed in case and control cohorts by a mean of 24.8 h, p < 0.001, and AEs were significantly more common in cases, p = 0.046. Unadjusted binary logistic regression indicated a possible relationship between time to surgery increasing the rate of AEs by 1.3% per hour of delay, 95% confidence interval [CI]: (1-1.03).

Conclusion

This study reveals a significant delay in surgery for PPFFs and PIFFs compared with standard hip fractures, leading to higher adverse event rates. While mortality and readmissions did not differ significantly, the delay underscores the need for timely intervention in these complex cases. Further research is needed to address these challenges and improve patient outcomes.

Level of Evidence

III.

Is the Timing of Surgery a Sufficient Predictive Factor for Outcomes in Patients with Proximal Femur Fractures? A Systematic Review

(1) Background: Hip fractures are currently recognized as major public health problems, raising many issues in terms of both patients' quality of life and the cost associated with caring for this type of fracture. Many authors debate whether to operate as soon as possible or to postpone surgery until the patient is stable. The purpose of this review was to review the literature and obtain additional information about the moment of surgery, the time to surgery, length of hospital stay, and how all of these factors influence patient mortality and complications. (2) Methods: The systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO guidelines, using the Google Scholar platform, for articles published between 2015 and 2023. Quality assessment was performed. (3) Results: After applying the inclusion criteria, 20 articles were included in the final list. Those who had surgery within 48 h had lower in-hospital and 30-day mortality rates than those who operated within 24 h. The American Society of Anesthesiologists (ASA) score is an important predictive factor for surgical delay, length of hospital stay (LOS), complications, and mortality. (4) Conclusions: Performing surgery in the first 48 h after admission is beneficial to patients after medical stabilization. Avoidance of delayed surgery will improve postoperative complications, LOS, and mortality.

Risk Factors of Serious Adverse Events for Geriatric Hip Fractures: Is it the Frailty or the Timing?

Objective

Preoperative frailty and surgical waiting times are associated with the occurrence of adverse outcomes in patients with hip fractures. Specifically, we aimed to investigate the influence of frailty status and surgical timing on the risk of serious adverse events during hospitalization.

Methods

This study utilized an observational single cohort design and included patients aged ≥60 years with a primary diagnosis of hip fracture. Frailty was assessed using the chart-derived frailty index (CFI), which was calculated based on demographic and routine laboratory variables. The primary outcome of interest was the occurrence of in-hospital serious adverse events. A multivariate logistic regression model was utilized to examine the risk factors influencing outcomes.

Results

The study included 427 participants, with a mean age of 80.28 ± 8.13 years and 64.2% of whom were female. Patients with high CFI have more comorbidities (P < .001), lower surgical rates (P = .002), and delayed surgical times (P = .033). A total of 239 patients (56.0%) experienced serious adverse events. The high CFI group had a significantly higher occurrence of serious adverse events compared to the low CFI group (73.4% vs 48.5%, P < .001). After adjusting for surgical timing and covariates, the multivariate logistic regression analysis revealed that high frailty significantly increased the risk for serious adverse events (OR = 2.47, 95% CI 1.398-4.412), infection (OR = 1.99, 95% CI 1.146-3.446), acute heart failure (OR = 3.37, 95% CI 1.607-7.045). However, the timing of surgery did not demonstrate any association with these outcomes. In addition, after adjusting for surgical factors, high CFI remains an independent risk factor for these complications.

Conclusions

Frailty serves as a reliable predictor of the probability of encountering severe adverse events while hospitalized for elderly individuals with hip fractures. This method has the potential to pinpoint particular modifiable factors that necessitate intervention, whereas the impact of surgical timing remains uncertain and necessitates additional research.

Delay between admission and surgery as a potential risk factor for postoperative morbidity and mortality in elderly patients with hip fractures: A retrospective study

BACKGROUND

This study aimed to assess the impact of delay between admission and surgery on the postoperative outcomes such as mortality and related complications in elderly patients with acute hip fractures.

METHODS

840 patients aged ≥65 years from January 2009 to September 2015 were included in this retrospective study. According to the interval from admission to surgery, the patients were divided into four groups: group A (surgery within 24 h), group B (surgery within 24 h-48 h), group C (surgery within 48 h-72 h), and group D (surgery later than 72 h). Postoperative complications during hospitalization and mortality at different follow-up time points were compared.

