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

Open and closed ankle fracture treatment in Japanese nonagenarians and octogenarians: Mortality, surgical site infections and readmissions

BACKGROUND

Several publications have suggested that elderly patients with open ankle fractures may have grave prognosis in terms of mortality, similarly to elderly patients with hip fractures. In this study we evaluated the effect of open ankle fractures on patient mortality in elderly population, including octogenarians and nonagenarians.

METHODS

This retrospective cohort included all patients above the age of 60 treated in Japan public emergency care hospitals between the years 2010 and 2018. Patients with lateral malleolus, medial malleolus, bimalleolar, trimalleolar and pilon fractures were included. The outcomes were mortality, length of hospital stay, surgical site infections and readmissions within one year.

RESULTS

There was a total of 6766 patients ages above 60, of whom 6062 had closed fractures and 704 had open fractures. Open fractures were not associated with higher mortality than closed fractures. Patients with open fractures stayed in the hospital for longer time (median of 51 vs 37 days, p < 0.001), had higher rate of surgical site infections (5.3 % vs 1.7 %, p < 0.001) and a lower rate of readmissions (2.6 % vs 6.2 %, p < 0.001).

CONCLUSION

The study shows that elderly patients with open ankle fractures are hospitalized for longer time and experience a higher rate of surgical site infections. However, they do not experience excess short-term mortality in this study setting.

LEVEL OF EVIDENCE

IV (non-experimental study).

Functional outcomes following injury in centenarians: a nationwide retrospective observational study

BACKGROUND

Advances in healthcare and the development of various technologies have improved disease-free longevity. Although the number of healthy centenarians is gradually increasing, studies on postinjury functions among centenarians are lacking. Therefore, we aimed to determine the clinical predictors of mortality and unfavorable functions after injury among centenarians.

METHOD

A retrospective study was conducted using a nationwide trauma database, and data from patients aged ≥ 100 years across ≥ 250 institutions during 2019-2022 were analyzed. Patient demographics, comorbidities, mechanism of injury, injury severity, vital signs on arrival, and pre- and in-hospital treatments were compared between survivors and non-survivors as well as between survivors who had and did not have the ability to live independently at discharge, which was defined as Glasgow Outcome Scale (GCS) score of ≤ 3. Independent predictors of in-hospital mortality and unfavorable functions after injury were examined using a generalized estimating equation model to account for institutional and regional differences in the management and characteristics of centenarians.

RESULTS

Of the 409 centenarians, 384 (93.9%) survived to discharge. Although 208 (50.9%) patients had lived independently before the injury, only 91 (22.2%) could live independently at discharge. All patients had blunt injury, and fall from standing was the most frequent (86.6%) mechanism. The injury severity score was 10 ± 5, and surgery/angiography was performed in < 2% of the centenarians, except for fracture fixation in the extremity/pelvis, which was conducted in 225 (55.0%) patients. The adjusted model revealed three independent predictors of in-hospital mortality: male gender, mechanism of injury other than fall from standing, and GCS score on arrival. In contrast, only injury severity in the extremity/pelvis was an independent predictor of unfavorable functions after injury.

CONCLUSION

Male gender, mechanisms of injury other than fall from standing, and GCS on arrival were associated with higher in-hospital mortality. Injury severity in the extremity/pelvis was related to dependent living after injury among centenarians.

Characteristics, outcomes, and complications among nonagenarian and centenarian patients admitted to the intensive care unit: a scoping review

INTRODUCTION

Nonagenarians and centenarians are a growing and vulnerable groups of patients admitted to ICU. There is limited information on their characteristics, outcomes, and complications.

METHODS

We performed a scoping review of studies focused on nonagenarians and centenarians admitted to ICU. We assessed their characteristics, the presence of frailty, the presence of comorbidities, their complications, their ICU and hospital length of stay and mortality and their long-term outcomes.

RESULTS

We assessed 36 studies, mostly retrospective, with one classified as a National Quality Registry study and another as a prospective analysis of two large multinational cohorts. The studies involved 16,859 patients with a mean age of 92.4 years and a male prevalence of 39.3%. Multiple comorbidities were present in the majority of patients. Overall, 40.7% of patients received mechanical ventilation, with a median of 36% (range: 0%-100%; IQR: 23.8%-50%). Mean duration of mechanical ventilation was 90.4 h, with a median of 84 h (range: 10-221 h; IQR: 12.25-146.5 h). Cardiovascular and renal complications were common. Mean ICU stay across studies was 5.4 days, with a median of 5 days (range: 0.9-13 days; IQR: 2.55-7.03 days). The median length of hospital stay was 12.4 days (range: 5.7-31 days; IQR: 11-17.6 days). The median hospital mortality was 25.55% (range: 0%-62.5%; IQR: 15%-35.5%). The mean six-month and 1-year mortality rates were 38.6% and 45.6%, respectively.

