Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients

Impact of sarcopenia in elderly patients undergoing elective total hip arthroplasty on postoperative outcomes: a propensity score-matched study

OBJECTIVE

Frailty poses a crucial risk for postoperative complications in the elderly, with sarcopenia being a key component. The impact of sarcopenia on postoperative outcomes after total hip arthroplasty (THA) is still unclear. This study investigated the potential link between sarcopenia and postoperative outcomes among elderly THA patients.

METHODS

Totally 198 older patients were enrolled in this study. Sarcopenia in this group was determined by assessing the skeletal muscle index, which was measured using computed tomography at the 12th thoracic vertebra and analyzed semi-automatically with MATLAB R2020a. Propensity score matching (PSM) was employed to evaluate postoperative complications of grade II and above (POCIIs).

RESULTS

The variables balanced using PSM contained age, sex and comorbidities including hypertension, diabetes, hyperlipidemia and COPD. Before PSM, sarcopenic patients with reduced BMI (24.02 ± 0.24 vs. 27.11 ± 0.66, P < 0.001) showed higher POCIIs rates (48.31% vs. 15%, P = 0.009) and more walking-assisted discharge instances (85.96% vs. 60%, P = 0.017) compared with non-sarcopenia patients. After PSM, this group maintained reduced BMI (23.47 ± 0.85 vs. 27.11 ± 0.66, P = 0.002), with increased POCIIs rates (54.41% vs. 15%, P = 0.002) and heightened reliance on walking assistance at discharge (86.96% vs. 60%, P = 0.008).

CONCLUSION

Sarcopenia patients exhibited a higher incidence of POCIIs and poorer physical function at discharge. Sarcopenia could serve as a valuable prognostic indicator for elderly patients undergoing elective THA.

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

Preoperative hemoglobin levels and mortality outcomes after hip fracture patients

PURPOSE

Hip fracture surgery is associated with a risk of morbidity and mortality, with admission hemoglobin levels being a significant predictor of mortality risk. The aim of this study is to evaluate the relationship between the preoperative hemoglobin (Hb) levels and mortality in patients who underwent hip fracture surgeries, with the goal of enhancing prognosis prediction and reducing complications within this patient subset. In addition, to assess the characteristics of patients at a higher risk of postoperative mortality.

METHODS

This retrospective study was conducted at Jordan University Hospital, a single tertiary care and educational center. It included patients with hip fractures who underwent surgical repair at the Department of Orthopedic Surgery and were recruited between December 2019 and February 2022. We examined the relationships between preoperative hemoglobin status and variables such as age at admission, gender, fracture type, surgery type, comorbidities, duration of hospital stay, intensive care unit (ICU) admission, and survival outcomes.

RESULTS

We included 626 patients; the mean age was 76.27 ± 9.57 years. 3-month and 6-month mortality rates were 11.2% and 14.1%, respectively. The highest mortality was observed in patients aged over 80 years (n = 53/245, 21.6%), and in male patients (n = 53/300, 17.7%). The Hb level upon admission was lower in individuals who died within 6 months compared to those who survived (10.97 ± 2.02 vs. 11.99 ± 2.39, p < 0.001). In multivariate analysis, the independent factors that were statistically significant in the model included gender (OR = 1.867; 95% CI 1.122-3.107, p = 0.016), age (OR = 1.060; 95% CI 1.029-1.092; p < 0.001), hemoglobin level upon admission (OR = 0.827; 95% CI 0.721-0.949; p = 0.007), history of renal disease (OR = 1.958; 95% CI 1.014-3.784; p = 0.045), length of hospital stay (OR = 1.080; 95% CI 1.036-1.126; p < 0.001), and ICU admission (OR = 1.848; 95% CI 1.049-3.257; p = 0.034).

CONCLUSION

Our study illustrates that low hemoglobin levels, history of renal disease, along with male gender, advanced age, extended hospital stays, and ICU admission were significantly associated with 6-month mortality. Future investigations should consider assessing varying degrees of anemia based on hemoglobin concentrations to provide a more comprehensive understanding of anemia's impact on mortality. This study investigated the relationship between preoperative hemoglobin levels, patient characteristics, and mortality in patients who underwent hip fracture surgeries. The results showed that lower hemoglobin levels, history of renal disease, male gender, advanced age, extended hospital stays, and ICU admission were significant predictors for mortality.