RESULTS

A total of 763 cases were successfully followed up, with an average follow-up time of 30.4 ± 13.1 months. The mean age of the patients was 79.4 ± 6.8 years. The difference in gross postoperative complications among groups was statistically significant in terms of pressure sore (P = 0.02), respiratory complications (P = 0.001), and urological complications (P < 0.001). The multivariate logistic regression analysis identified 3 factors independently associated with the postoperative morbidity, including age (odds ratio [OR] = 1.040), postoperative drainage volume (OR = 1.002) and time from admission to surgery (OR = 1.108). The difference in postoperative mortality among groups was statistically significant at 1 year (P = 0.046) after operation. The multivariate logistic regression analysis identified that age, postoperative drainage volume and time from admission to surgery were independently associated with mortality at 1 year postsurgery.

CONCLUSION

The incidence of postoperative morbidity and mortality in elderly patients with hip fracture is usually the result of multiple factors, surgeons should pay attention to the patient's age, postoperative wound status and surgical delay time, which may significantly affect the outcome of the treatment.

How proximal femur fracture patients aged 65 and older fare in survival and cause of death 5+ years after surgery: A long-term follow-up

Although the incidence of proximal femur fractures (PFFs) is increasing, few detailed reports on associated long-term outcomes and causes of death exist. We aimed to evaluate long-term outcomes and causes of death ≥5 years after surgical treatment of PFFs. This retrospective study included 123 patients (18 males, 105 females) with PFFs treated at our hospital between January 2014 and December 2016. Cases (median age: 90 [range, 65-106] years) comprised 38 femoral neck fractures (FNFs) and 85 intertrochanteric fractures (IFs). Surgical procedures included bipolar head arthroplasty (n = 35), screw fixation (n = 3), and internal fixation with nails (n = 85). The mean post-surgical follow-up time was 58.9 (range, 1-106) months. Surveyed items included survival (1 vs 5 years; sex; age, >90 vs <90 years; IF vs FNF), comorbidities, waiting time after the injury (died vs survived), operative time (proximal femoral nail antirotations [PFNA] vs FNF, died vs Survived), blood loss (PFNA vs FNF; died vs survived), and cause of death (IF vs FNF; <1 vs >1 year). Among all patients, 83.7% had comorbidities (IF, 90.5%; FNF, 81.5%). Among patients who died and survived, 89.1% and 80.5% had comorbidities, respectively. The most common comorbidities were cardiac (n = 22), renal (n = 10), brain (n = 8), and pulmonary (n = 4) diseases. Overall survival (OS) rates at 1 and 5 years were 88.9% and 66.7%, respectively. Male/female OS rates were 88.8%/88.3% and 66.6%/66.6% (P = .89) at 1 and 5 years, respectively. OS rates for the <90/≥90 age groups were 90.1%/76.7% and 75.3%/53.4 (P < .01) at 1 and 5 years, respectively. The 1- and 5-year OS (IF/FNF) rates were 85.7%/88.8% and 60%/81.5%, respectively; patients with IFs had significantly lower OS than those with FNFs at both timepoints (P = .015). There was a marked difference in the operative time between died (43.5 ± 24.0: mean ± S.D.) and survived (60 ± 24.4: mean ± S.D.) patients. The main causes of death were senility (n = 10), aspiration pneumonia (n = 9), bronchopneumonia (n = 6), worsening heart failure (n = 5), acute myocardial infarction (n = 4), and abdominal aortic aneurysm (n = 4). Overall, 30.4% of the cases were related to comorbidities and related causes (e.g., hypertension-related ruptured large abdominal aneurysm). Managing comorbidities may improve long-term postoperative outcomes of PFF treatment.

Waiting more than 24 hours for hip fracture surgery is associated with increased risk of adverse outcomes for sicker patients: a nationwide cohort study of 63,998 patients using the Swedish Hip Fracture Register

BACKGROUND AND PURPOSE

Waiting time to surgery is a modifiable risk factor in hip fracture surgery. However, there is no consensus regarding the acceptable duration of waiting time. We used the Swedish Hip Fracture Register RIKSHÖFT and 3 administrative registers to explore the association between time to surgery and adverse outcomes after discharge.

