Survival and functional outcome in patients 90 years of age or older after hip fracture

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.

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.

Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study

Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.

INTRODUCTION

Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.

METHODS

A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m² and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.

RESULTS

A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P₂₅-P₇₅ 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.

CONCLUSION

Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.

Outcomes in Nonagenarians with Hip Fractures Treated Conservatively and Surgically

Introduction

We aimed to assess the clinical outcomes in nonagenarians following a hip fracture. We also further investigated the factors that influence these outcomes, such as method of treatment (operative versus conservative), co-morbidities, and pre-morbid function.

Materials and methods

We studied 65 nonagenarians that were identifiable from our hospital hip fracture database. We reviewed various parameters of these patients admitted after sustaining a hip fracture (neck of femur or intertrochanteric) and investigated how these parameters affected patient outcomes. The main outcomes studied were: inpatient morbidity, and mortality at one year.

Results

Inpatient morbidity was more likely in patients with an ASA grade of 3 to 5. Urinary tract infection was the most common medical complication. The 1-year mortality was 15.4% and was significantly influenced by advancing age. Surgically managed patients had a 1-year mortality rate (14.3%) slightly less than non-operative patients (17.4%). Post injury mobility was significantly better in those who received operative treatment with 63% of surgical cases regaining ambulatory status versus 7% of conservatively managed patients.

Conclusions

We presented the outcomes of hip fractures in an extreme age group in the population. In nonagenarians with hip fractures surgery was associated with a 1-year mortality rate of 14.3% which is comparable to the general hip fracture population and less than the mortality rate of conservatively managed patients (17.4%). The primary advantage of surgery would be that two-thirds of patients return to ambulatory status. This information is useful to counsel patients and their families especially since the elderly are often more fearful of surgical intervention.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of mobilization and weight bearing on in-hospital outcome in geriatric patients with hip fractures

INTRODUCTION

Early recovery of mobilization after a fracture of the hip is associated with improved long-term ability to walk, lower complication rates, and mortality. In this context, early mobilization and full weight bearing are favorable. The aim of this study was (1) to analyze the influence of time between operation and first mobilization on in-hospital outcome and (2) the influence of early mobilization, full weight bearing, and ASA on pain, mobility of the hip, and ability to walk during the in-hospital phase of recovery.

METHODS

This is a retrospective in-hospital study of 219 patients aged 70 years or older who were treated with surgery after a hip fracture. Data were collected by a review of medical records. The outcomes were mortality, complications, length of stay, and the Merle d'Aubigné score which evaluates pain, mobility of the hip, and ability to walk. Factors were sought in bivariate and multivariate analyses.

RESULTS

A shorter time between operation and first mobilization was significantly associated with lower in-hospital mortality and complications. Early mobilization (within 24 h after the operation) and full weight bearing had no influence on pain, mobility of the hip, and ability to walk as well as length of stay in our cohort. Fracture type and treatment influenced mobility of the hip, while age as well as physical health status affected the ability to walk.

DISCUSSION

Patients with femoral neck fractures, respectively after total hip arthroplasty, had less pain and showed better mobility of the hip and ability to walk during hospitalization than patients with trochanteric fractures; these results were irrespective of early vs. late mobilization and full vs. partial weight bearing. Foremost, a shorter time between operation and first mobilization is associated with lower complication and mortality rates.

Impact of rehabilitation on mortality and readmissions after surgery for hip fracture

Background

Hip fracture in elderly patients is a rising global public health concern because of population ageing, and increasing frailty. Long-term morbidity related to poor management of hip fracture is associated with decreased quality of life, survival, and increase in healthcare costs. Receiving postoperative rehabilitation is associated with better outcomes and a higher likelihood of returning to pre-existing level of functioning. However little is known about which postoperative rehabilitation pathways are more effective to optimize patient outcomes. Few studies have analyzed postoperative rehabilitation pathways in a universal healthcare system. The aim of this study is to analyze the impact of post-acute rehabilitation pathways on mortality and readmission in elderly patients undergoing surgery for hip fracture in a large metropolitan area in Italy.

