Predictors of 30-day mortality following hip/pelvis fractures

Economic impact of a clinical pharmacist in the orthopaedic sector: a review of the literature

OBJECTIVES

This review of the literature aimed to evaluate the economic impact of a clinical pharmacist in the orthopaedic sector.

METHODS

The review followed the PRISMA recommendations. A bibliographic search was conducted on 23 June 2023 using PubMed, Cochrane Library and Web of Science. All articles in French or English with economic data on clinical pharmacy activities in orthopaedics were included. Articles not mentioning the term 'orthopaedics' and those published prior to 1990 were excluded. Data from the studies were compiled in an Excel table. A bias analysis using the ROBINS-I Cochrane tool was performed. The methodology of the studies was compared and weighted using the CHEERS and STROBE checklists.

RESULTS

Among 529 articles initially identified, 10 were included in the review. The cost-benefit ratio of a clinical pharmacist in orthopaedics ranged from 0.47:1 to 28:1. The maximum savings reached US$73 410 /year in the American study and €1 42 356 /year in the French study. For three studies, the cost of a clinical pharmacist was not evaluated. Eight studies showed a positive economic impact. The Dutch study showed a balance and the Danish study showed a negative economic impact of €3442/month.

CONCLUSIONS

This literature review has shown an economic benefit of a clinical pharmacist in the orthopaedic sector despite several biases and methodological limitations. The two studies that did not confirm this benefit only evaluated a limited number of expected benefits. Nevertheless, the economic impact of the clinical pharmacist in the orthopaedic sector seems positive and undervalued.

Risk factors for short-term mortality in elderly hip fracture patients with complicated heart failure in the ICU: A MIMIC-IV database analysis using nomogram

BACKGROUND

Hip fracture is a prevalent and hazardous injury among the elderly population that often results in intensive care unit (ICU) admission due to various complications, despite advanced medical science. One common complication experienced in the ICU by elderly hip fracture patients is heart failure, which significantly impacts short-term survival rates. Currently, there is a deficit of adequate predictive models to forecast the short-term risk of death following heart failure for elderly hip fracture patients in the ICU. This study aims to identify independent risk factors for all-cause mortality within 30 days for elderly patients with hip fractures and heart failure while in the ICU in order to develop a predictive model.

METHOD

A total of 641 elderly patients with hip fractures combined with heart failure were recruited from the Medical Information Mart for Intensive Care IV dataset and randomized to the training and validation sets. The primary outcome was all-cause mortality within 30 days. The least absolute shrinkage and selection operator regression was used to reduce data dimensionality and select features. Multivariate logistic regression was used to build predictive models. Consistency index (C-index), receiver operating characteristic curve, and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram.

RESULT

Our results showed that these variables including MCH, MCV, INR, monocyte percentage, neutrophils percentage, creatinine, and combined sepsis were independent factors for death within 30 days in elderly patients with hip fracture combined with heart failure in the ICU. The C-index was 0.869 (95% CI 0.823-0.916) and 0.824 (95% CI 0.749-0.900) for the training and validation sets, respectively. The results of the area under the curve and decision curve analysis (DCA) confirmed that the nomogram performed well in predicting elderly patients with hip fractures combined with heart failure in the ICU.

CONCLUSION

We developed a new nomogram model for predicting 30-day all-cause mortality in elderly patients with hip fractures combined with heart failure in the ICU, which could be a valid and useful clinical tool for clinicians for targeted treatment and prognosis prediction.

Major surgery for metastatic bone disease is not a risk for 30-day mortality: a population-based study from Denmark

BACKGROUND AND PURPOSE

Surgery for bone metastases in the appendicular skeleton (aBM) is a trade-off between limb function and survival. A previous study from a highly specialized center found that extended surgery is not a risk for 30-day mortality and hypothesized that wide resection and reconstruction might reduce postoperative mortality. The study aimed to investigate whether parameters describing the surgical trauma (blood loss, duration of surgery, and degree of bone resection) pose a risk for 30-day mortality in patients treated with endoprostheses (EPR) or internal fixation (IF) in a population-based cohort.

PATIENTS AND METHODS

A population-based cohort having EPR/IF for aBM in the Capital Region of Denmark 2014-2019 was retrospectively assessed. Intraoperative variables and patient demographics were evaluated for association with 30-day mortality by logistic regression analysis. Kaplan-Meier estimate was used to evaluate survival with no loss to follow-up.

RESULTS

437 patients had aBM surgery with EPR/IF. No parameters describing the magnitude of the surgical trauma (blood loss/duration of surgery/degree of bone resection) were associated with mortality. Overall 30-day survival was 85% (95% confidence interval [CI] 81-88). Univariate analysis identified ASA group 3+4, Karnofsky score < 70, fast-growth primary cancer, and visceral and multiple bone metastases as risk factors for 30-day mortality. Male sex (OR 2.8, CI 1.3-6.3), Karnofsky score < 70 (OR 4.2, CI 2.1-8.6), and multiple bone metastases (OR 3.4, CI 1.2-9.9) were independent prognostic factors for 30-day-mortality in multivariate analysis.

CONCLUSION

The parameters describing the surgical trauma were not associated with 30-day mortality but, instead, general health status and extent of primary cancer influenced survival post-surgery.