PATIENTS AND METHODS

63,998 patients ≥ 65 years, admitted to a hospital between January 1, 2012, and August 31, 2017 were included. Time to surgery was divided into < 12, 12-24, and > 24 hours. Diagnoses investigated were atrial fibrillation/flutter (AF), congestive heart failure (CHF), pneumonia, and "acute ischemia" (a combination of stroke/intracranial bleeding, myocardial infarction, and acute kidney injury). Crude and adjusted survival analyses were performed. Time spent in hospital following the initial hospitalization was described for the 3 groups.

RESULTS

Waiting > 24 hours was associated with an increased risk of AF (HR 1.4, 95%CI 1.2-1.6), CHF (HR 1.3, CI 1.1-1.4) and "acute ischemia" (HR 1.2, CI 1.01-1.3). However, stratifying for ASA grade revealed that these associations were present only in patients with ASA 3-4. There was no association between waiting time and pneumonia after the initial hospitalization (HR 1.1, CI 0.97-1.2), but one was found with pneumonia during hospital stay OR 1.2 (CI 1.1-1.4). Time in hospital after the initial hospitalization was similar over the waiting time groups.

CONCLUSION

The associations between waiting > 24 hours for hip fracture surgery and AF, CHF, and acute ischemia suggest that shorter waiting time may reduce adverse outcomes for the sicker patients.

[What risk factors are associated with mortality and readmissions in osteoporotic hip fracture?]

INTRODUCTION AND OBJECTIVE

Hip fracture in the elderly leads to long hospital stays, readmissions and mortality.

OBJECTIVE

To identify risk factors associated with mortality and readmissions in elderly with hip fracture.

PATIENTS AND METHODS

Prospective observational study in people over 65years with hip fracture between October-2017 and November-2018, followed for 12months (128 patients).

STATISTICAL ANALYSIS

SPSS vs27.0.

RESULTS

6 (4.7%) patients were readmitted at 1 month; at year 24 (19.4%); 55 (44.4%) consulted for emergencies; 4 (3.1%) died during admission, and 26 (20.3%) in 12months; hospital stay 6.5 (SD: 4.80) days. Those with a previous Barthel less than 85 (6 [8.5%] vs 0 [0%]; P=.037) and less EuroQol5D (6 [10.0] vs 0 [0%]; P=.011) were readmitted more at one month. Those taking anticoagulants (OR: 3.33 (1.13-9.81); P=.003) and those with high surgical risk (18 [23.4%] vs 1 [5.6%]) were readmitted more after one year; P=.038). There was higher intra-episode mortality with renal failure (OR: 34.2 [3.25-359.93]; P=.003) and decompensated heart failure (OR: 23.8 [2.76-205.25]; P=.015). Higher mortality at one year in those older than 85years (OR: 4.3 [1.48-12.49]; P=.007); in those taking benzodiazepines (OR: 2.86 [1.06-7.73]; P=.038); if Barthel was less than 85 (OR: 2.96 [1.1-7.99]; P=.027) and if EuroQol5D was low (0.249 vs 0.547; P=.025). Those operated after 72h (24 [57.1%] vs. 29 [38.2%]; P=.047) consulted more for the emergency department.

CONCLUSIONS

Renal failure and cardiac decompensation increased intra-episode mortality. Older age, benzodiazepines, and previous low functionality and low EuroQol5D increased mortality at one year. They were readmitted more if higher surgical risk, previously anticoagulated and worse quality of life and functionality.

Incidence and Risk Factors for Surgical Site Infection after Femoral Neck Fracture Surgery: An Observational Cohort Study of 2218 Patients

Background

Surgical site infection (SSI) was a formidable challenge for surgical management of femoral neck fractures; however, there was a lack of studies with comprehensive variables. We conducted this study to investigate the incidence and risk factors of SSI in elderly patients with femoral neck fractures.