Risk Factors and Outcomes of Extended Length of Stay in Older Adults with Intertrochanteric Fracture Surgery: A Retrospective Cohort Study of 2132 Patients

We aimed to identify the risk factors associated with an extended length of hospital stay (eLOS) in older hip-fracture patients and to explore the relationships between eLOS and mortality and functional outcomes. In this retrospective analysis of surgically treated intertrochanteric fracture (IF) patients, all variables were obtained and compared between the eLOS group and the normal LOS group. All participants were followed-up for a minimum of two years and the relation between the eLOS and all-cause mortality and functional outcomes were compared. After adjustment for potential confounders, we identified that patients with high modified Elixhauser's Comorbidity Measure (mECM) had the highest likelihood of eLOS, followed by obesity, admission in winter, living in urban, pulmonary complications, admission in autumn, and time from injury to surgery. In addition, our results showed no significant difference in the mortality and functional outcomes between the two groups during follow-up. By identifying these risk factors in the Chinese geriatric population, it may be possible to risk-stratify IF patients and subsequently streamline inpatient resource utilization. However, the differences between health care systems must be taken into consideration. Future studies are needed to preemptively target the modifiable risk factors to demonstrate benefits in diminishing eLOS.

COVID-19 Elderly Patients Treated for Proximal Femoral Fractures during the Second Wave of Pandemic in Italy and Iran: A Comparison between Two Countries

Background and objevtive: The worldwide spread of SARS-CoV-2 has affected the various regions of the world differently. Italy and Iran have experienced a different adaptation to coexistence with the pandemic. Above all, fractures of the femur represent a large part of the necessary care for elderly patients. The aim of this study was to compare the treatment in Italy and Iran of COVID-19-positive patients suffering from proximal femur fractures in terms of characteristics, comorbidities, outcomes and complications. Materials and Methods: Medical records of COVID-19-positive patients with proximal femoral fractures treated at IRCCS Istituto Ortopedico Galeazzi in Milan (Italy) and at Salamat Farda and Parsa hospitals in the province of Tehran (Iran), in the time frame from 1 October 2020 to 16 January 2021, were analyzed and compared. Results: Records from 37 Italian patients and 33 Iranian patients were analyzed. The Italian group (mean age: 83.89 ± 1.60 years) was statistically older than the Iranian group (mean age: 75.18 ± 1.62 years) (p value = 0.0003). The mean number of transfusions for each patient in Italy was higher than the Iranian mean number (p value = 0.0062). The length of hospital stay in Italy was longer than in Iran (p value < 0.0001). Furthermore, laboratory values were different in the post-operative value of WBC and admission and post-operative values of CRP. Conclusions: The present study shows that differences were found between COVID-19-positive patients with proximal femoral fractures in these two countries. Further studies are required to validate these results and to better explain the reasons behind these differences.

Age and clinical outcomes after hip fracture surgery: do octogenarian, nonagenarian and centenarian classifications matter?

BACKGROUND

older patients with hip fractures are arbitrarily classified as octogenarians, nonagenarians and centenarians. We have designed this study to quantify in-hospital mortality and complications among each of these groups. We hypothesised that the associations between age and in-hospital mortality and complications are continuously increasing, and that these risks increase rapidly when patients reach a certain age.

METHODS

this research is a retrospective cohort study using nationwide database between 2010 and 2018. Patients undergoing hip fracture surgery, and aged 60 or older, were included. The associations between patient age, in-hospital mortality and complications were visualised using the restricted cubic spline models, and were analysed employing multivariable regression models. Then, octogenarians, nonagenarians and centenarians were compared.

RESULTS

among a total of 565,950 patients, 48.7% (n = 275,775) were octogenarians, 23.0% (n = 129,937) were nonagenarians and 0.7% (n = 4,093) were centenarians. The models presented three types of association between age, in-hospital mortality and complications: (i) a continuous increase (mortality and respiratory complications); (ii) a mild increase followed by a steep rise (intensive care unit admission, heart failure, renal failure and surgical site hematoma) and (iii) a steep increase followed by a limited change (coronary heart disease, stroke and pulmonary embolisms).

CONCLUSION

we identified three types of association between age and clinical outcomes. Patients aged 85-90 may constitute the upper threshold for age categorisations, because the risk of in-hospital complications changed dramatically at that stage. This information can improve clinical awareness of various complications and support collective decision-making.

Risk Factors for Mortality After Uncemented Bipolar Hemiarthroplasty for Geriatric Displaced Femoral Neck Fracture

Uncemented bipolar hemiarthroplasty (UBHA) has been widely used to treat geriatric displaced femoral neck fracture (GDFNF), which results in a high 30-day mortality rate among the elderly. To date, few studies have focused on the risk factors for mortality after UBHA for GDFNF. In this retrospective study, elderly patients (age ≥70 years) who underwent UBHA for GDFNF were studied in order to provide helpful insight into the risk factors for mortality postoperatively. This retrospective study enrolled 835 elderly patients who underwent UBHA for GDFNF from January 2010 to December 2017. The Kaplan-Meier method and Cox regression analysis were used to identify significant risk factors predicting mortality after UBHA for GDFNF. Univariate analysis showed that underweight (body mass index <18.5 kg/m²), smoking, alcohol use, hypertension, chronic kidney disease, hypoproteinemia, low activities of daily living (ADL) score (0 to 2), and postoperative delirium were identified as the potential risk factors responsible for mortality after UBHA for GDFNF. Multivariate analysis suggested that underweight, hypoproteinemia, low ADL score, and postoperative delirium were significant risk factors predicting mortality after UBHA for GDFNF. Postoperative delirium was the most robust risk factor for mortality after UBHA for GDFNF. Underweight, hypoproteinemia, and low ADL score were also closely associated with mortality after UBHA for GDFNF. [Orthopedics. 2021;44(4):e570-e576.].