CONCLUSIONS

Nonagenarians and centenarians admitted to ICU are a highly comorbid and vulnerable population who experience prolonged hospital stays and complications. However four out of five survive to hospital discharge and half are alive at one year after admission. Therefore, through judicious patient selection, ICU care can be both meaningful and beneficial. Our findings underscore the need for a standardized reporting structure for nonagenarians and centenarians admitted to the ICU to allow comparability across studies, enhanced data quality and reliability, greater research efficiency, and better identification of the unique health needs in this vulnerable patient cohort.

Comparison of Hemiarthroplasty, total hip arthroplasty, and internal fixation for hip fractures in patients over eighty years of age: factors affecting mortality: a nationwide cohort study of fifty three thousand, four hundred and ninety five patients from Türkiye

PURPOSE

Hip fractures are a common cause of mortality in elderly patients. This study aimed to determine the predictive factors affecting mortality among patients over the age of 80 who underwent surgical treatment for hip fractures.

METHODS

We searched the Turkish Ministry of Health's e-health database to identify patients over 80 years old who had undergone surgery for proximal femoral fractures from 2016 to 2022. This process yielded 53,495 patients. Demographic data as well as comorbidities, blood transfusions, postoperative 90 days medical complications, and mortality was investigated. Multivariate logistic regression analysis was performed to identify risk factors for one year mortality in patients undergoing surgical treatment for proximal hip fractures.

RESULTS

The mortality rate was 37.2% in the first year. The mean Charlson comorbidity index(CCI) was 6.8 (range: 4-22). In the postoperative period, 68.6% of the patients received blood transfusions. Logistic regression analysis identified significant predictors of one-year mortality in surgical patients, including male gender, increased age, higher CCI scores, AKI, PE, pneumonia, electrolyte imbalance, gastrointestinal bleeding, blood transfusion, and increased mortality risks with hemiarthroplasty and internal fixation compared to total hip arthroplasty. (p < 0.001 for all).

CONCLUSIONS

This large cohort study demonstrated that the mortality rate is high and that the type of surgery, male gender, older age, blood transfusion requirements, and high CCI score are associated with mortality in patients over 80 years of age who have undergone surgery for hip fractures. Preoperative optimization and postoperative care are critical for these vulnerable elderly patients.

Trends and mortality in hip fracture surgery among octogenarians, nonagenarians, and centenarians: high postoperative mortality in centenarians despite few comorbidities

INTRODUCTION

The older population, especially centenarians, is growing. Hip fractures significantly affect this demographic; however, studies on centenarians are limited. This study aimed to compare hip fracture mortality and associated risk factors between centenarians, nonagenarians, and octogenarians with focus on centenarians.

METHODS

Data from the Korean Health Insurance Review and Assessment database were retrospectively analyzed. Individuals aged ≥ 80 years with an ICD-10 diagnosis code (S72) and procedure codes indicative of hip fracture surgery between 2012 and 2022 were included. The primary outcome was mortality at 1, 3, 6 months, and 1 year postoperatively. The secondary outcomes included the prevalence of comorbidities and postoperative complications.

RESULTS

131,746 patients were included (106,244 [80.6 %] octogenarians, 24,842 [18.9 %] nonagenarians, and 660 [0.5 %] centenarians). Centenarians had lower Charlson Comorbidity Index than that of nonagenarians and octogenarians (4.4, 4.9, and 5.7, respectively; P < 0.000). However, perioperative medical complications such as acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), pneumonia, sepsis, and urinary tract infection increased linearly with age, significantly affecting centenarians. Mortality rates were highest in centenarians, especially within the first 3 postoperative months. The risk factors for 3-month mortality included the male sex (odds ratio [OR] 1.79, 95 % confidence interval [CI] 1.01-3.12, P = 0.046), and heart failure (OR 1.72, 95 % CI 1.07-2.79, P = 0.026) preoperatively, and AKI (OR 3.92, 95 % CI 1.97-7.82, P < 0.000), ARDS (OR 2.92, 95 % CI 1.04-8.23, P = 0.04), pneumonia (OR 1.91, 95 % CI 1.11-3.29, P = 0.02), and sepsis (OR 10.01, 95 % CI 3.52-28.45, P < 0.000) postoperatively.