The Impact of Blood Transfusion in Developing Postoperative Delirium in Patients with Hip Fracture Surgery

BACKGROUND

Many studies have been conducted to explore the risk factors associated with postoperative delirium (POD) in order to understand its underlying causes and develop prevention strategies, especially for hip fracture surgery. However, the relationship between blood transfusion and POD has been heatedly debated. The purpose of this study was to evaluate the risk factors of POD and the relationship between blood transfusions and the occurrence of POD in hip fracture surgery through big data analysis.

METHODS

Medical data (including medication history, clinical and laboratory findings, and perioperative variables) were acquired from the clinical data warehouse (CDW) of the five hospitals of Hallym University Medical Center and were compared between patients without POD and with POD.

RESULTS

The occurrence of POD was 18.7% (228 of 2398 patients). The risk factors of POD included old age (OR 4.38, 95% CI 2.77-6.91; p < 0.001), American Society of Anesthesiology physical status > 2 (OR 1.84 95% CI 1.4-2.42; p < 0.001), dementia (OR 1.99, 95% CI 1.53-2.6; p < 0.001), steroid (OR 0.53 95% CI 0.34-0.82; p < 0.001), Antihistamine (OR 1.53 95% CI 1.19-1.96; p < 0.001), and postoperative erythrocyte sedimentation rate (mm/h) (OR 0.97 95% CI 0.97-0.98; p < 0.001) in multivariate logistic regression analysis. The postoperative transfusion (OR 2.53, 95% CI 1.88-3.41; p < 0.001) had a significant effect on the incidence of POD.

CONCLUSIONS

big data analytics using a CDW was a good option to identify the risk factors of POD and to prevent POD in hip fracture surgery.

Total hip arthroplasty reduces the risk of dislocation after femoral neck fracture

INTRODUCTION

Femoral neck fracture in the elderly patient can either be managed using hemi-arthroplasty (HA) or total hip arthroplasty (THA). The aim of this study was to explore the rate of three selected complications in each procedure: is the dislocation rate higher with HA compared to THA? Is the blood transfusion rate higher with THA compared to HA? Do the patients who underwent THA require more ICU transfer than the patients who underwent HA? Is the ICU transfer correlated to the use of cement for stem fixation?

METHOD

Based on a national health-care database, a comparative and retrospective study was conducted. 96,184 patients were included after having a surgery for femoral neck fracture between 2014 and 2017. The mean follow up was 3.5 years (Min. 2 years-Max. 5 years). The population was divided into two groups: hemiarthroplasty (HA) and total hip arthroplasty (THA). The primary outcome was the dislocation rate and the secondary outcomes were the blood transfusion rate and the need for ICU after surgery.

RESULTS

At two years of follow up in the Hemiarthroplasty group, 3647 patients had a dislocation episode over 64,106 patients: 5.69%. In the Total Hip Arthroplasty group: 1904 patients had a dislocation episode over 32,078 patients: 5.94% (p=0.26711). The percentage of deceased patient without dislocation was 17.76% in the HA group and 11.56% in the THA group (p<0.001). The univariate hazard ratio for dislocation was higher in the THA group: HR 1.063 IC 95% (0.993-1.138) p=0.077. The multivariate analysis calculating competitive risk with death and dislocation found THA to be a protective factor of dislocation HR 0.926 IC 95% (0.866-0.991) p=0.0266. The rate of blood transfusion was 5.59% in the THA group and 7.03% in the HA group (p<0.001), The multivariate analysis found HR=1.062 IC 95% (0.99-1.139) p=0.0955. The need for ICU transfer after the surgery was 7.04% in the HA group and 8.08% in the THA group (p<0.001). The multivariate analysis found HR 0.995 IC 95% (0.921-1.076) p=0.9094. Finally, only cement was found as an independent risk factor of ICU transfer after surgery: HR 1.254 IC 95% (1.164-1.35) p<0.0001.

CONCLUSION

THA for femoral neck fracture allows to reduce the risk of dislocation compared to hemiarthroplasty. The multivariate analysis failed to prove the superiority of one procedure over the other regarding blood transfusion risk and the need for ICU transfer. The use of cemented stem appears to be a risk factor of ICU transfer after hip arthroplasty.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients

BACKGROUND

According to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures.

HYPOTHESIS

The aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance.

PATIENTS AND METHODS

A cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded.

RESULTS

46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%).

CONCLUSION

In geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests-consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test-are well suited for further reproducible, objective studies with a larger patient collective.

LEVEL OF EVIDENCE

IV.

Frailty and comorbidity predict 30 day postoperative outcomes, independent of anatomical site of fracture

INTRODUCTION

Fragility fractures are a major threat to geriatric patients. However, it is unclear whether this patient population's inherent frailty and comorbidity or the physiologic insult caused by the fracture and its surgery contribute more to undesirable patient outcomes. Hence, this study examines if frailty and comorbidity can predict 30 day postoperative outcomes while the effects of multiple fracture sites are accounted for.

METHODS

A retrospective review of patients ≥ 65 years of age in the National Surgical Quality Improvement Program who underwent surgical treatment between 2013 and 2017 was performed. A total of 52,497 patients were included in the final analysis, including fracture cases of the extremities, limbs, and hip. Demographics, several metrics of preoperative health, temporal variables, and fracture location were tested in bivariate analysis of 30 day postoperative mortality, length of stay in hospital, discharge outcome, and complications. Significant variables were considered for multivariate logistic regression models for each outcome.