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures

Background: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery. Methods: In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient’s ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO’s BMI groups. Results: The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5–30 kg/m²) tended to achieve the best results, as represented by a higher Barthel index score and the patient’s ability to walk on crutches. Conclusion: Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.

Survival and functionality in the elderly over 85 years of age with hip fracture

BACKGROUND

There is a tendency for the aging population to fracture their hips. Our aim was to compare survival and functionality at one year, among elderly and very elderly patients with hip fracture.

MATERIAL AND METHODS

A prospective cohort of patients included in the Institutional Registry of Elderly Patients with Hip Fracture between 2014 and 2017. We classified patients as elderly patients (EP) <65 and <85 years and very elderly patients (VEP) ≥85 years.

RESULTS

We included 952 patients, 43% were EP and 57% were VEP. The proportion of women was 84% and 86% (P=.33) and with 2 or more points in the Charlson comorbidities index (28 and 31%, P= .36), respectively. The VEP were more dependent according to the Barthel score (34% and 62%, P<.01) and frailer according to the Edmonton score (30% and 61%, P<.01). One-year survival was 91% (95% CI 86-93) in the EP and 76% (95% CI 70-89) in the VEP. In-hospital complications were more frequent in the VEP 12% (7% in the EP, P<.01). Age is an independent risk factor for one-year survival (HR 2.11; 95% CI 1.36-3.29, P<.001).

CONCLUSIONS

Age is a risk factor for the VEP group survival despite fragility and comorbidities. Because of their vulnerability, an appropriate care plan should be considered for VEP.

Medical and economic consequences of perioperative complications in older hip fracture patients

Patients suffering from complications during inpatient treatment after hip fracture surgery are associated with a worse mid-term outcome. While surgically treatable complications only delay the healing process, internal complications seem to worsen the outcome in the long run. All complications come with significant increased costs during the hospital stay.

PURPOSE

Due to the demographic changes, the importance of hip fractures is still increasing nowadays. Not only surgical but also medical complications represent a major challenge in the treatment of those patients. Nevertheless, only few is known about the functional, medical, and economic consequences of complications.

METHODS

A total of 402 hip fracture patients ≥ 60 years were observed prospectively at a German university hospital. Complications were assessed during the inpatient stay and classified by Clavien and Dindo. Afterwards their influence on acute care costs was examined as well as their influence on the mortality, health-related quality of life (HRQL) (EQ5D), functional capacities (Barthel index), and mobility (Tinetti score) in the follow-up periods of 6 and 12 months.

RESULTS

Complications that required surgical revision/treatment (type III) were associated with an increased 6 months' mortality, while type II and IV complications did not influence mortality after 6 and 12 months. Six months after surgery, HRQL, Barthel score, and Tinetti score were reduced in patients suffering from all different types of complications. After 12 months however, HRQL, Barthel score, and Tinetti score following type II and IV complications remained reduced, while the scores improved in patients suffering from type III complication. All types of complications led to significantly increased acute care costs.

CONCLUSIONS

The results of the present study emphasize the crucial role of perioperative complications in older patients with hip fractures. Therefore, special attention has to be given to the prevention of those complications, e.g., with orthogeriatric treatment models, which have been shown to be effective in the reduction of complications.

Protocol for a multicentre retrospective observational cohort study in Denmark: association between the intraoperative peripheral perfusion index and postoperative morbidity and mortality in acute non-cardiac surgical patients

INTRODUCTION

Perioperative haemodynamic instability is associated with postoperative morbidity and mortality. Macrocirculatory parameters, such as arterial blood pressure and cardiac output are associated with poor outcome but may be uncoupled from the microcirculation during sepsis and hypovolaemia and may not be optimal resuscitation parameters. The peripheral perfusion index (PPI) is derived from the pulse oximetry signal. Reduced peripheral perfusion is associated with morbidity in critically ill patients and in patients following acute surgery. We hypothesise that a low intraoperative PPI is independently associated with postoperative complications and mortality.

METHODS AND ANALYSIS

We plan to conduct a retrospective cohort study in approximately 2300 patients, who underwent acute non-cardiac surgery (1 November 2017 to 31 October 2018) at two Danish University Hospitals. Data will be collected from patient records including patient demographics, comorbidity and intraoperative haemodynamic values with PPI as the primary exposure variable, and postoperative complications and mortality within 30 and 90 days as outcome variables. We primarily assess association between PPI and outcome in multivariate regression models. Second, the predictive value of PPI for outcome, using area under the receiver operating characteristics curve is assessed.