CONCLUSION

Despite having fewer comorbidities, centenarians had the highest postoperative mortality, primarily due to organ dysfunction such as pneumonia, AKI, ARDS, and sepsis, rather than vascular events. Tailored medical management strategies focusing on these complications are crucial for improving centenarians outcomes.

Characteristics, outcomes and complications among nonagenarians and centenarians admitted to intensive care: a scoping review protocol

INTRODUCTION

Nonagenarians and centenarians, compared with other age groups, often exhibit distinct physiological characteristics and a higher prevalence of comorbidities, thus further complicating their care in intensive care unit (ICU) settings. Despite the increasing number of such patients being admitted to ICUs, comprehensive research and studies on their characteristics, outcomes and complications during their ICU stays remain lacking. This scoping review will comprehensively address the following question: What are the characteristics, outcomes, complications and mortality rates among nonagenarians and centenarians admitted to ICUs, including their preadmission health status, reasons for admission, duration of hospital/ICU stays, and factors associated with adverse outcomes? The key objectives are to map the breadth and depth of the available evidence and identify key concepts, gaps and variations in research focus. Finally, we aim to highlight well-studied areas suitable for systematic synthesis, point to underexplored topics warranting further investigation and propose standardised approaches to research design and reporting in this domain.

METHODS AND ANALYSIS

We will conduct a systematic search of MEDLINE, Embase and the Cochrane Library in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. All studies and publications reporting data on patients aged ≥90 years will be included, from an unlimited timeline to 31 August 2024. Studies reporting the characteristics, outcomes and complications of nonagenarians and centenarians admitted to ICUs will be included. The data will be analysed and summarised descriptively through a narrative approach. Qualitative data related to quality-of-life outcomes will be analysed thematically, as applicable.

ETHICS AND DISSEMINATION

Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.

Prognostic Factors for Mortality in Patients Aged 90 Years and Older with Proximal Femoral Fractures Undergoing Surgery: A Retrospective Study

Background/Objectives: Proximal femoral fractures (PFFs) among individuals aged ≥90 years are becoming more common with an aging population and are associated with high morbidity and mortality. This study analyzed the prognostic factors influencing survival in nonagenarian patients undergoing surgery for PFFs. Methods: We enrolled 285 patients who underwent surgery between 2016 and 2022. Patients were classified into two groups: those with postoperative survival >1 year (L) and those with postoperative survival ≤1 year (D). Factors assessed included age, sex, body mass index (BMI), cognitive impairment, fracture type, surgical timing, length of hospital stay, implant type, preoperative hemoglobin/albumin/white blood cell levels, and Geriatric Nutritional Risk Index (GNRI). Results: The mean age at surgery was 93.2 ± 2.8 years (mean follow-up = 18.9 months). The 12-month mortality rate was 28.8%. Intertrochanteric fractures were observed in 136/47 patients, and femoral neck fractures were observed in 67/35 patients in the L/D group, respectively (p = 0.13). Days from admission to surgery were not significantly associated with mortality (p = 0.56). The mean hospital stay was 17/22 days in the L/D group, respectively. Univariate analysis identified age, BMI, cognitive impairment, albumin level, and GNRI as statistically significant predictors. Multivariate analysis revealed length of hospital stay (odds ratio [OR] = 1.048 [95% confidence interval (CI): 1.019-1.078]; p = 0.001), cognitive impairment (OR = 3.082 [95% CI: 1.367-6.945]; p = 0.007), and GNRI (OR = 0.929 [95% CI: 0.901-0.958]; p < 0.001) as independent predictors of mortality. Conclusions: This study identified cognitive impairment, a low GNRI, and prolonged hospital stay as independent prognostic factors for 1-year mortality in nonagenarian patients with PFFs. These findings highlight the importance of addressing malnutrition and cognitive decline through tailored interventions, alongside optimizing surgical timing and hospital care. A multidisciplinary approach remains essential for improving survival outcomes in this vulnerable population.