RESULTS

Frailty, comorbidity, and time to surgery were found to be the significant predictors in multivariate analysis of each 30 day postoperative outcome, independent of the effects of fracture site (p < 0.05). Examination of 30 day mortality found that American Society of Anesthesiologists Class ≥ 3 (2.30 Odds Ratio), modified Frailty Index > 0 (1.37 OR), Charleston Comorbidity Index ≥ 6 (1.63 OR), and time to surgery (1.45 OR) were especially important (all p < 0.05). Additionally, the worst outcomes were associated with fractures of the pelvis/hip and femur/knee, including 30 day mortality (5.90 and 5.12 OR, respectively; both p < 0.05).

CONCLUSION

The effects of the preoperative health were found to be independent of patient demographics and fracture site. Additionally, specific high-risk fracture sites are significant predictors of outcome, supporting the need to prioritize these patients. Clinical care pathways for geriatric patients may benefit from emphasis on these high-risk fractures and preoperative patient health.

Thirty-Day Morbidity and Mortality in Patients With COPD Following Open Reduction and Internal Fixation for Rotational Ankle Fractures

Prior orthopedic literature has found patients with chronic obstructive pulmonary disease (COPD) to be at an increased risk for postoperative morbidity and mortality. Thus, the purpose of this study is to identify whether there are any differences in risk for 30-day morbidity or mortality following ORIF for ankle fractures between adult patients with COPD and without COPD. Patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database from 2006 to 2018. Patients were divided into 2 cohorts: non-COPD and COPD patients. In this analysis, demographics data, medical comorbidities, and thirty-day postoperative outcomes were analyzed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10,346 total patients who underwent operative treatment for ankle fracture, 9986 patients (96.5%) did not have a history of COPD whereas 360 (3.5%) had COPD. Following adjustment to control for demographic and comorbidity data, relative to patients without COPD, those with COPD had an increased risk of pneumonia (odds ratio [OR] 4.601; p = .001), unplanned intubation (OR 3.085; p = .043), and hospital readmission (OR 1.828; p = .020). Patients with COPD did not have a statistically significant difference with regards to mortality (OR 2.729; p = .080). Adult patients with COPD are at an increased risk for pneumonia, unplanned intubation, and hospital readmission within 30 days following ORIF of ankle fractures compared to patients without COPD. Despite these risks, this is a relatively safe procedure for these patients and the presence of COPD alone should not serve as a barrier to surgery.

Relationship between pressure ulcer risk and sarcopenia in patients with hip fractures

OBJECTIVE

Pressure ulcer (PU) is a frequent complication of hip fractures. PUs can develop at any time after a hip fracture but most appear within 2-4 days after surgery. The purpose of this study was to investigate the association between hip fractures due to sarcopenia and the risk of PUs in patients with hip fracture.

METHOD

Between March 2017 and March 2019, patients aged ≥65 years of age with hip fractures were included in this retrospective cohort study. PU risk assessment according to the Braden Scale was performed within the first few hours after arrival at hospital. Skeletal muscle mass index (SMI) and hand grip strength were evaluated for a diagnosis of sarcopenia.

RESULTS

Of the 289 patients admitted to the study institution, 180 patients were finally enrolled in the study (129 females; 51 males). In male patients, as SMI increased, so too did the Braden Scale score, which was statistically significant (p=0.02). However, there was no statistically significant difference between SMIs and Braden Scale scores in female patients (p=0.304). In male patients, there was no statistically significant difference between hand grip strength and Braden Scale score (p=0.251). However, in female patients, as hand grip strength increased, so too did the Braden Scale score; this was also statistically significant (p=0.041).

CONCLUSION

In this study, decreased muscle mass and muscle weakness in patients with hip fractures were associated with increased PU risk as measured by Braden Scale scores in both males and females.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Red Blood Cell Transfusion and Postoperative Delirium in Hip Fracture Surgery Patients: A Retrospective Observational Cohort Study

Background

Patients having hip fracture surgery are at high risk for postoperative delirium. Red blood cell (RBC) transfusion may increase postoperative delirium risk by causing neuroinflammation. We hypothesized that RBC transfusion would be associated with postoperative delirium in patients having hip fracture surgery.

Methods

An observational cohort study was performed using the United States National Surgical Quality Improvement Program (NSQIP) participant use files for hip fracture from 2016 to 2018. Propensity score analysis and inverse probability of treatment weighting (IPTW) were used to reduce bias from confounding. An IPTW adjusted odds ratio for developing postoperative delirium was calculated for patients who received RBC transfusion during surgery or in the 72 hours after.

Results

There were 20,838 patients who had eligible current procedural terminology (CPT) codes for primary hip fracture surgery and complete study data. After employing strict exclusions to balance covariates and reduce bias, 3,715 patients remained in the IPTW cohort. Of these, 626 patients (16.9%) received RBC transfusion and 665 patients (17.9%) developed postoperative delirium. IPTW adjustment led to good covariate balance between patients who received RBC transfusion and those who did not. Patients who received RBC transfusion had significantly higher odds of postoperative delirium, IPTW adjusted odds ratio = 1.21, 95% CI = 1.03 to 1.43, and P = 0.02. Discharge location also differed significantly between patients who received RBC transfusion and those who did not (P < 0.001) with in-hospital mortality or referral to hospice occurring in 1.6% of patients who received RBC transfusion and 1.3% of patients who were not transfused.

Conclusion

RBC transfusion is associated with increased odds of postoperative delirium after hip fracture surgery and may be associated with worse clinical outcome.