ETHICS AND DISSEMINATION

Data will be reported according to the Strengthening the Reporting of Observational Studies in Epidemiology and results published in a peer-reviewed journal. The study is approved by the regional research ethics committee, storage and management of data has been approved by the Regional Data Protection Agency, and access to medical records is approved by the hospital board of directors (ClinicalTrials.gov registration no: NCT03757442).

A predictive model for increased hospital length of stay following geriatric hip fracture

BACKGROUND

The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator.

MATERIALS AND METHODS

This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS.

RESULTS

614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855).

CONCLUSIONS

This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

Predictors of long-term survival after hip fractures?-5-year results of a prospective study in Germany

The incidence of hip fractures is increasing due to demographic transition. Data on long-term survival and influencing factors are sparse. Our prospective observational study with 395 patients shows a survival of 38% after 5 years. Significant risk factors were male gender, higher age, lower Barthel Index, lower Charlson Comorbidity Score, lower Mini-Mental State Examination, and delirium during hospitalization.

PURPOSE

The incidence of hip fractures is increasing due to demographic transition. Until now, they are associated with poor results and high mortality rates. Data on long-term survival and influencing factors are sparse. Therefore, a prospective observational study was conducted.

METHODS

Patients ≥ 60 years with hip fracture were included in this prospective study between 2009 and 2011. Demographic parameters, as well as ASA Score, pre-fracture Barthel Index and EQ-5D, Mini-Mental State Examination, Charlson Comorbidity Score, fracture type, type of surgical treatment, place of discharge, and arising complications were registered. Outcome parameter was survival during a 5-year follow-up period.

RESULTS

A total of 539 patients attended to our emergency room during the period of recruitment. The recruitment rate was 75%. A total of 402 patients were included; 7 were lost to follow-up, and 152 (38%) survived the study period. The mortality was more than 25% in the first year after fracture. Subsequently, it was between 7 and 9% per year. In the multivariate analysis, significant risk factors for dying were male gender (p = 0.002), higher age (p < 0.001), lower Charlson Comorbidity Score (p = 0.033), lower Barthel Index (p = 0.024), lower Mini-Mental State Examination (p = 0.002), and occurrence of delirium during hospitalization (p = 0.008).

CONCLUSION

Our results confirm poor results of geriatric patients after hip fracture. While early results might be influenced by optimal fracture care, long-term results seem to be determined by not changeable patient factors. Nevertheless, more than one third of surviving patients after 5 years justify the elaborate treatment algorithms for these fragile patients.

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Functionality, comorbidity, complication & surgery of hip fracture in older adults by age distribution

BACKGROUND

Hip fractures may be the greatest complication secondary to osteoporotic disorder. The objective of this study was to determine the influence of age distribution in the functionality, comorbidity, complications and surgical features of older adults with hip fractures.

METHODS

A prospective cohort study was carried out from 2013 to 2014. A sample of 557 adults over 75 years old with osteoporotic hip fractures was recruited from the Orthogeriatric Unit of the León University Hospital (Spain). Age distributions of 75-84, 85-90 and >90 years old were considered. Firstly, sociodemographic data, fracture type and hospital staying days were collected. Secondly, baseline functionality (Barthel index), ambulation, cognitive impairment and comorbidities were described. Thirdly, surgical intervention, urgency, type, American Association of Anesthesiologists (ASA) scores, non-surgical cause, and baseline pharmacologic treatments were determined. Finally, complications and features at hospital discharge were observed.

RESULTS

The age ranges did not show any statistically-significant differences (P<.05; R2=.000-.005) for gender, fracture type, or number of hospital staying days. Statistically-significant differences (P<.05; R2=.011-.247) between age groups were observed for Barthel index, cognitive impairment, dementia, osteoporosis, Parkinson's disease, aortic stenosis, surgery type, ASA-score, non-surgical cause, benzodiazepines, antidementia, anti-osteoporosis, insulin, pharmacologic treatments, renal function alteration, heart failure, destination and ambulation features. All other measurements did not show statistically-significant differences (P>.05; R2=.000-.010).

CONCLUSION

Age distributions greater than 75 years old may determine the functionality, comorbidities, surgical features, baseline pharmacologic treatments, complications and features at hospital discharge for older adults who suffer a hip fracture.

Usefulness of simple biomarkers at admission as independent indicators and predictors of in-hospital mortality in older hip fracture patients

INTRODUCTION

The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.

PATIENTS AND METHODS

In 1820 consecutive patients with low-trauma osteoporotic HF aged >60 years (mean age 82.8 ± 8.1 years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (≥60 years of age) HF patients (mean age 82.1 ± 8.0 years, 72.1% women).

RESULTS

The mortality rate was 6% (n = 109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33 g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8 pmol/L; 25(OH)vitamin D < 25 nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60 ml/min/1.73 m²] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70-0.80). The risk of in-hospital death was 1.6-2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6-6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% -none RF to 16.8%- ≥4RF). The prognostic value of a single RF was low (AUC ≤0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77-0.90) when ≥4 RFs (versus 0-1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or ≥4 RFs and observed deaths were practically similar.

