Place of residence before and place of discharge after femoral neck fracture surgery are associated with mortality: A study of 1238 patients with at least three years' follow-up

How do early geriatric intervention and time to surgery influence each other in the management of proximal hip fractures?

INTRODUCTION

Time to surgery (TTS) increases mortality risk in old patients with proximal femur fractures (PFFs). Orthogeriatric care pathways reduce mortality and length of stay, but the interaction between TTS and geriatric intervention remains unclear.

OBJECTIVE

To identify organisational variables-including geriatric intervention-that are predictive of 90-day mortality and explore their interactions with TTS.

MATERIALS AND METHODS

This retrospective study included 7756 PFFs aged over 60 who underwent surgery between 2005 and 2017. Organisational factors influencing 90-day mortality (main outcome) were identified in an administrative database using log-rank tests. Variables such as a mobile geriatric team (MGT) intervening in the emergency department were screened. Selected variables were included in a Cox model alongside TTS and the AtoG score, a validated multidimensional prognostic tool (from 0 no comorbidity to ≥5). Statistical interactions between TTS and organisational variables were calculated.

RESULTS

MGT was one of the rare organisational variables with a protective effect: hazard ratio (HR) = 0.81, CI 95% [0.68-0.98], P = 0.03. MGT's strongest effect was for TTS up to 1 day (HR = 0.70, CI95% [0.53-0.92], P = 0.01) and then decreased beyond 2 days (HR = 0.97, CI95% [0.73-1.3], P = 0.08). In patients with an AtoG score ≤ 2, MGT was the strongest parameter: HR = 0.76, CI95% [0.60-0.93], P = 0.03, while the HR for TTS was 1.01 CI 95% [0.99; 1.02], P = 0.15. In patients with an AtoG>2, there was a synergic interaction between MGT and reduced TTS (P = 0.05).

CONCLUSION

Geriatric intervention modulated the effect of TTS on 90-day mortality up to a TTS of 2 days. MGT had a positive impact on both vulnerable and earthier patients.

Higher Comorbidities are Correlated With Readmission Following Arthroplasty for Femoral Neck Fracture

Background

A desire to control cost and improve patient outcomes following arthroplasty led to the introduction of the Center for Medicare and Medicaid Service Comprehensive Care for Joint Replacement Program. Hemi and total hip arthroplasty for femoral neck fracture has been shown to have worse outcomes than those for osteoarthritis. However, little has been studied about the effect of comorbidities on costs associated with arthroplasty for femoral neck fracture. This study investigates how the number of comorbidities influence 90-day outcomes and cost following hemi or total hip arthroplasty for displaced femoral neck fracture in patients covered by the Comprehensive Care for Joint Replacement bundle.

Methods

We reviewed all Medicare hip fracture patients undergoing hemi or total hip arthroplasty at our institution between April 2016 and November 2020. Basic demographic and perioperative information was collected. The primary outcome was hospital readmission within 90 days. The data set captured 90-day readmission to any institution, not just within our system. Secondary outcomes included 90-day reoperation and outpatient complications. Multiple logistic regression was used to examine the influence of number of comorbidities on the primary and secondary outcomes while controlling for other variables.

Results

The cohort comprised 378 patients (72% female), mean age 82 (±9) years, mean body mass index 23.4 (±4.7) kg/m2. For every additional comorbidity, the odds of related readmission without reoperation increased by 1.261 (95% confidence interval [1.055-1.507], P = .011). Odds of reoperation and odds of outpatient complication did not show statistical significance with the available numbers.

Conclusions

Increasing preoperative comorbidities results in a higher odd of readmission within 90 days following arthroplasty for femoral neck fracture in this Medicare population.

AtoG: A simple score to predict complications and death after hip fractures, in line with the comprehensive geriatric assessment

INTRODUCTION

Proximal Femur Fractures (PFFs) are a significant public health issue and occur in the context of global frailty and aging. Recent literature identifies new patient-related prognostic factors that focus on socioeconomic environment, patient well-being, or nutrition status. Specific scores have been developed, but in most cases, they fail to be in line with the comprehensive geriatric assessment, or do not assess the newly identified prognostic factors, contain multitude collinearities, or are too complex to be used in the daily practice. Hypothesis A comprehensive score with equal representation of the patient's dimensions does at least as good as the Charlson score (CCI), to predict complications and mortality.