Urinary catheter use in patients with hip fracture: Are current guidelines appropriate? A retrospective review

Background:

Guidelines for urinary catheterization in patients with hip fracture recommend limiting catheter use and using intermittent catheterization preferentially to avoid complications such as urinary tract infection (UTI) and postoperative urinary retention (POUR). We aimed to compare current practices to clinical guidelines, describe the incidence of POUR and UTI, and determine factors that increase the risk of these complications.

Methods:

We retrospectively reviewed the charts of patients with hip fracture who presented to a single large tertiary care centre in southeastern Ontario between November 2015 and October 2017. Data collected included comorbidities, catheter use and length of stay. We compared catheter use to guidelines, and investigated the incidence of and risk factors for POUR and UTI.

Results:

We reviewed the charts of 583 patients, of whom 450 (77.2%) were treated with a catheter, primarily indwelling (416 [92.4%]). Postoperative urinary retention developed in 98 patients (16.8%); however, it did not affect length of stay (p = 0.2). Patients with indwelling catheters for more than 24 hours after surgery had a higher incidence of POUR than those who had their catheter removed before 24 hours (65/330 [19.7%] v. 10/98 [10.2%]) (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.06–4.38). A UTI developed postoperatively in 62 patients (10.6%). Catheter use was associated with a 6.6-fold increased risk of UTI (OR 6.6, 95% CI 2.03–21.4). Patients with indwelling catheters did not have a significantly higher incidence of UTI than those with intermittent catheterization (57/416 [13.7%] v. 2/34 [5.9%]) (p = 0.2). Patients who developed a UTI had significantly longer catheter use than patients who did not (p < 0.002).

Conclusion:

Indwelling catheters were used frequently, which suggests low compliance with clinical guidelines. Longer duration of catheter use led to higher rates of UTI and POUR. Further investigation of the reasons for the common use of indwelling rather than intermittent catheterization is needed.

Partial pressure of oxygen level at admission as a predictor of postoperative pneumonia after hip fracture surgery in a geriatric population: a retrospective cohort study

OBJECTIVE

To identify whether the partial pressure of oxygen in arterial blood (PaO₂) level at admission is an independent risk factor as a prognostic biomarker to predict postoperative pneumonia (POP) in the geriatric population who have undergone hip fracture surgical repair at our hospital.

DESIGN

A retrospective cohort study.

SETTING

This is a retrospective chart review of POP after hip fracture surgery in China.

PARTICIPANTS

In training cohort, patients aged ≥65 years who had hip fracture surgery between 1 January 2018 and 30 November 2019. In the validation cohort, a series of patients who underwent hip fracture surgery between 1 January 2020 and 28 February 2020.

INTERVENTIONS

Receiver operating characteristic (ROC) analysis was used to obtain the area under the ROC curve (AUC) and cut-off values of PaO₂ to predict POP. A binomial logistic regression model was used to identify potential risk factors for POP by analysing demographic distribution factors, laboratory results, preoperative comorbidities and surgical factors. Then the regression model was validated using an independent cohort.

RESULTS

In the training cohort, ROC curves were generated to compare the predictive performance of PaO₂ for the occurrence of POP, and the area under the receiver operating characteristic curve (AUC) was 0.653 (95% CI 0.577 to 0.729, p<0.0001), with sensitivity and specificity values of 60.0% and 63.8%, respectively. The cut-off value of the PaO₂ for POP was 72.5 mm Hg. Binary logistic regression analysis revealed that hypoxaemia (PaO₂ <72.5 mm Hg) at hospital admission (OR=3.000, 95% CI 1.629 to 5.528; p<0.0001) was independent risk factors associated with POP after hip fracture surgery. In the validation cohort, PaO₂ had a predictive effect for POP (AUC 0.71, 95% CI 0.541 to 0.891).

CONCLUSIONS

The current study revealed that the PaO₂ level at hospital admission is a simple and widely available biomarker predictor of POP after hip fracture surgery in elderly patients.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Preoperative Platelet and International Normalized Ratio Thresholds and Risk of Complications After Primary Hip Fracture Surgery

BACKGROUND

A paucity of data exists on safe platelet and international normalized ratio (INR) thresholds for hip fracture surgery. Recent work has called into question the safety of preoperative INRs < 1.5 for total knee arthroplasty, and optimal platelet thresholds are unknown. The purpose of this study was to identify the risk of 30-day postoperative morbidity and mortality in patients with thrombocytopenia or elevated INRs undergoing hip fracture surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing surgical treatment of a native hip fracture from 2012 to 2017 (N = 86,850). Patient demographic, laboratory, and complication data were collected. Patients with preoperative platelet counts or INRs within one day of surgery were included for analysis. Preoperative platelet counts and INRs were divided into four groups (<50 k/μL, ≥50 k to 100 k/μL, ≥100 k to 150 k/μL, ≥150 k/μL, and ≤1.0, >1.0 to 1.5, >1.5 to 2.0, and >2.0, respectively). Multivariable logistic regressions were used to assess the independent association between platelet count and INR on bleeding complications requiring transfusion, wound complications, reoperations, readmissions, and deaths.