CONCLUSIONS

In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management.

Incidence and risk factors of medical complications and direct medical costs after osteoporotic fracture among patients in China

We analyzed the incidence of medical complications after osteoporotic fractures and estimated its risk factors and cost impacts. Osteoporotic fractures can result in lots of serious medical complications, which is associated with patients' baseline characteristics such as patients' disease history and significantly increased patients' direct medical costs.

PURPOSE

The purpose of the study is to investigate the incidence and identify the risk factors of medical complications after osteoporotic fracture, and quantify patients' economic burden.

METHODS

Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2009-2014). Patients aged ≥ 50 years, had ≥ 1 diagnoses of hip or vertebral fracture between 2010 and 2012, and continuously enrolled from 12 months before to 24 months after the first identified fracture were included. The incidence of medical complications was estimated within 12 months before and after fracture. Direct medical costs were measured and compared between patients with at least one medical complication and without any medical complications. Logistic regression was applied to identify risk factors for any medical complications.

RESULTS

Three thousand seven hundred nineteen patients were identified; 45.0% had hip fracture, and 56.2% had vertebral fracture. After osteoporotic fracture, the accumulative incidence of the most common medical complications including constipation (25.6%, RR 1.38 [1.28, 1.48]), stroke (25.2%, 1.16 [1.09, 1.24]), pneumonia (17.0%, 1.55 [1.40, 1.73]), urinary tract infection (16.3%, 1.23 [1.12, 1.36]), and arrhythmia (11.8%, 1.39 [1.23, 1.56]) was significantly higher than that before fracture. Advanced age; male sex; retirement status; diagnosis of hypertension, chronic heart disease, cerebrovascular disease, hemiplegia, or Parkinson's disease; and higher direct medical costs at baseline were significant predictors of complications. The all-cause direct medical cost during 24-month follow-up was $5665. Medical complications significantly increased patients' direct medical costs.

CONCLUSIONS

Osteoporotic fractures led to amount of medical complications, which significantly increased patients' economic burden. Complications correlate to various factors such as patients' disease history.

Predictors of noninstitutionalized survival 1 year after hip fracture: A prospective observational study to develop the Marburg Rehabilitation Tool for Hip fractures (MaRTHi)

Hip fractures are frequent fractures in geriatric patients. These fractures have great socioeconomic implications because of the significantly higher risk of mortality and institutionalization. The aim of this study was to develop a prognostic tool to predict survival without institutionalization within 1 year after hip fracture.A total of 402 hip fracture patients aged >60 years (84% community-dwelling) were included in a prospective observational cohort study. Multiple regression analyses determined independent predictors for noninstitutionalized 1-year survival. Finally, the Marburg Rehabilitation Tool for Hip fractures (MaRTHi) was developed based on these independent predictors.Of the 312 patients who were followed up for 1 year, 168 (54%) survived noninstitutionalized, 104 (33%) died, and 40 (13%) lived in nursing homes. Independent predictors for patients' noninstitutionalized survival included the American Society of Anesthesiologists (ASA) score [ASA 1 or 2: odds ratio (OR) = 7.828; 95% confidence interval (CI) = 2.496-24.555 and ASA 3: OR = 8.098; 95% CI = 2.982-21.993 compared with ASA 4 or 5], the Mini Mental State Examination upon admission to the hospital (OR = 7.365; 95% CI = 2.967-18.282 for 27-30 compared with 0-10), patients' age (OR = 2.814; 95% CI = 1.386-5.712 for 75-89 y and OR = 2.520; 95% CI = 0.984-6.453 for 90-99 y compared with 60-74 ys), and prefracture EQ-5D (OR = 2.163; 95% CI = 1.119-4.179 for EQ-5D >0.80 compared with <0.60). The area under the receiver-operating characteristic curve was 0.756 (95% CI = 0.703-0.809), and the sensitivity analysis yielded a MaRTHi score that ranged from 0 to 12 points.The MaRTHi score is the first instrument to predict noninstitutionalized survival with only 4 variables. In addition to 3 well-known factors influencing outcome (age, comorbidities, and cognitive ability), prefracture health-related quality of life was identified as an independent predictor of noninstitutionalized survival. Further studies must be conducted to validate the MaRTHi score and define cutoff scores. Health-related quality of life seems to be an important patient-reported outcome measurement and may play a role in determining patient prognosis.

[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]

BACKGROUND

In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity.

OBJECTIVES

In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated.

MATERIAL AND METHODS

Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification.

RESULTS

Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS.

DISCUSSION

Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil

Objective

To analyze the mortality rate at one-year follow-up of patients with hip fracture who underwent surgery at the university hospital of this institution.