OBJECTIVE

To develop a new comprehensive prognostic score, predicting inpatient complications and mortality up to 5-year after PFF.

MATERIAL AND METHODS

The patients treated surgically for PFF on a native hip, between 2005 and 2017 were selected from a French national database. The variables were the gender, age, the type of treatment (osteosynthesis or arthroplasty), and the CCI. The outcomes were the medical and surgical complications as inpatient and the mortality (up to 5-year). Variables were grouped into dimensions with similar clinical significance, using a Principal Component Analysis, for instance, bedsores and malnutrition. The dimensions were tested for 90-day mortality and complications, in regressions models. Two scores were derived from the coefficients: SCOREpond (strict ponderation), and SCORE (with loose ponderation: 1 point/risk factors, -1 point/protective factors). Calibration, discrimination (ROC curves with Area Under Curves AUC), and cross-validation were assessed for SCOREpond, SCORE, and CCI.

RESULTS

Analyses were performed on 7756 fractures. The factorial analysis identified seven dimensions: age; brain-related conditions (including dementia): 1738/7756; severe chronic conditions (for instance, organ failures) 914/7756; undernutrition: 764/7756; environment, including social issues or housing difficulties: 659/7756; associated trauma: 814/7756; and gender. The seven dimensions were selected for the prognostic score named AtoG (ABCDEFG, standing for Age, Brain, Comorbidities, unDernutrition, Environment, other Fractures, Gender). The median survival rate was 50.8 months 95% CI [49-53]. Anaemia and urologic complications were the most prevalent medical complications (1674/7756, 21%, and 1109/7756, 14.2%). A total of 149/7756 patients (1.9%) developed a mechanical inpatient complication (fractures or dislocations), with a slightly higher risk for arthroplasties. The AUCs were 0.69, 0.68, and 0.67 for AtoGpond, AtoG, and CCI, respectively, for 90-day mortality, and 0.64, 0.63, and 0.56 for complications. Compared to patients with AtoG=0, Hazard Ratios for 90-day mortality were 2.3 95% CI [1.7-2.9], 4.2 95% CI [3.1-5.4], 6 95% CI [4.5-8.1], 8.3 95% CI [6.5-12.9], and 13.7 95% CI [8-24], from AtoG=1 to AtoG≥5, respectively (p<10-4); the 90-day survival decreased by 5%/point, roughly. The sur-risk of mortality associated with AtoG was up to 5-year: HR=1.51 (95% CI [1.46-1.55], p<10-4). Compared to AtoG=0, from AtoG=1 to AtoG≥5, the pooled Odd Ratios were 1.14 95% CI [1.06-1.2], 1.53 95% CI [1.4-1.7], 2.17 95% CI [1.9-2.4], 2.9 95% CI [2.4-3.4], and 4.9 95% CI [3.3-7.4] for any complication (p<10-4).

CONCLUSION

AtoG is a multidimensional score in line with the concept of comprehensive geriatric assessment. It had good discrimination and performance in predicting 90-day mortality and complications. Performances were as good as CCI for 90-day mortality, and better than it for the complications.

LEVEL OF PROOF

IV; retrospective cohort study.

The Nomogram Model and Factors for the Postoperative Mortality of Elderly Patients with Femoral Neck Fracture Undergoing Artificial Hip Arthroplasty: A Single-Institution 6-Year Experience

OBJECTIVE

Artificial hip arthroplasty (AHA) is widely accepted in elderly patients with femoral neck fractures, but it is associated with high risk of death and various postoperative complications due to old age and accompanying chronic diseases. Therefore, this study aimed to explore the risk factors for death in elderly patients with femoral neck fractures after AHA and to establish a nomogram risk prediction model, which is expected to reveal high-risk patients and improve the postoperative quality of life and survival rate of patients.

METHODS

Elderly patients who underwent AHA for femoral neck fractures in our hospital from September 2014 to May 2021were retrospectively analyzed. These patients were divided into a survival group and a death group according to their clinical outcomes. The following clinical data were recorded for the patients in the two groups: sex, age, underlying diseases, smoking and drinking history, preoperative nutritional risk score (NRS) and American Society of Anesthesiologists (ASA) score, as well as relevant indicators about the operation. These data were subject to univariate analysis and then logistic analysis to determine the risk factors of death. Subsequently, a nomogram risk prediction model was established and further validated with the receiver operating characteristic curve (ROC) and the Hosmer-Lemeshow test. Finally, the effects of predictive risk factors were analyzed using the Kaplan-Meier survival curve.