The Perioperative NonaGEnaRIan And cenTenarian suRgICal (GERIATRIC) Risk Stratification Tool

Objective

To develop age-appropriate nonaGEnaRIan And cenTenarian suRgICal (GERIATRIC) risk tool for classifying patients who may or may not develop postoperative complications or die within their index hospital admission.

Background

There are no validated perioperative risk stratification tools for use in nonagenarian and centenarian patients-people aged 90 to 99 years and >100 years.

Methods

In this retrospective observational study, nonagenarians and centenarians undergoing any surgical procedure were profiled. Surgery severity was stratified, and the incidence and grade of postoperative complications were recorded. Multivariable logistic regression analysis was performed on a training cohort, followed by calibration on a validation cohort, followed by performance evaluation on a testing cohort. The discriminative accuracy was compared to that of the age-adjusted Charlson Comorbidity Index for each outcome. The primary outcome was the ability of the risk stratification tool to effectively classify patients into those who may or may not experience a postoperative complications or mortality within their index hospital stay.

Results

A total of 3085 patients were enrolled. The GERIATRIC risk tool had good discriminative accuracy for any postoperative complication [area under the receiver operating characteristic curves (AUROC), 0.857; 95% CI = 0.824-0.890] and any severe postoperative complication (AUROC, 0.833; 95% CI = 0.793-0.874), and fair discriminative accuracy for in-hospital mortality (AUROC, 0.780; 95% CI = 0.668-0.893).

Conclusions

Compared to the age-adjusted Charlson Comorbidity Index, The GERIATRIC risk tool was accurate in classifying patients into those who may or may not experience severe complications or die during their index admission. The tool can be used to assist perioperative clinicians with shared decision-making and short-term prognostication.

Predictive modeling of preoperative acute heart failure in older adults with hypertension: a dual perspective of SHAP values and interaction analysis

BACKGROUND

In older adults with hypertension, hip fractures accompanied by preoperative acute heart failure significantly elevate surgical risks and adverse outcomes, necessitating timely identification and management to improve patient outcomes.

RESEARCH OBJECTIVE

This study aims to enhance the early recognition of acute heart failure in older hypertensive adults prior to hip fracture surgery by developing a predictive model using logistic regression (LR) and machine learning methods, optimizing preoperative assessment and management.

METHODS

Employing a retrospective study design, we analyzed hypertensive older adults who underwent hip fracture surgery at Hebei Medical University Third Hospital from January 2018 to December 2022. Predictive models were constructed using LASSO regression and multivariable logistic regression, evaluated via nomogram charts. Five additional machine learning methods were utilized, with variable importance assessed using SHAP values and the impact of key variables evaluated through multivariate correlation analysis and interaction effects.

RESULTS

The study included 1,370 patients. LASSO regression selected 18 key variables, including sex, age, coronary heart disease, pulmonary infection, ventricular arrhythmias, acute myocardial infarction, and anemia. The logistic regression model demonstrated robust performance with an AUC of 0.753. Although other models outperformed it in sensitivity and F1 score, logistic regression's discriminative ability was significant for clinical decision-making. The Gradient Boosting Machine model, notable for a sensitivity of 95.2%, indicated substantial capability in identifying patients at risk, crucial for reducing missed diagnoses.

CONCLUSION

We developed and compared efficacy of predictive models using logistic regression and machine learning, interpreting them with SHAP values and analyzing key variable interactions. This offers a scientific basis for assessing preoperative heart failure risk in older adults with hypertension and hip fractures, providing significant guidance for individualized treatment strategies and underscoring the value of applying machine learning in clinical settings.

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

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

Outcomes of hip fracture in centenarians: a systematic review and meta-analysis

PURPOSE

Outcomes of hip fractures in centenarians remain underreported owing to the small number of patients reaching 100 years of age. This review aimed to determine outcomes of hip fracture in centenarians and to identify the most common comorbidities among centenarians with hip fracture to better characterise this population.

METHODS

Published and unpublished literature databases, conference proceedings and the reference lists of included studies were searched to the 25th of January 2023. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design.

RESULTS

Twenty-three studies (6970 centenarians) were included (retrospective period: 1990-2020). The evidence was largely moderate to low in quality. One-year mortality following a hip fracture was 53.8% (95% CI 47.2 to 60.3%). Pooled complication rate following a hip fracture in centenarians was 50.5% (95% CI 25.3 to 75.6%). Dementia (26.2%, 95% CI 15.7 to 38.2%), hypertension (15.6%, 95% CI 3.4 to 33.1%), and diabetes (5.5%, 95% CI 1.9 to 10.7%) were the most common comorbidities among centenarians with hip fracture.