RESULTS

A total of 72,306 and 56,027 patients were included for analysis of preoperative platelet and INR levels, respectively. In reference to platelet levels ≥150 k/μL, a notably increased risk of bleeding events was observed for patients with platelet counts ≥100 k to 150 k/μL (odds ratio [OR] 1.21, 95% confidence interval 1.15 to 1.27), ≥50 to 100 k/μL (OR 1.85, 1.69 to 2.03), and <50 k/μL (OR 1.60, 1.25 to 2.04). Decreasing platelet counts were associated with a stepwise increased risk of mortality from OR 1.12 (1.02 to 1.22) for platelet counts ≥100 k to 150 k/μL to OR 1.63 (1.41 to 1.90) and OR 1.59 (1.06 to 2.39) for platelet counts ≥50 k to 100 k/μL and <50 k/μL, respectively. Elevated INR was associated with an increased risk of reoperations, readmissions, and death (P < 0.001 for all), with largest effect sizes observed starting at INRs >1.5.

DISCUSSION

The results of this study suggest that preoperative platelet thresholds of <100,000/μL and INR thresholds of 1.5 serve as an important risk factor for complications after hip fracture surgery. Future work is warranted to determine whether preoperative platelet transfusions and/or INR reversal will improve outcomes for these patients.

LEVEL OF EVIDENCE

Prognostic Level III.

Elderly patients with concurrent hip fracture and lower respiratory tract infection: the pathogens and prognosis over different bedridden periods

BACKGROUND

Elderly patients who experience hip fractures often become bedridden and are at risk of developing lower respiratory tract infections. The current study was to investigate the etiology and bacterial drug resistance patterns of elderly patients with hip fractures and lower respiratory tract infections on prolonged bedridden time and to determine their prognosis.

METHODS

Patients diagnosed with hip fractures admitted from May 2015 to April 2017 were included. The basic characteristics including the patients' gender, age, fracture type, operation mode, bedridden duration, length of hospital stay, prognosis, past medical history, routine bloodwork, C-reactive protein (CRP), procalcitonin (PCT), blood biochemistry, blood gas analysis, glycosylated hemoglobin (HbA1C%), sputum smear, sputum culture, and anti-infection and related therapy were recorded. All patients were classified into three groups based on bed rest duration, including short-term (<1 month), mid-term (1-12 months), and long-term (> 12 months). The correlation between the bedridden time and the patients' basic characteristics, disease history, laboratory examination results, pathogen, anti-infection, and related therapy were evaluated. The risk factors related to the prognosis of the disease were investigated.

RESULTS

Prolonged bed rest in patients led to an increase in hospitalization time, mortality rates, and decreased serum albumin levels (P < 0.05). Sputum bacteriological culture results showed that, with bed rest prolongation, the proportion of Pseudomonas aeruginosa and fungal infections increased. Binomial logistic regression of pulmonary infection prognosis, glucocorticoid use during the anti-infective period, prolonged bedridden time, and serum albumin level showed that intravenous use of glucocorticoid during anti-infective treatment, bed rest > 1 year, and low serum albumin level were related to poor prognosis.

CONCLUSION

Elderly hip fracture patients with prolonged bedridden time had an increased chance of opportunistic pulmonary infection and decreased nutritional status. Glucocorticoids should be used cautiously.

Patients aged ninety years and older are exposed to increased risk of one-year mortality after hip fractures

BACKGROUND

The increase in the population over 90 years old suggests an expected surge in the number of extreme elderly patients sustaining hip fractures.

OBJECTIVE

The aim of this study is to identify factors associated with 1-year mortality and determine the conditions that are associated with an unfavorable survival outcome in nonagenarians.

DESIGN

Cross-sectional study SUBJECTS: Nonagenarian patients presenting with hip fractures between 2013 and 2018.

METHODS

Bivariate and multivariate analyses were performed to identify variables associated with mortality, and a survival analysis was conducted to determine whether the Charlson Comorbidity Index (CCI) is associated with mortality.

RESULTS

A total of 127 patients, with a mean age of 92.84 years was assessed, identifying 1-year mortality rate in 53.5% of patients. According to the bivariate analysis, requirement of postoperative vasopressor support, transfusion, decompensated heart failure and general anesthesia were associated with a higher probability of 1-year mortality after surgery. Body mass index, health status, dementia or CCI ≥ 3 were not associated with mortality. Similarly, the Kaplan-Meier survival analysis showed no difference in mortality rate of patients with CCI ≥ 3 (p = 0.282).

CONCLUSION

Patients older than 90 years with hip fractures have higher mortality rates per year than younger patients. Some associations were found, but more studies are needed to reach final conclusions, which could help identify higher-risk patients and be able to implement additional measures.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Machine Learning Algorithms to Predict Mortality and Allocate Palliative Care for Older Patients With Hip Fracture

OBJECTIVES

To evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs).

DESIGN

Retrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility-Patient Assessment Instrument data.

SETTING AND PARTICIPANTS

A total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture.

MEASURES

Patient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models.

RESULTS

For 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95).

CONCLUSION AND IMPLICATIONS

A scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.

A retrospective study of end-stage kidney disease patients on maintenance hemodialysis with renal osteodystrophy-associated fragility fractures

BACKGROUND

Nephropathy associated metabolic disorder induces high incidence of fragility fracture in end-stage renal disease (ESRD) patients. As the risk factors and prognosis of fragility fracture in ESRD patients are unclear, more research is needed. This study aimed to evaluate various risk factors for ESRD-related fragility fractures, explore factors affecting the prognosis of patients with such fractures, and provide information for prevention and treatment of renal osteopathy to improve the prognosis of patients.