RESULTS

Follow-up was completed by 260 patients, including 206 patients in the survival group and 54 patients in the death group; the overall death rate was 20.77%, and the follow-up time, age, postoperative 1, 3 and 5-year death rates were 3.47 ± 1.93 years, 75.32 ± 9.12 years, 5.77%, 12.51%, and 25.61%, respectively. The top three causes of death in 54 patients were respiratory disease, cerebrocardiovascular disease, and digestive disease, respectively. The logistic analysis indicated that elderly patients with femoral neck fractures, the risk factors for death after AHA were age ≥ 80 years, preoperative NRS ≥ 4, HB ≤ 90 g/L, CR ≥ 110 umol/L, and ASA score ≥ 3, as well as postoperative albumin ≤ 35 g/L, the nomogram was established, and then its predictive performance was successfully validated using the ROC curve (AUC = 0.814, 95% confidence interval = 0.749-0.879) and the Hosmer-Lemeshow test (p = 0.840). Furthermore, Kaplan-Meier survival curve analysis revealed that the abovementioned six indicators were correlated with the post-AHA survival time of elderly patients with femoral neck fractures (pLog Rank  < 0.05).

CONCLUSION

Old age, preoperatively high NRS and ASA score, anemia, poor renal function, and postoperative hypoproteinemia are the major risk factors for death in elderly patients with femoral neck fractures after AHA; they are also associated with postoperative survival. Early identification and effective interventions for optimization of modifiable risk factors are recommended to improve the postoperative quality of life and survival rates.

Can the prognostic score proposed by Elliot serve as an educational tool to shorten the time to surgery for hip fractures in geriatric patients?

INTRODUCTION

Hip fractures require surgical treatment within 48hours to decrease the risk of postoperative complications. Elliott proposed a prognostic score to identify which patients should be prioritized for surgery. This study was designed to answer the following questions: 1- Does using this score shorten the time to surgery? 2- Does shortening the time to surgery reduce mortality at 6 months and 1 year? 3- What factors delay the surgical procedure? We hypothesized that using this score as an educational tool would reduce the time to surgery in patients over 75 years of age who have a hip fracture.

MATERIAL AND METHODS

This single-center study involved two populations: 244 patients were included prospectively who had the score applied with the aim of optimizing the time to surgery; 476 patients were included from a historical cohort to serve as a reference group.

RESULTS

The mean time to surgery was 2.5 days±1.9 [95% CI: 2.41-2.77] and the median was 2 days (minimum 0, maximum 18 days) in the reference group; the mean was 1.4 days±1.0 [95% CI: 1.46-1.67] and the median was 1 day (min. 0, max 6 days) in the prospective cohort, which was a significant reduction (p<0.001). At 6 months, the mortality rate was 22.5% in the reference population and 23% in the prospective cohort. At 1 year, the mortality rate was 47% and 46%, respectively, with no significant difference. Surgical delays were attributed to lack of OR availability, management of anticoagulants, request for cardiac ultrasound and administrative reasons.

DISCUSSION/CONCLUSION

Elliot's prognostic at-risk score for hip fracture can shorten the time to surgery when used an educational tool to raise the medical staff's awareness of the benefits of rapid surgical care.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Hip fractures after 60 years of age in France in 2005-2017: Nationwide sample of statutory-health-insurance beneficiaries

BACKGROUND

Proximal femoral factures (PFFs) constitute a heavy medical, social, and economic burden. Overall, orthopaedic conditions vary widely in France regarding the patients involved and treatments applied. For PFFs specifically, data are limited. Moreover, the ongoing expansion of geriatric orthopaedics holds promise for improving overall postoperative survival. The objectives of this retrospective study of a nationwide French database were: 1) to describe the pathway of patients with PFFs regarding access to care, healthcare institutions involved, and times to management; 2) to look for associations linking these parameters to post-operative mortality.

HYPOTHESIS

Across France, variations exist in healthcare service availability and time to management for patients with PFFs.