Methods

This was a retrospective study of patients who presented with femoral neck fractures and underwent surgery in our institution between January 2016 and April 2020. All data were collected from a previously validated database. Patients were divided into SSI and non-SSI groups. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for SSI.

Results

A total of 2218 patients with femoral neck fractures were enrolled in the study, of whom 22 (1%) developed SSI, including 15 (0.7%) superficial and 7 (0.3%) deep SSIs. After multivariable adjustment for confounding factors, patients with and without SSI significantly differ in terms of gender, prolonged time to surgery, CHE < 5 U/L, and injury mechanism.

Conclusions

Our results were helpful for stratification of SSI risk and improved management of hip fracture. Clinicians should be alert to patients with these factors and improve modifiable factors such as preoperative waiting time.

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use

Introduction

Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures.

Materials and Methods

This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups.

Results

Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging.

Discussion

Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ.

Conclusion

Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Comparação epidemiológica entre as fraturas de fêmur proximal atendidas em um hospital secundário e um terciário

Objetivo: comparar a ocorrência de fraturas de fêmur proximal atendidas em um hospital secundário e em um terciário.Método: a amostra deste estudo foi composta por todos os pacientes que apresentaram fratura de fêmur proximal atendidos em dois serviços hospitalares, no período de 2015 a 2017, sendo realizada a avaliação dos prontuários.Resultados: embora um maior número de cirurgias tenha sido realizado no hospital terciário, os pacientes atendidos no hospital secundário apresentaram maior número de complicações, provavelmente em decorrência de mais tempo de espera pelo procedimento, incluindo as cirurgias que precisaram ser remarcadas. É provável, também, que esse fato tenha implicado em maior tempo de internação e necessidade de encaminhamento para UTI no período pós-operatório imediato, fenômenos também observados no hospital secundário.Conclusão: estes resultados chamam atenção para a necessidade de reformulação dos protocolos de atendimento a pacientes com fratura proximal de fêmur, visando sanar os problemas aqui apresentados.

Comparação epidemiológica entre as fraturas de fêmur proximal atendidas em um hospital secundário e um terciário

Objetivo: comparar a ocorrência de fraturas de fêmur proximal atendidas em um hospital secundário e em um terciário.Método: a amostra deste estudo foi composta por todos os pacientes que apresentaram fratura de fêmur proximal atendidos em dois serviços hospitalares, no período de 2015 a 2017, sendo realizada a avaliação dos prontuários.Resultados: embora um maior número de cirurgias tenha sido realizado no hospital terciário, os pacientes atendidos no hospital secundário apresentaram maior número de complicações, provavelmente em decorrência de mais tempo de espera pelo procedimento, incluindo as cirurgias que precisaram ser remarcadas. É provável, também, que esse fato tenha implicado em maior tempo de internação e necessidade de encaminhamento para UTI no período pós-operatório imediato, fenômenos também observados no hospital secundário.Conclusão: estes resultados chamam atenção para a necessidade de reformulação dos protocolos de atendimento a pacientes com fratura proximal de fêmur, visando sanar os problemas aqui apresentados.

Waiting time for hip fracture surgery: hospital variation, causes, and effects on postoperative mortality : data on 37,708 operations reported to the Norwegian Hip fracture Register from 2014 to 2018

Aims

This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time.

Methods

Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated.

Results

Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively.

Conclusion

There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates.

Cite this article: Bone Jt Open 2021;2(9):710–720.

Incidence and risk factors of surgical site infection after intertrochanteric fracture surgery: A prospective cohort study

Surgical site infection (SSI) is a challenging complication after intertrochanteric fracture surgery but without a large-sample size study to investigate the incidence and risk factors of it. The present study was to investigate the incidence and risk factors of SSI after intertrochanteric fracture surgery. A total of 1941 patients underwent intertrochanteric fracture surgery between October 2014 and December 2018 were included. Demographic data, surgical variables, and preoperative laboratory indexes were obtained from a prospective database and reviewed by hospital records. The optimum cut-off value for quantitative data was detected by receiver operating characteristic analysis. The univariate analysis and multivariable analysis were conducted to analyse the risk factors. In total, 25 patients (1.3%) developed SSI, including 22(1.1%) superficial infection and 3(0.2%) deep infection. After adjustment of multiple variables, gender (odds ratio[OR] 2.64, P = .024), time to surgery>4 days (OR 2.41, P = .046), implant (intramedullary or extramedullary devices) (OR 2.96, P = .036), ALB<35 g/L (OR 2.88, P = .031) remained significant factors. In conclusion, the incidence of SSI after intertrochanteric fractures surgery was 1.3%, with 1.1% for superficial and 0.2% for deep infection. Gender, time to surgery>4 days, the implant (intramedullary or extramedullary devices), and ALB<35 g/L were independent risk factors for the rate of SSI.