METHODS

In this retrospective case-control study, the case notes of 521 ESRD patients who received maintenance dialysis for at least 3 months were examined. Finally, 44 patients diagnosed with fragility fractures were assigned to the fragility fracture (FF) group and 192 patients were included in the control group (CG). Demographic information, underlying diseases, nutritional, bone metabolism, and renal function parameters, along with the number and causes of any deaths, were recorded for multiple statistical analysis.

RESULTS

The FF group had increased incidences of essential hypertension and diabetes mellitus and higher serum calcium, corrected calcium, alkaline phosphatase, and hemoglobin levels. Immunoreactive parathyroid hormone (iPTH), total cholesterol (TC), and low density lipoprotein (LDL) levels were higher in the CG. Multivariate Cox regression analysis revealed that fragility fracture was an independent risk factor for all-cause mortality in ESRD patients (P < .001, RR: 4.877, 95% CI: 2.367-10.013).

CONCLUSIONS

Essential hypertension and diabetes, high serum calcium and alkaline phosphatase levels, and reduced iPTH levels were risk factors for fragility fracture in ESRD patients. Maintaining iPTH and serum TC levels may protect against fragility fractures in them. Fragility fractures may yield poor prognosis and shorter lifespan. The presence of fragility fracture was an independent predictor of all-cause death in ESRD patients.

Chronic Obstructive Pulmonary Disease and Incidence of Hip Fracture: A Nested Case-Control Study in the EpiChron Cohort

Purpose

To determine whether chronic obstructive pulmonary disease (COPD) is a risk factor for hip fracture and identify other factors associated with hip fracture.

Patients and Methods

Observational nested case-control study was conducted in Aragon, Spain in 2010. We included COPD patients aged >40 years, in the EpiChron cohort. Each COPD patient was matched for age, sex, and number of comorbidities with a control subject without COPD. Patients with an existing diagnosis of osteoporosis and those with hip fracture before 2011 were excluded. We collected baseline demographic, comorbidity, and pharmacological treatment data. During a 5-year follow-up period, we recorded the incidence of hip fracture. A logistic regression model was constructed to identify factors associated with hip fracture.

Results

The study population consisted of 26,517 COPD patients and the same number of controls (median [interquartile range] age, 74 [17] years; women, 24.7%). Smoking and heart failure were more frequent in COPD patients, and obesity, hypertension, diabetes, dyslipidemia, stroke, arthritis, and visual or hearing impairment were less frequent (all p<0.001). Consumption of benzodiazepines (p=0.037), bronchodilators (p<0.001), and corticosteroids (p<0.001) was higher in the COPD group, while that of beta-blockers and thiazides was lower (both p<0.001). During follow-up, 898 (1.7%) patients experienced hip fracture, with no differences observed between COPD and control patients. Multivariate analysis revealed that independent of COPD status, age, female sex, chronic liver disease, heart failure, and benzodiazepine use were independently associated with a higher risk of hip fracture, and obesity with a lower risk. In COPD patients, use of inhaled anticholinergics was independently associated with hip fracture (OR, 1.390; 95% CI 1.134-1.702; p=0.001).

Conclusion

COPD is not a risk factor for a hip fracture within 5 years. The association between the use of inhaled anticholinergics and risk of hip fracture warrants further study.

Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture

OBJECTIVE

To determine how timing of surgery affects transfusion, major complications, and mortality in patients who sustain a geriatric hip fracture while taking dual antiplatelet therapy (DAPT; typically aspirin and clopidogrel).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated Level 1 Trauma Center.

PATIENTS

Patients 65 years of age or older on DAPT with a geriatric hip fracture were investigated at a single institution between 2002 and 2017. Demographic and perioperative data were collected from patient records, institutional databases, and national hip fracture registry.

INTERVENTION

Fixation or arthroplasty.

MAIN OUTCOME MEASUREMENT

Transfusion, major complications, and 30-day mortality.

RESULTS

Of the 6724 patients sustaining a geriatric hip fracture, 122 patients were taking DAPT on admission. Timing of surgery did not influence transfused units (incidence rate ratio 1.00, 95% confidence interval: 0.87-1.15, P = 0.968) but did affect major complications (time modeled as quadratic term; odds ratios ranging from 0.20 to 7.91, ptime = 0.001, ptime*time<0.001) and 30-day mortality (odds ratio 1.32, 95% confidence interval: 1.03-1.68, P = 0.030).

CONCLUSION

Surgical delay does not change the need for transfusion of hip fracture patients on DAPT, but it is associated with increased probabilities of major complications and 30-day mortality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis of femoral head in young patients with femoral neck fracture: a retrospective study of 250 patients followed for average of 7.5 years

Objective

To investigate the risk factors for osteonecrosis of the femoral head (ONFH) after the treatment of femoral neck fracture in patients under 60 years old.

Methods

A total of 250 cases of femoral neck fracture treated at 3 hospitals in Xuzhou from January 2002 to January 2016 were studied. The patients were followed up for 1~15 years, and the clinical data on femoral head necrosis after the femoral neck operation were analysed retrospectively. Risk factors were recorded, including age, gender, preoperative traction, time from injury to operation, reduction method, type of reduction, BMI, ASA classification, and quality of reduction. Logistic regression analysis was used to evaluate the independent risk factors for ONFH after treatment of femoral neck fracture.