CONCLUSION

Hip fractures in centenarians typically involve complex patient presentations with diverse comorbidities. However, the current evidence-base is moderate to low in quality. Effective cross-discipline communication and intervention is suggested to promote treatment outcomes.

Orthogeriatric co-managements lower early mortality in long-lived elderly hip fracture: a post-hoc analysis of a prospective study

OBJECTIVE

To evaluate the clinical effectiveness of orthogeriatric co-management care in long-lived elderly hip fracture patients (age ≥ 90).

METHODS

Secondary analysis was conducted in long-lived hip fracture patients between 2018 to 2019 in 6 hospitals in Beijing, China. Patients were divided into the orthogeriatric co-management group (CM group) and traditional consultation mode group (TC group) depending on the management mode. With 30-day mortality as the primary outcome, multivariate regression analyses were performed after adjusting for potential covariates. 30-day mobility and quality of life were compared between groups.

RESULTS

A total of 233 patients were included, 223 of whom completed follow-up (125 in CM group, 98 in TC group). The average age was 92.4 ± 2.5 years old (range 90-102). The 30-day mortality in CM group was significantly lower than that in TC group after adjustments for (2.4% vs. 10.2%; OR = 0.231; 95% CI 0.059 ~ 0.896; P = 0.034). The proportion of patients undergoing surgery and surgery performed within 48 h also favored the CM group (97.6% vs. 85.7%, P = 0.002; 74.4% vs. 24.5%, P < 0.001; respectively). In addition, much more patients in CM group could walk with or without aids in postoperative 30 days than in the TC group (87.7% vs. 60.2%, P < 0.05), although differences were not found after 1-year follow-up. And there was no significant difference in total cost between the two groups (P > 0.05).

CONCLUSIONS

For long-lived elderly hip fracture patients, orthogeriatric co-management care lowered early mortality, improved early mobility and compared with the traditional consultation mode.

Association between additional weekend rehabilitation and in-hospital mortality in patients with hip fractures

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Methods

A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups.

Results

The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group.

Conclusion

Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted.

Outcomes and complications of nonagenarians undergoing cardiac surgery: a scoping review protocol

INTRODUCTION

Continually rising life expectancy and a shift towards an ageing population are resulting in an increasing population of nonagenarians. By 2030, the global population of nonagenarians is expected to exceed 30 million. The incidence of symptomatic cardiac disease is reported to occur in 25% of those aged over 75 years. Therefore, the number of nonagenarians undergoing cardiac surgery is also expected to increase. A linear relationship between advanced age and surgical risk has previously been demonstrated; however, it is not yet known whether this knowledge extends to the perioperative course and mortality of nonagenarians undergoing cardiac surgery. This scoping review aims to review the literature, assess whether a deficiency exists in the published literature and potentially identify knowledge gaps to guide future efforts to improve the understanding of nonagenarians undergoing cardiac surgery.

METHODS AND ANALYSIS

Following the relevant aspects of the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review guidelines, electronic databases of MEDLINE, EMBASE and the Cochrane Library will be systematically searched, with additional reference tracking of eligible studies. Studies reporting the outcomes of nonagenarians undergoing open cardiac surgery or minimally invasive cardiac surgery requiring cardiopulmonary bypass will be included. Screening and data extraction will be performed by two reviewers independently. The data will be analysed and summarised descriptively with a narrative approach. Qualitative data that capture quality-of-life outcomes will be subjected to thematic analysis where feasible. Additionally, reporting results will highlight similarities and differences in nonagenarian selection for surgery.

ETHICS AND DISSEMINATION

Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures

Objective

The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality.

Materials and Methods

This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality.

Results

We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]).

Conclusion

Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

Would giving priority in surgery timing to the oldest patients result in lower mortality?

PURPOSE

Early hip fracture surgery in elderly patients is recognized as a positive prognostic factor. When applied as an intervention, it does not always reduce overall patient mortality. A plausible explanation for this is that not all patients equally benefit from early surgery. The purpose of the study is to investigate the effect of early surgery on mortality in patients ages 80 and older.