The effects of preoperative oral carbohydrate drinks on energy intake and postoperative complications after hip fracture surgery: A pilot study

BACKGROUND

Hip fractures represent a major clinical burden for patients. Studies on the effect of preoperative carbohydrate loading before different surgical interventions have shown promising results but have not been tested in patients with hip fracture.

AIM

This study aimed to investigate the effects of preoperative oral carbohydrate drinks on the postoperative energy intake and incidence of complications after hip fracture surgery.

METHOD

This was a pilot study using a quasi-experimental design with a control group and an intervention group.

RESULT

The number of patients affected by more than one complication was higher in the control group than in the intervention group. According to the logistic regression analysis, the risk of any postoperative complication was reduced by approximately 50% OR (95% CI) 0.508 (0.23-1.10) in patients in the IG compared to those in the CG (p = 0.085).

CONCLUSION

The result of this pilot study indicated that using preoperative carbohydrate drinks can decrease the number of postoperative complications in patients with a hip fracture. Furthermore, the number of patients who meet their energy needs during the first three days postoperatively might increase. More research is needed to confirm the effect of preoperative carbohydrate drinks.

Prevalence of Swallowing and Eating Difficulties in an Elderly Postoperative Hip Fracture Population-A Multi-Center-Based Pilot Study

Elderly patients operated for hip fracture are characterized by high age and high degree of comorbidity and need of care, factors previously found to be associated with swallowing and eating difficulties. The aim of this study was to investigate the prevalence of swallowing and eating difficulties in an elderly postoperative hip fracture population and to identify factors associated with swallowing and eating difficulties. A cross-sectional multi-center pilot study was performed, including patients ≥65 years, operated for hip fracture, and able to participate in a swallowing and eating assessment. A clinical assessment was conducted using Danish versions of the standardized tools Volume-Viscosity Swallow Test and Minimal Eating Observation Form-version II. Demographic data and clinical characteristics were examined. A total of 78 patients (mean age 81.4 years (SD 7.8), 30.8% male) were included. Swallowing and eating difficulties were present in 60 patients (77%). Swallowing and eating difficulties were significantly associated with living in a nursing home before hospital admission (p = 0.014), low habitual New Mobility Score (p = 0.018), and absence of cardiac comorbidity (p = 0.023). The results underline the importance of focusing on swallowing and eating difficulties in elderly patients operated for hip fracture to ensure effectivity and safety and optimize the prognosis for the patient.

No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study

RATIONALE

Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients.

METHODS

160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups.

RESULTS

Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups.

CONCLUSION

Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.

The identification of adverse events in hip fracture patients using the Global Trigger Tool: A prospective observational cohort study

INTRODUCTION

Hip fracture is common in the elderly and is associated with high comorbidity, mortality and complication rates. There has been an increase in the investigation of healthcare-related adverse events (AEs) in some patient groups but there is limited knowledge about hip fracture patients. The aim was to explore the incidence, preventability and nature of AEs in hip fracture patients.

METHODS

One hundred and sixty three hip fracture patients participated. A record review was conducted of prospectively collected data using Global Trigger Tool methodology to identify AEs up to 90 days after surgery.

RESULTS

Sixty two (38.0%) of 163 patients had at least one AE (range 1-7). One hundred and two AEs were identified and 62 (60.8%) were deemed preventable. Healthcare-associated infections e.g. pneumonia, urinary tract infections and pressure ulcers were common. AEs were more common in older patients and those with pre-existing health conditions. Fifty eight (56.9%) AEs caused temporary harm and 4 (3.9%) contributed to patient death.