Method

The authors reviewed 213 medical records of hospitalized patients aged 65 years or older, following to the order they were admitted to the orthopedics and traumatology service from January 2012 to August 2013.

Results

One-year mortality rate was 23.6%. Mortality was higher among women, with a 3:1 ratio. Anemia (p = 0.000) and dementia (p = 0.041) were significantly associated with the death group. Patients who remained hospitalized for less than 15 days and who were discharged within seven days after surgery showed increased survival.

Conclusion

In the present sample of patients with hip fracture who underwent surgery, one-year mortality rate was 23.6%, and the main comorbidities associated with this outcome were anemia and dementia.

Nutritional intervention in cognitively impaired geriatric trauma patients: a feasibility study

Background

Most studies focusing on improving the nutritional status of geriatric trauma patients exclude patients with cognitive impairment. These patients are especially at risk of malnutrition at admission and of worsening during the perioperative fasting period. This study was planned as a feasibility study to identify the difficulties involved in including this high-risk collective of cognitively impaired geriatric trauma patients.

Patients and methods

This prospective intervention study included cognitively impaired geriatric patients (Mini–Mental State Examination <25, age >65 years) with hip-related fractures. We assessed Mini Nutritional Assessment (MNA), Nutritional Risk Screening (NRS 2002), body mass index, calf circumference, American Society of Anesthesiologists’ classification, and Braden Scale. All patients received parenteral nutritional supplementation of 800 kcal/d for the 96-hour perioperative period. Serum albumin and pseudocholinesterase were monitored. Information related to the study design and any complications in the clinical course were documented.

Results

A total of 96 patients were screened, among whom eleven women (median age: 87 years; age range: 74–91 years) and nine men (median age: 82 years; age range: 73–89 years) were included. The Mini–Mental State Examination score was 9.5 (0–24). All patients were manifestly undernourished or at risk according to MNA and NRS 2002. The body mass index was 23 kg/m² (13–30 kg/m²), the calf circumference was 29.5 cm (18–34 cm), and the mean American Society of Anesthesiologists’ classification status was 3 (2–4). Braden Scale showed 18 patients at high risk of developing pressure ulcers. In all, 12 patients had nonsurgical complications with 10% mortality. Albumin as well as pseudocholinesterase dropped significantly from admission to discharge. The study design proved to be feasible.

Conclusion

The testing of MNA and NRS 2002 was feasible. Cognitively impaired trauma patients proved to be especially at risk of malnutrition. Since 96 hours of parenteral nutrition as a crisis intervention was insufficient, additional supplementation could be considered. Laboratory and functional outcome parameters for measuring successive supplementation certainly need further evaluations involving randomized controlled trials.

Surgical delay as a risk factor for wound infection after a hip fracture

PURPOSE

Analysis of significant risk factors for mortality and for medical and orthopaedic complications.

PATIENTS AND METHODS

Observational study of a prospective consecutive cohort of 697 patients diagnosed of hip fracture from December 2012 to December 2014. Average age was 85±9years and 520 were female (75%). Intracapsular fractures (308, 44%) were treated non-operatively, (19 patients), with cannulated screws (58) or with hip arthroplasty (228 bipolar, 3 total hip atrhoplasty). Extracapsular fractures (389, 56%) were reduced and fixed with 375 trochanteric nails and 14 sliding-hip-screw-plates. Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6 and 12months. Bivariate analysis (Pearson, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Odds Ratio were calculated.

RESULTS

Surgical delay reached 2.1±2.2days, 1.7±1.9 in medically stable patients. Main reason for delay was anticoagulant/anti-platelet therapy. Immediate weight-bearing was begun for 72% of patients. Average time in-hospital was 12±8days and 63% returned to previous environment. Lost-to-follow-up reached 4% after 1month and 8% after 6months. After 1year, 6% of previously-walking patients were unable to walk. Mortality reached 4% while in-hospital and 14% after 1year, with older age as only significant risk factor (p=0.004), OR=1.9. Wound infection developed in 2.3% of the series, and surgical delay longer than 24hours was a significant risk factor (p=0.023), with an OR=3.48 (1.1-10.8). Fixation failed in 7.9% of cannulated screws and 1.9% of trochanteric nails (1.1% cut-out, 0.8% nail fracture), while 2.7% of arthroplasty patients suffered a prosthesis dislocation and 1.3% a periprosthetic fracture. Pyelonephritis appeared in 6.7%, pneumonia in 6.3% and cardiac failure in 2.2% of patients; significant risk factors were previous comorbidity for pneumonia (p=0.007) (OR=2.7) and cardiac failure (p=0.007) (OR=9.7), as well as older age (p=0.006) (OR=2.2) for pneumonia.

CONCLUSIONS

Surgical delay longer than 24hours has been an important risk factor for wound infection, a finding not previously described in literature. Older age is a significant risk factor for mortality and pneumonia, and previous comorbidity for cardiac failure and pneumonia.

Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients

BACKGROUND

Only a little is known about whether type of surgical intervention has an effect on mortality of these patients. Our primary objective was to assess whether different type of surgical procedures has an effect on mortality among elderly patients with hip fracture. A secondary objective was to examine factors that are related to mortality in our patient population. Our hypothesis is that type of surgical procedure, especially external fixation, should have an influence on mortality outcomes.

METHODS

We included 785 patients age 65 years or older, with hip fractures. Operative treatment consisted of external fixation, internal fixation, total hip arthroplasty and hip hemiarthroplasty. Age, gender, type of fracture, type of surgery performed, American Society of Anesthesiology (ASA) grade, clinical comorbidities, anesthesia type, blood transfusion requirement, time to surgery, intensive care unit requirement, operation length and length of hospital stay and number of comorbidities were documented.

RESULTS

During the study period, 785 patients (262 male, 523 female) were included to study, Overall mortality rate was 37.2 % (292/785). Their age ranged between 65 and 100 years (mean 81). Surgery type Kaplan-Meier cumulative mortality curves suggested no significant difference between four different types of surgery groups (p = 0.064). Transfusion requirement was significantly lower in external fixation group comparing to other groups (p = 0.014). Cox regression analysis showed the number of comorbidities 2 and ≥ 3 (p = 0.0027, p = 0.015), transfusion requirement (p = 0.0001), ASA 4 (p = 0.016) to be significant predictors of mortality.

CONCLUSIONS

Transfusion requirement, ASA grade 4 and having more than two comorbidities are risk factors for mortality in geriatric hip fractures. Type of surgical intervention and fracture type had similar mortality rates in our patient population.

One-Year Outcome of Geriatric Hip-Fracture Patients following Prolonged ICU Treatment

Purpose. Incidence of geriatric fractures is increasing. Knowledge of outcome data for hip-fracture patients undergoing intensive-care unit (ICU) treatment, including invasive ventilatory management (IVM) and hemodiafiltration (CVVHDF), is sparse. Methods. Single-center prospective observational study including 402 geriatric hip-fracture patients. Age, gender, the American Society of Anesthesiologists (ASA) classification, and the Barthel index (BI) were documented. Underlying reasons for prolonged ICU stay were registered, as well as assessed procedures like IVM and CVVHDF. Outcome parameters were in-hospital, 6-month, and 1-year mortality and need for nursing care. Results. 15% were treated > 3 days and 68% < 3 days in ICU. Both cohorts had similar ASA, BI, and age. In-hospital, 6-month, and 12-month mortality of ICU > 3d cohort were significantly increased (p = 0.001). Most frequent indications were cardiocirculatory pathology followed by respiratory failure, renal impairment, and infection. 18% of patients needed CVVHDF and 41% IVM. In these cohorts, 6-month mortality ranged > 80% and 12-month mortality > 90%. 100% needed nursing care after 6 and 12 months. Conclusions. ICU treatment > 3 days showed considerable difference in mortality and nursing care needed after 6 and 12 months. Particularly, patients requiring CVVHDF or IVM had disastrous long-term results. Our study may add one further element in complex decision making serving this vulnerable patient cohort.

Impact of Parkinson's disease on the acute care treatment and medium-term functional outcome in geriatric hip fracture patients

INTRODUCTION

Patients with Parkinson's disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures.

MATERIALS AND METHODS

A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors.

RESULTS

A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p > 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038).

CONCLUSION

PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.

The fate of proximal femoral fractures in the 10th decade of life: an analysis of 117 consecutive patients

INTRODUCTION

To date, there is a lack of valid data with larger populations of patients in their 10th decade of life in the analyses of proximal femoral fractures.

MATERIAL AND METHODS

The inclusion criteria focused on all proximal femoral fractures in patients 90-99 years of age who underwent surgical treatment between 2009 and 2012. After a period of at least 2 years post-surgery, a retrospective collection of empiric data, including the survival time and surgical revision rate, was performed. Missing data were collected per telephone interview.

RESULTS

A total of 121 proximal femoral fractures in 117 patients in their 10th decade of life were treated. The mean age was 92.3 years. 61 fractures of the femoral neck received hemi- or total hip arthroplasty, while 60 pertrochanteric or subtrochanteric fractures were treated by osteosynthesis using proximal femoral nail (PFN) or dynamic hip screw (DHS). At the time of follow-up, 83/117 patients (71%) were already deceased. The mortality after 30 days, 6 months, 1 year and 2 years was 16%, 37%, and 43%, and 55%, respectively. A total of 22 surgical revisions (19%) were performed: 10 due to early infections, 8 due to haematomas, and 4 due to implant failures with a "cut out" of the femoral neck screw exclusively in DHS. The duration of surgery (with regard to surgical revision) and ASA classification (with regard to survival rate) were significant influence factors. Contralateral proximal femoral fractures were identified in 24/117 patients (20%), irrespective of study period.