Methods

In this retrospective cohort study, we analyzed 6-month mortality from admission and 6-month readmission after hospital discharge in patients who underwent surgical repair for hip fracture in the hospitals of the Bologna metropolitan area between 1.1.2013 and 30.6.2014. Data were drawn from the regional hospital discharge records database. Kaplan-Meier estimates and multiple Cox regression were used to analyze mortality as a function of rehabilitation pathways. Multiple logistic regression determined predictors of readmission.

Results

The study population includes 2208 patients, mostly women (n = 1677, 76%), with a median age of 83.8 years. Hospital rehabilitation was provided to 519 patients (23.5%), 907 (41.1%) received rehabilitation in private inpatient rehabilitation facilities (IRF) accredited by the National Health System, and 782 (35.4%) received no post-acute rehabilitation. Compared with patient receiving hospital rehabilitation, the other groups showed significantly higher mortality risks (no rehabilitation, Hazard Ratio (HR) = 2.19, 95%CI = 1.54–3.12, p < 0.001; IRF rehabilitation, HR = 1.66, 95%CI = 1.54–1.79, p < 0.001). The risk of readmission did not differ significantly among rehabilitation pathways.

Conclusions

Intensive hospital rehabilitation was significantly associated with a lower risk of mortality compared to IRF rehabilitation and no rehabilitation. Our results may help in the development of evidence-based recommendations aimed to improve resource utilization and quality of care in hip fracture patients. Further research is warranted to investigate the impact of the rehabilitation pathway on other outcomes, such as patients’ functional status and quality of life.

Patients' preferences and existential perspective: what to consider and how should patient's expectations be guided?

With an ageing population, surgical procedures in older patients are becoming increasingly more common. This can pose clinical and ethical dilemmas, during which clinicians need to make complex decisions. In this paper we discuss the importance of assessing mental capacity to assess if the older patient can make his or her own decisions relating to surgery. We also discuss the importance of understanding ethical principles, in order that clinicians can better guide patient's decision-making. In addition, we look at ageism, frailty, and co-morbidities, and their influence on clinician's decisions regarding surgery in older patients. Further to this, we look at the influence of evidence-based medicine on treatment options, and the under representation of older people in clinical trials and the importance of this. Finally, we consider the importance of considered decisions regarding resuscitation, when considering surgical intervention in older patients. We conclude that patient-centred individualised care, considering patients expectations, wishes, and priorities is vital, whilst aiming to improve or maintain quality of life, and minimise risks when able.

Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures

BACKGROUND

The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality.

METHODS

Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery.

RESULTS

Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036).

CONCLUSIONS

Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.

Periprosthetic femoral fractures after hemiarthroplasty. An analysis of 17 cases

PURPOSE

To describe the characteristics of patients with periprosthetic femoral fractures after hemiarthroplasty and analyze their treatment.

MATERIAL AND METHOD

An observational, longitudinal, retrospective study was conducted on a series of 17 patients with periprosthetic femoral fractures after hip hemiarthroplasty. Fourteen fractures were treated surgically. The characteristics of patients, fractures and treatment outcomes in terms of complications, mortality and functionality were analyzed.

RESULTS

The large majority (82%) of patients were women, the mean age was 86 years and with an ASA index of 3 or 4 in 15 patients. Ten fractures were type B. There were 8 general complications, one deep infection, one mobilization of a non-exchanged hemiarthroplasty, and 2 non-unions. There were 85% consolidated fractures, and only 5 patients recovered the same function prior to the injury. At the time of the study 9 patients had died (53%).

DISCUSSION

Periprosthetic femoral fractures after hemiarthroplasty will increase in the coming years and their treatment is difficult.

CONCLUSION

Periprosthetic femoral fractures after hemiarthroplasty are more common in women around 90 years-old, and usually occur in patients with significant morbidity. Although the Vancouver classification is reliable, simple and reproducible, it is only a guide to decide on the best treatment in a patient often fragile. The preoperative planning is essential when deciding a surgical treatment.

Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians

BACKGROUND

The number of hospitalized nonagenarians is increasing. Only a few studies have evaluated long-term predictors of survival in these patients. The aim of this study was to determine the 5-year outcome of a cohort of hospitalized nonagenarians, and to identify predictors of long-term survival.