CONCLUSION

AEs are common in hip fracture patients and most are preventable. If the focus is on improving healthcare for these patients, we should be concentrating our efforts on reducing the number of these preventable AEs, with a particular emphasis on improving the care of older patients with pre-existing health conditions.

Intravenous Iron May Improve Outcomes in Elderly Patients With Operative Hip Fractures

Introduction:

Hip fractures are common injuries with high morbidity and mortality rates. These patients often become anemic and require allogenic blood transfusion. Transfusions are costly with potential complications. This study examines the effect of intravenous (IV) iron on patients with hip fractures, undergoing surgery within 48 hours, and being treated with a highly restrictive transfusion protocol.

Materials and Methods:

A retrospective chart review performed on patients admitted to a level 1 tertiary care center with fractures of the proximal femur from December 2015 to December 2017 included 239 patients. Patients who received 300 mg of IV iron when their hemoglobin fell below 11 g/dL were compared to a control group of patients who never received IV iron with respect to transfusion rate, 30-day readmission rate, nosocomial infections, length of stay, and hospital costs.

Results:

There were no significant differences in transfusion rates (P = .118). There was a trend toward decreased length of stay (P = .063) and 30-day readmission rates (P = .051) with a 59% reduction in the odds of 30-day readmission when a patient received IV iron. There were no differences in nosocomial infection rates or cost of hospitalization.

Discussion:

This study presents a compelling argument for further research regarding the use of IV iron in elderly patients undergoing surgery for a hip fracture. Length of stay and transfusion rates are increased in patients with intertrochanteric fractures and undergoing intramedullary nailing. A higher number of these patients in the IV iron group may have falsely increased these rates. A prospective, randomized, controlled trial is needed to assess the true effects of perioperative IV iron.

Conclusions:

This study showed no significant benefit to IV iron use in elderly patients undergoing surgical treatment of hip fracture. The decrease in 30-day readmission rate should be further examined with a prospective randomized controlled trial.

Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable.

PATIENTS AND METHODS

This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival.

RESULTS

The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI>30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score>3-4) (p<0.004) and/or cognitive disorders (p<0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort.

CONCLUSION

Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA>3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death.

LEVEL OF EVIDENCE

IV, Retrospective study.

The In-Hospital Length of Stay after Hip Fracture in Octogenarians: Do Delirium and Dementia Shape a New Care Process?

BACKGROUND

Hip fracture is a major health problem and a patient's biological age, comorbidity, and cognitive vulnerability have an impact on its related outcomes. Length of stay (LOS) for these highly vulnerable patients is rather long and the possible causes have not been clearly identified yet.

OBJECTIVE

We aimed to assess the main clinical factors associated with protracted LOS, focusing on delirium with or without dementia in older age hip fractured patients.

METHODS

218 subjects (mean age 86.70±6.18 years), admitted to the Orthogeriatric Unit of the Ospedale Policlinico San Martino (Italy), were recruited. All patients received physical and comprehensive geriatric assessment. Days to surgery, days from surgery to rehabilitation, and LOS were recorded. In-hospital and three months' mortality were reported.

RESULTS

Prevalent delirium at hospital admission was of 3.1%. 35% of patients developed incident delirium. 56.4% were affected by dementia of Alzheimer-type. In addition, 52% of patients developed delirium superimposed to dementia. Mean LOS was 13.5±4.99 days. Namely, delirium, time to surgery, and complication rate disproportionally affected LOS. The analysis with 3 months mortality, based on cognitive vulnerability profiles, showed how delirium mainly affect short-term mortality in patients with dementia.

CONCLUSION

Our exploratory study originally pointed out the high incidence of delirium superimposed to dementia in orthogeriatric wards and how delirium turns to be a moderator of LOS. The results meet the need for additional research by virtue of a deeper understanding of the impact of delirium and dementia on orthogeriatric clinical management and outcomes.

Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs.

PURPOSE

To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs.

METHODS

This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission.

RESULTS

The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs.

CONCLUSIONS

Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.

Delay in surgery, risk of hospital-treated infections and the prognostic impact of comorbidity in hip fracture patients. A Danish nationwide cohort study, 2005-2016

Purpose: We examined the association between delay in surgery and hospital-treated infections in hip fracture patients with and without known comorbidities.