Results

The duration of follow-up was 1~15 years, with an average of 7.5 years. None of the 250 patients had fracture non-union, but 40 (16%) had necrosis of the femoral head. The time to necrosis of the femoral head was 1~7 years after the operation, with an average of 3.8 years. Univariate analysis showed that the type of fracture, the quality of reduction, the removal of internal fixation, BMI and ASA classification were risk factors affecting necrosis of the femoral head in patients with femoral neck fracture, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that internal fixation, fracture type (displacement), reduction quality (dissatisfaction), BMI (> 25), and ASA grade (III + IV) were independent risk factors affecting femoral head necrosis in patients with femoral neck fracture.

Conclusion

A variety of high-risk factors for femoral head necrosis are present after surgery with hollow compression screws for femoral neck fracture in adults. Removal of internal fixation, type of fracture, quality of reduction, BMI, and ASA classification were the most important risk factors influencing the development of femoral head necrosis. During treatment, there should be some targeted measures to reduce the incidence of necrosis of the femoral head.

Elixhauser comorbidity measures-based risk factors associated with 30-day mortality in elderly population after femur fracture surgery: a propensity scorematched retrospective case-control study

Background:

As the average life expectancy increases, anesthesiologists confront unique challenges in the perioperative care of elderly patients who have significant comorbidities. In this study, we evaluated Elixhauser comorbidity measures-based risk factors associated with 30-day mortality in patients aged 66 years and older who underwent femur fracture surgery.

Methods:

We used the Medical Information Mart for Intensive Care III which contains the medical records of patients admitted to the intensive care unit (ICU) at Beth Israel Deaconess Medical Center in the United States between 2001 and 2012 to identify patients admitted to the ICU after femur fracture surgery (n=209). Patients who died within 30 days of admission (case group, n=49) were propensity score-matched to patients who did not (control group, n=98). The variables for matching were age, sex, race, anemia (hemoglobin ≤10 g/dl), and malignancy. We attempted to explain mortality via nine independent factors: hypertension, uncomplicated diabetes, complicated diabetes, congestive heart failure (CHF), cardiac arrhythmias, chronic pulmonary disease, renal failure, neurological disorders other than paralysis, and peripheral vascular disease.

Results:

Logistic regression identified three significant risk factors: CHF, arrhythmias, and neurological disorders other than paralysis. The odds ratio (OR) for the 30-day mortality of CHF was 4.99 (95% confidence interval [CI], 2.18 to 12.06). The equivalent ORs for cardiac arrhythmias and neurological disorders other than paralysis were 2.61 (95% CI, 1.14 to 6.21) and 2.40 (95% CI, 0.95 to 6.48), respectively.

Conclusions:

Identifying patients with these risk factors (CHF, arrhythmias, and neurological disorders other than paralysis) will assist clinicians with perioperative planning and provide caregivers with valuable information for decision-making.

Effect of heart failure on postoperative short and long-term mortality in elderly patients with hip fracture

INTRODUCTION

We designed a comparative study using elderly hip fracture patients with and without heart failure (HF). The purpose of this study was to assess 1) prevalence of HF, compare 2) early and late mortality after elderly hip fracture between HF and non-HF patients and to assess 3) risk factors of mortality after hip fractures in elderly patients with HF. In addition, we also investigated 4) whether there is a difference in mortality according to the severity of left ventricular (LV) systolic dysfunction classified by LV ejection fraction (EF) in HF patients through subgroup analysis.

METHODS

This study included 1992 patients (1992 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between January 2004 and June 2018. The patients were categorized into a non-HF group (1782 patients) and a HF group (210 patients; mild [119 patients] and moderate-to- severe HF subgroups [91 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-HF and HF. Logistic regression analysis was conducted to identify independent factors associated with mortality.

RESULTS

Of 1992 patients, 210 (10.5%) patients were diagnosed with HF. The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were respectively 1.6%, 3.6%, 5.1%, 8.4%, and 12.9% in the non-HF group, and 5.7%, 9.5%, 12.4%, 17.1%, and 25.2% in the HF group (p ≤ 0.001). The factors that affected 1-year mortality were sex (OR, 2.10; 95% CI, 1.62-2.72; p < 0.001) and age (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001) and presence of HF (OR, 1.62; 95% CI, 1.45-1.86; p = 0.005). In subgroup analysis, the factors that affected 30-day mortality were only moderate-to-severe HF (OR, 4.01; 95% CI, 1.10-8.78; p = 0.009).

CONCLUSIONS

In elderly patients with hip fracture, the comparison between the HF and non-HF patients revealed that HF was an independent factor of mortality at a minimum of 1-year follow-up, and severity of LV systolic dysfunction classified by LVEF in patients with hip fracture was also a risk factor of 30-day mortality.

Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery

INTRODUCTION

Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF.

METHODS

Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated.

RESULTS

Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64).

CONCLUSION

HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures

INTRODUCTION

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population.

METHODS

In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation.

RESULTS

After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival.

DISCUSSION

A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

INTRODUCTION

We conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD.

METHODS

This study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality.

RESULTS

The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD.

CONCLUSIONS

In elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.

Functional Outcomes After Hip Fracture in Independent Community-Dwelling Patients

OBJECTIVES

To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients.

DESIGN

Retrospective cohort study.

SETTING

Academic hospital with ambulatory follow-up.

PARTICIPANTS

Community-dwelling adults 65 years or older independent in ADLs undergoing hip fracture surgery in 2015 (n = 184).