METHODS

This is a retrospective cohort of 3463 patients with hip fractures, operated upon within seven days of admission in a tertiary medical center between 2010 and 2018. Patients were divided into five groups: ages 80-84, 85-89, 90-94, 95-99, and 100 or above. Baseline characteristics were compared between groups. Mortality at one year post-operatively as a function of surgery delay was visualized for each group, using restricted spline curve analysis.

RESULTS

Patients with increasing age were operated on earlier, had increased co-morbidities with a higher ASA score and experienced higher mortality. Spline curve analysis in younger patients, ages 80 to 94, demonstrated an inflection point at 48 hours after admission, prior to which mortality was rising rapidly and after which it continued rising slowly. In the two oldest age cohorts, there was no increased mortality with an increasing surgical delay.

CONCLUSIONS

In patients ages 80-94 surgery on day one may be preferable to surgery on day two. In patients ages 95 and older, surgery time did not influence mortality. Pursuit of better patient outcomes may include prioritizing early surgery in younger patients.

Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients

BACKGROUND

Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population.

AIM

This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

METHODS

This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted.

RESULTS

There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001).

CONCLUSION

The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.

Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study

Background

There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care.

Methods

After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012–December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients.

Results

A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90–94] and the median body mass index was 25.0 (kg/m²) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility.

Conclusion

In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).

Outcomes After Definitive Surgery for Nonagenarians with Isolated Hip Fractures within 24 hours of Admission

BACKGROUND

Isolated hip fractures are a common orthopedic injury in the elderly population. Estimates are that there will be over 21 million hip fractures globally by 2050. Current recommendations are early operative fixation within 48 hours. Despite evidence showing that fixation of hip fractures within 24 hours is beneficial in the elderly population, the effect this has on the nonagenarian population has yet to be examined.

METHODS

This is a single institution retrospective cohort study examining isolated hip fractures from 2014 to 2020 from an American College of Surgeons verified trauma center. Patients ≥65 years old with IHF were included. A total number of 1150 isolated hip fracture patients 65 years or older were included in this study. Three cohorts were examined: (1) patients ≥90 years old; (2) patients 65-89 years old; and (3) patients stratified by ≥90 vs 65-75 years old and ≥90 vs 75-89 years old. Patients were then sub stratified by timing of surgery whether it was performed ≤24 hours or >24 hours. The primary outcome was inpatient mortality.

RESULTS

Nonagenarians who had delayed surgery had higher mortality rates compared to nonagenarians with early surgery (15.2% vs 4.2%; P = .02). Patients aged 65-75 had higher complication rates with delayed surgery (12.9% vs 4.1%; P = .01) as did those aged 76-89 (9.0% vs 3.2%, P = .004).

DISCUSSION

Early surgical intervention of isolated hip fractures in the nonagenarian population within 24 hours is associated with good clinical outcomes as well as a lower inpatient mortality that approaches significance.

Characteristics, comorbidity burden and outcomes in centenarians undergoing surgery in a university hospital: A case series

Introduction

As the population ages, so too does the age of those requiring surgery. People over the age of 100, centenarians, often have a greater degree of comorbidity and frailty than their younger counterparts but may also have a greater incidence of events requiring surgical intervention. There is, however, a dearth of literature describing the clinical course and practical considerations for this vulnerable population undergoing surgery. We aimed to describe the demographics of centenarians undergoing surgery, the procedures they receive, their intraoperative anaesthesia management, and their postoperative outcomes.

Presentation of cases

A retrospective cohort study was completed to understand key perioperative and intraoperative variables linked to improved outcomes. Of the 25 patients included in this study, 22 (88%) were female and the median age was 101 years. Emergency cases predominated (72%) and 44% of surgeries occurred after hours. 60% underwent an intermediate risk surgery, and no centenarians underwent high risk surgery in this study period.

Discussion

64% of patients experienced at least one episode of intraoperative hypotension, with a median 3.5 epochs per patient. 68% of patients experienced postoperative complications and 20% of patients had a complication of Clavien-Dindo severity ≥ III. In centenarians, the risk of high severity postoperative complications was independent of the intrinsic procedural risk.

Conclusion

Centenarian patients have an elevated burden of comorbidity, presenting often in the emergent setting. However, age alone should not preclude surgical intervention as expert multidisciplinary care can have acceptable outcomes.

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Centenarian patients undergoing surgery are frail

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Most centenarian patients experience postoperative complications

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Surgery in centenarians can be feasible and undertaken safely

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Appropriate patient selection leads to acceptable outcomes

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Centenarians should not be denied surgery based on age alone