METHODS

In 124 consecutive medical hospitalized patients older than 89 years, and followed up during 5 years, the following variables were prospectively recorded: sociodemographic characteristics, main diagnoses, Charlson comorbidity index, Barthel index, Lawton-Brody test, Mini-Mental State Examination, Short Portable Mental Status Questionnaire of Pfeiffer, Mini Nutritional Assessment, albumin levels, and the 5-year survival.

RESULTS

Out of the 124 patients, 109 died (87.9%) during the follow-up. The probability of being alive at 1, 3 and 5 years was 45%, 22% and 12%, respectively. A worse 5-year survival was significantly related to the diagnoses of pneumonia (p=0.037), heart failure (p=0.045), higher Charlson index (p=0.026), poorer functional status measured by the Barthel index (p=0.003), and the Lawton-Brody test (p=0.007), cognitive impairment measured by the Pfeiffer test (p=0.011), and lower levels of albumin (p=0.028). In the multivariate analysis, the Charlson index (p<0.001), and the Barthel index (p=0.003) were independently related to 5-year survival. These two variables were also 5-year survival prognostic factors in the subgroup of discharged patients. A prognostic index using these two variables was created: PI=(0.2 × Charlson index + 0.6 × Barthel index) × 0.92.

CONCLUSIONS

In hospitalized nonagenarian patients, poor scores in the Barthel Index and a higher comorbidity evaluated by the Charlson index are independently related to 5-year survival.

Nonagenarian hip fracture: treatment and complications

BACKGROUND

Hip fracture is a common yet serious injury sustained by the elderly patient and represents one of the major healthcare challenges today. The aim of this study was to better define the unique characteristics of treating nonagenarian peritrochanteric hip fractures and their subsequent complications during hospital stay.

METHODS

Seven hundred twenty-two patients underwent surgery for isolated fracture around the femoral neck. These patients were divided into one of three age groups: A, <50 years; B, 51-89 years; and C, >90 years. We performed a retrospective chart review to compare these groups in terms of patient characteristics, comorbidities, postoperative complications, fracture type, type of surgery performed, and mortality rate.

RESULTS

There was no difference in time to surgery between groups. Comorbidities were similar in groups B and C but were higher than group A. Nonagenarians received a significantly greater percentage of hemiarthroplasties compared with those aged 51 years to 89 years. Cardiac complications were significantly higher in group C. In patients with sustained cardiac complications, the odds ratio for mortality was 15.88.

CONCLUSIONS

Our results suggest that groups B and C were not significantly different pre- or intraoperatively. Nevertheless, there is an increase in cardiac complications and mortality in nonagenarians postoperatively. Nonagenarians should undergo similar treatment in the operating room compared with less elderly patients with the caveat that older patients, especially those with cardiac disease, may be more at risk for complication. The surgeon must evaluate the elderly patient with a hip fracture on a case-by-case basis, while ignoring chronological age.

LEVEL OF EVIDENCE

III, prognostic study.

Proximal femoral nail antirotation versus hemiarthroplasty: a study for the treatment of intertrochanteric fractures

Intertrochanteric fractures in elderly patients are always associated with poor prognosis in the functional outcome as a result of the complications and mortality. A retrospective study was performed in our institution, 303 consecutive patients were followed up with mean age of 81.7 years. 147 were treated with PFNA, and 156 were underwent hemiarthroplasty. The average follow-up period was 39.9 months. The mortality at 1 month, 1 year, 3 years and the total was 6.6%, 18.6%, 27.6% and 30.3%, respectively. There were no significant differences between the groups in terms of demographic data. There were statistical significances in the operative statistics, especially the anaesthesia, operation lasting time, blood loss, blood transfusion and the drainage. There was no significant difference in Harris Hip Score between PFNA and hemiarthroplasty group, but the detail items were quite different. Significant difference was found in the excellent-to-fine rate (PFNA 90.2% and hemiarthroplasty 79.6%). Complications occurred in 34 patients, although incidences of complications were higher in hemiarthroplasty group (14.1% vs. PFNA 8.96%), no statistical difference was found. For elderly patients with intertrochanteric fractures, PFNA was superior to hemiarthroplasty according to the operative statistics, but there were no significant differences in functional outcome.