CONCLUSIONS

The proximal femoral fractures in the 10th decade of life are associated with high postoperative mortality within the first 6 months. Surgical revision due to complications did not result in a statistically significant reduction of the survival time. From the osteosynthetic perspective, the DHS was associated with a significantly higher "cut-out" rate compared to PFN procedure. With regard to the alloarthoplasty, there were no significant differences observed between hemi- and total hip arthroplasty. A contralateral femoral fractures was observed in 20% of the total study population, but peri-implant or periprosthetic femoral fractures have not been observed in any of the cases thus far.

Impact of age on the clinical outcomes of major trauma

PURPOSE

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.

METHODS

Review of the literature.

RESULTS

Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.

CONCLUSION

The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Predictors of not regaining basic mobility after hip fracture surgery

PURPOSE

Regaining basic mobility after hip fracture surgery is a milestone in the in-hospital rehabilitation. The aims were to investigate predictors for not regaining basic mobility at the fifth post-operative day and at discharge after undergoing hip fracture surgery.

METHOD

In a prospective cohort study 274 hip fracture patients were included. Patients with compromised ability to exercise were excluded leaving 167 patients for analysis. Patient demographics, functional level, method of operation, post-operative hemoglobin and the completion of physiotherapy was registered. Basic mobility was assessed by the Cumulated Ambulation Score. Multivariate logistic regression was performed.

RESULTS

Age >80 years (OR = 7.5), low prefracture functional level (OR = 3.0), not completed the physiotherapy on first post-operative day (OR = 4.6) and hemoglobin <6 mmol/L measured on first post-operative day (OR = 5.8) were significant predictors of not regaining basic mobility within the fifth post-operative day (p values: 0.04 - <0.0001). Predictors of not regaining basic mobility at discharge were: Age >80 years (OR = 4.3), prefracture functional level (OR = 7.0) and not completed the physiotherapy on first post-operative day (OR = 3.3) (p values: 0.009-<0.0001).

CONCLUSIONS

This study shows that patients undergoing hip fracture surgery, who are not able to complete physiotherapy on first post-operative day, are at a greater risk of not regaining basic mobility during hospitalization. This highlights the importance of physiotherapy as part of the interdisciplinary treatment.

IMPLICATIONS FOR REHABILITATION

Regaining abilities in basic mobility after hip fracture surgery is a primary goal of rehabilitation during hospitalization in the acute ward. The following factors are indentified to predict patients not regaining their previous level of basic mobility: Age >80 years, low prefracture functional level, patients not being able to complete the physiotherapy on the first post-operative day and hemoglobin value <6 mmol/l on the first post-operative day. In future strategies, the findings regarding both modifiable and unmodifiable factors, can be used to conduct early planning of discharge and to take actions in relation to patients who are at a risk of not regaining basic mobility.

Patients with hip fracture admitted to critical care: epidemiology, interventions and outcome

INTRODUCTION

Although there is much current debate about the use of critical care to enhance peri-operative care of patients with hip fracture there are limited supporting data. We investigated the epidemiology, critical care interventions and outcomes of patients with hip fracture admitted to a large UK critical care unit.

PATIENTS AND METHODS

We reviewed all patients with hip fracture (excluding those with multiple trauma, and those with femoral shaft or peri-prosthetic fracture) who were admitted to our critical care unit during a four year period. We recorded patient characteristics, reason for admission to critical care, interventions and organ support performed, and patient outcome.

RESULTS

We identified 99 patients with a mean age of 81 years; this represented 1% of patients admitted to critical care, and 2.4% of patients with hip fracture admitted to hospital during the study period. Fifty-two patients required no organ support; 19 received only respiratory support, 13 only cardiovascular support, 12 received both respiratory and cardiovascular support, and 3 received respiratory, cardiovascular and renal support. Outcome worsened as the level of organ support increased (p=0.01). Fifteen patients died in critical care, acute hospital mortality was 33% and 1-year mortality was 54%. No patient for whom admission was planned before surgery died in critical care and the 30-day mortality for this group was 13%. Outcome was related to the time between surgery and critical care admission: patients admitted before surgery or longer than 2 days after surgery had worse outcomes (p=0.001). The reason for admission to critical care also influenced outcome: patients with sepsis had poor outcome with one-third dying in critical care and a further one-third not surviving to hospital discharge.

CONCLUSIONS

The major determinants of outcome in this population were reason for admission, and timing of admission to critical care. One year survival was better than that for unselected patients aged >80 years admitted to critical care. Admission to critical care and use of enhanced peri-operative care for selected hip fracture patients is entirely appropriate and beneficial.

Mortality after proximal femur fracture with a delay of surgery of more than 48 h

PURPOSE

For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay.

METHODS

One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01-72 h (2-3 days), 72.01-120 h (3-5 days), 120.01-168 h (5-7 days), 168 h (>7 days).

RESULTS

94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5-9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient's age at the time of injury (p = 0.005).

CONCLUSIONS

In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.