MEASUREMENTS

Baseline, 3- and 6-month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race.

RESULTS

Predictors of new ADL disability at 3 months were dementia (odds ratio [OR] = 11.81; P = .001) and in-hospital delirium (OR = 4.20; P = .002), and at 6 months were age (OR = 1.04; P = .014), dementia (OR = 9.91; P = .001), in-hospital delirium (OR = 3.00; P = .031) and preadmission opiates (OR = 7.72; P = .003). Predictors of worsened mobility at 3 months were in-hospital delirium (OR = 4.48; P = .001) and number of medications (OR = 1.13; P = .003), and at 6 months were age (OR = 1.06; P = .001), preadmission opiates (OR = 7.23; P = .005), in-hospital delirium (OR = 3.10; P = .019), and number of medications (OR = 1.13; P = .013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR = 1.07; P = .014; 6 months: OR = 1.06; P = .017) and number of medications (3 months: OR = 1.13; P = .004; 6 months: OR = 1.22; P = .013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility.

CONCLUSION

Age, dementia, in-hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery.

Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: A Propensity Score-Matched, Population-Based Study

BACKGROUND

Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.

METHODS

A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.

RESULTS

Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).

CONCLUSIONS

Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short-term Medical Complications Following Short Versus Long Cephalomedullary Nails

The purpose of this retrospective cohort study was to evaluate whether there is an increased rate of short-term medical complications following short vs long cephalomedullary nails for the treatment of intertrochanteric hip fractures. A total of 899 patients treated surgically with cephalomedullary nails from January 1, 2005, to September 1, 2014, were included. Patients who received short nails (n=334) were older and had a higher incidence of coronary artery disease and diabetes mellitus compared with patients who received long nails (n=565). The incidences of 30-day medical complications, including myocardial infarction, stroke, deep venous thrombosis, pulmonary embolism, blood transfusion, non-surgical site infection, surgical site infection, and mortality, were recorded. The orthopedic complications of periprosthetic fracture of the ipsilateral hip and implant failure through the latest outpatient follow-up were recorded. No significant difference was found between nails for any studied medical complication (63.5% short vs 66.0% long, P=.4393) or mortality (6.9% short vs 5.3% long, P=.3322). There was also no significant difference in the incidence of orthopedic complications (P=.70). Longer operating room time was associated with superficial surgical site infection. [Orthopedics. 2018; 41(5):e636-e642.].

Predictive factors for thirty day mortality in geriatric patients with hip fractures: a prospective study

PURPOSE

The study aims to analyze the incidence of 30-day mortality in elderly patients who underwent surgery for hip fractures and its associated factors.

METHODS

A prospective multicentric study was performed. All patients aged ≥ 65 years, with fragility hip fractures, consecutively admitted in two Italian hospitals were included. Patients with periprosthetic or pathological fractures were excluded. Logistic regression was used to identify patient and patient care variables that independently influenced the 30-day mortality and receiver operating characteristic (ROC) curve analysis to assess their predictive capacity on the outcome.

RESULTS

Of the patients, 728 met the inclusion criteria, of whom approximately 5% died within 30 days after admission. The 45.7% of the deceased patients died while hospitalized. Multivariate analysis showed that advancing age was the only independent predictor of 30-day mortality (OR = 1.084, 95% CI = 1.024-1.147), while a higher presence of informal caregivers was a protective factor (OR = 0.988, 95% CI = 0.979-0.997). The area under the ROC curve of the model was 0.723 (CI95% 0.676-0.770) for 30-day mortality in elderly hip fractures patients.

CONCLUSIONS

Patients with an advanced age need careful follow-up, especially within 30 days following operation for hip fracture; at the same time, the presence of informal caregivers at the patient's bedside should be promoted.

Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery

OBJECTIVES

To determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery.

DESIGN

Retrospective cohort study.

SETTING

Integrates health care delivery system across 38 facilities in the United States.

PATIENTS/PARTICIPANTS

We identified 16,695 patients 65 years of age and older who underwent emergent hip fracture repairs between 2009 and 2014 through the Kaiser Permanente hip fracture registry and excluded pathologic or bilateral fractures.

INTERVENTION

Hip fracture surgery with general or regional anesthesia.

MAIN OUTCOMES MEASURES

Data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) were analyzed among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv).

RESULTS

Compared with RA, the hazard ratio for GA for in-hospital mortality was 1.38 and 2.23 for the Cv group; the time ratio for GA-associated time to death was 0.97 and 0.89 for the Cv group. The GA-associated time ratio for LOS before discharge was 1.01, and the hazard ratio for home discharge was 0.86, but no significance was found with the Cv group.

CONCLUSIONS

RA may offer advantages over GA for fragility hip fracture surgeries when possible. In-hospital mortality, time to death, increased LOS, and discharge to an institute rather than home were all adversely influenced by GA. Furthermore, the previously understudied Cv group demonstrated adverse outcomes for in-hospital mortality and time to death.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Overlapping Surgery With Increased Risk for Complications Following Hip Surgery: A Population-Based, Matched Cohort Study

IMPORTANCE

Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.

OBJECTIVE

To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The "hip fracture" cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The "total hip arthroplasty" (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.

EXPOSURES

Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.

MAIN OUTCOMES AND MEASURES

Complication (infection, revision, dislocation) within 1 year.

RESULTS

There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).

CONCLUSIONS AND RELEVANCE

Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.