MATERIAL AND METHODS

A retrospective analysis of data in a de-identified representative sample of statutory-health-insurance beneficiaries in France (Échantillon généraliste des bénéficiaires, EGB, containing data for 1/97 beneficiaries) was conducted. All patients older than 60 years of age who were managed for PFFs between 2005 and 2017 were included. The following data were collected for each patient: age, management method, Charlson's Comorbidity Index (CCI), home-to-hospital distance by road, and type of hospital (public, non-profit private, or for-profit private), and time to surgery were collected. The study outcomes were the incidence of PFF, mortality during the first postoperative year, changes in mortality between 2005 and 2017, and prognostic factors.

RESULTS

In total 8026 fractures were included. The 7561 patients had a median age of 83.8 years and a mean CCI of 4.6; both parameters increased steadily over time, by 0.18 years and 0.06 points per year, respectively (p<10-4 for both comparisons). Management was by total hip replacement in 3299 cases and internal fixation in 4262 cases; this information was not available for 465 fractures. The overall incidence increased from 90/100,000 in 2008 to 116/100,000 in 2017 (p=0.03). Of the 8026 fractures, 5865 (73.1%) were managed in public hospitals (and this proportion increased significantly over time), 1629 (20.3%) in non-profit private hospitals (decrease over time), and 264 (3.3%) in for-profit private hospitals. The home-to-hospital distance ranged from 7.5 to 38.5km and increased over time by 0.26km/year (95% confidence interval [95%CI]: 0.15-0.38) (p<10-4). Median time to surgery was 1 day [1-3 days], with no significant difference across hospital types. Mortality rates at 90 days and 1 year were 10.5% (843/8026) and 20.8% (1673/8026), respectively. Two factors were significantly associated with day-90 mortality: the CCI (hazard ratio [HR], 1.087 [95%CI: 1.07-1.10] [p<10-4]) and time to surgery>1 day (HR 1.35 [95%CI: 1.15-1.50] [p<0.0001]). Day-90 mortality decreased significantly from 2005 to 2017 (HR 0.95 [95%CI: 0.92-0.97] [p<10-4]), with no centre effect.

CONCLUSION

The management of PFF in patients older than 60 varied widely across France. Time to surgery longer than 1 day was a major adverse prognostic factor whose effects persisted throughout the first year. This factor was present in over half the patients. Day-90 mortality decreased significantly from 2005 to 2017 despite increases in age and comorbidities.

LEVEL OF EVIDENCE

IV Retrospective cohort study.

Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients

BACKGROUND

Bone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to (1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS grade 2 or 3: BCIS gr2/3, and (2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA.

HYPOTHESIS

Large wedge-shaped (or "shape-closed") femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA.

PATIENTS AND METHODS

A total of 128 OFNF patients, who aged over 75years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3.

RESULTS

The prevalence of overall BCIS and BCIS-gr2/3 was 32.8% (n=42) and 6.2% (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3% and 4.7%, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5% vs. 10.0%, p=0.001). Multivariate analysis showed that age>90years (OR=9.4, 95% CI: 1.4-62.9, p=0.02), preinjury Parker mobility score<4 (OR=48.8; 95% CI: 2.7-897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95% CI: 1.8-204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients.

CONCLUSION

BCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Trajectories and prognostic factors for recovery after hip fracture: a longitudinal cohort study

PURPOSE

The aim of this study was to determine recovery trajectories and prognostic factors for poor recovery in frail and non-frail patients after hip fracture.

METHODS

Patients with a hip fracture aged 65 years and older admitted to a hospital in the Netherlands from August 2015 to November 2016 were asked to complete questionnaires at one week and one, three, six, 12, and 24 months after injury. The questionnaires included the ICEpop CAPability measure for older people, Health Utility Index, and the Hospital Anxiety Depression Scale. Latent class trajectory analysis was used to determine trajectories of recovery. Patient and injury characteristics for favourable and unfavourable outcome were compared with logistic regression.

RESULTS

In total, 696 patients were included of which 367 (53%) patients were frail. Overall, recovery trajectories in frail patients were worse compared to trajectories in non-frail patients. In frail patients, poor recovery was significantly associated with dementia. Lower age was a prognostic factor for good recovery. Immobility, loneliness and weight loss were prognostic for respectively poor capability and symptoms of anxiety and depression. In non-frail patients, recovery after hip fracture was associated with loneliness and the type of hip fracture.

CONCLUSION

Although frailty is associated with poor recovery in older patients with hip fracture, a large proportion of frail patients show good recovery. Loneliness determines poor recovery with anxiety and depressive symptoms.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT02508675 (July 27, 2015).