Patients and methods: All hip fracture patients aged ≥65 years registered in the Danish Multidisciplinary Hip Fracture Registry from 2005 to 2016 were included (n=72,520). Delay in surgery was defined as the time in hours from admission to surgery and was divided into 3 groups (12, 24 and 48 hrs). The outcomes were hospital-treated pneumonia, urinary tract infection and reoperation due to infection 0–30 days after surgery. As a measure of comorbidity, we used the Charlson Comorbidity Index (CCI): none (no registered comorbidities prior to the fracture), medium (1–2 points) and high (≥3 points).

Results: Overall, there was an association between a delay of 12 hrs and pneumonia. A delay of 12 hrs was associated with an increased risk of pneumonia in patients with no comorbidities (adjusted hazard ratio (HR) 1.20, confidence interval (CI) 1.03–1.40) and a delay of 24 hrs was associated with an increased risk of pneumonia in patients with a medium level of comorbidity (HR 1.12, CI (1.02–1.23)). Overall, delay was associated with reoperation due to infection, particularly among patients with comorbidities, although the confidence intervals of some of the estimates were wide. A delay of 48 hrs was associated with an increased risk of reoperation due to infection in patients with a high level of comorbidity (HR 2.36, CI 1.19–4.69).

Conclusion: Delay in surgery was associated with an increased risk of hospital-treated pneumonia and reoperations due to infection within 30 days of surgery. The number of postoperative hospital-treated infections within 30 days may be reduced by continuously targeting pre-, per- and postoperative optimization not only for patients with high level of comorbidity but also for hip fracture patients without known comorbidities prior to surgery.

Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis

We aimed to assess the impact of timing of surgery in elderly patients with acute hip fracture on morbidity and mortality. We systematically searched MEDLINE, the Cochrane Library, Embase, PubMed, and trial registries from 01/1997 to 05/2017, as well as reference lists of relevant reviews, archives of orthopaedic conferences, and contacted experts. Eligible studies had to be randomised controlled trials (RCTs) or prospective cohort studies, including patients 60 years or older with acute hip fracture. Two authors independently assessed study eligibility, abstracted data, and critically appraised study quality. We conducted meta-analyses using the generic inverse variance model. We included 28 prospective observational studies reporting data of 31,242 patients. Patients operated on within 48 hours had a 20% lower risk of dying within 12 months (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.66-0.97). No statistical significant different mortality risk was observed when comparing patients operated on within or after 24 hours (RR 0.82, 95% CI 0.67-1.01). Adjusted data demonstrated fewer complications (8% vs. 17%) in patients who had early surgery, and increasing risk for pressure ulcers with increased time of delay in another study. Early hip surgery within 48 hours was associated with lower mortality risk and fewer perioperative complications.

Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years

Background

Emergency surgery is unplanned by definition and patients are scheduled for surgery with minimal preparation. Some patients who have sustained emergency orthopaedic trauma or other conditions must be operated on immediately or within a few hours, while others can wait until the hospital’s resources permit and/or the patients’ health status has been optimised as needed. This may affect the prioritisation procedures for both emergency and elective surgery and might result in waiting lists, not only for planned procedures but also for emergencies.

Method

The main purpose of this retrospective, observational, single-centre study was to evaluate and describe for the number and reasons of delays, as well as waiting times in emergency orthopaedic surgery using data derived from the hospital’s records and registers. All the emergency patients scheduled for emergency surgery whose procedures were rescheduled and delayed between 1 January 2007 and 31 December 2013 were studied.

Result

We found that 24% (8474) of the 36,017 patients scheduled for emergency surgeries were delayed and rescheduled at least once, some several times. Eighty per cent of these delays were due to organisational causes. Twenty-one per cent of all the delayed patients had surgery within 24 h, whilst 41% waited for more than 24 h, up to 3 days.

Conclusion

A large number of the clinic’s emergency orthopaedic procedures were rescheduled and delayed and the majority of the delays were related to organisational reasons. The results can be interpreted in two ways; first, organisational reasons are avoidable and the potential for improvement is great and, secondly and most importantly, the delays might negatively affect patient outcomes.