Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly

The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.

Delay of total joint replacement is associated with a higher 90-day revision rate and increased postoperative complications

PURPOSE

Delay of elective surgeries, such as total joint replacement (TJR), is a common procedure in the current pandemic. In trauma surgery, postponement is associated with increased complication rates. This study aimed to evaluate the impact of postponement on surgical revision rates and postoperative complications after elective TJR.

METHODS

In a retrospective analysis of 10,140 consecutive patients undergoing primary total hip replacement (THR) or total knee replacement (TKR) between 2011 and 2020, the effect of surgical delay on 90-day surgical revision rate, as well as internal and surgical complication rates, was investigated in a university high-volume arthroplasty center using the institute's joint registry and data of the hospital administration. Moreover, multivariate logistic regression models were used to adjust for confounding variables.

RESULTS

Two thousand four hundred and eighty TJRs patients were identified with a mean delay of 13.5 ± 29.6 days. Postponed TJR revealed a higher 90-day revision rate (7.1-4.5%, p < 0.001), surgical complications (3.2-1.9%, p < 0.001), internal complications (1.8-1.2% p < 0.041) and transfusion rate (2.6-1.8%, p < 0.023) than on-time TJR. Logistic regression analysis confirmed delay of TJRs as independent risk factor for 90-day revision rate [OR 1.42; 95% CI (1.18-1.72); p < 0.001] and surgical complication rates [OR 1.51; 95% CI (1.14-2.00); p = 0.04].

CONCLUSION

Alike trauma surgery, delay in elective primary TJR correlates with higher revision and complication rates. Therefore, scheduling should be performed under consideration of the current COVID-19 pandemic.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Development of machine-learning algorithms for 90-day and one-year mortality prediction in the elderly with femoral neck fractures based on the HEALTH and FAITH trials

To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making.

A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes

Objective

To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R).

Data sources

We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases.

Study selection

Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction.

Data extraction

The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared.

Data synthesis

Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group.

Conclusions

Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA.

Level of evidence

Therapeutic level III.

Predictors of Mortality and Refracture in Patients Older Than 65 Years With a Proximal Femur Fracture

OBJECTIVES

To evaluate potential predictors of subsequent fracture and increased mortality in a population 65 years or older who suffered a proximal femur fragility fracture.

METHODS

This was a longitudinal study that included patients with a proximal femur fragility fracture, referred from the Orthopedics Inpatient Department to the Rheumatology Department's Fracture Liaison Service, from March 2015 to March 2017.

RESULTS

Five hundred twenty-two patients were included, with a median age (IQR) of 84 years (interquartile range [IQR], 11 years), 79.7% (n = 416) female. Nine percent (n = 47) suffered a new fracture, with a median time to event of 298 days (IQR, 331 days). Cumulative probability without refracture at 12 months was 93% (95% confidence interval [CI], 90.2%-95.0%); 22.8% (n = 119) patients died, with median time to death of 126 days (IQR, 336 days). Cumulative survival probability at 12 months was 81.7 (95% CI, 77.9-84.8). Neurologic disease (hazard ratio [HR], 2.30; 95% CI, 0.97-5.50; p = 0.06) and chronic obstructive pulmonary disease (HR, 3.61; 95% CI, 1.20-10.9; p = 0.022) were both predictors of refracture. Age older than 80 years (HR, 1.54; 95% CI, 0.99-2.38; p = 0.052), higher degree of dependence (HR, 1.24;95% CI, 1.09-1.42; p = 0.001), male sex (HR, 1.55; 95% CI, 1.03-2.33; p = 0.034), femoral neck fracture (HR, 0.45; 95% CI, 0.24-0.88; p = 0.018), Charlson score (HR, 2.08; 95% CI, 1.17-3.69; p = 0.012), heart failure (HR, 2.44; 95% CI, 1.06-5.63; p = 0.037), hip bone mass density (HR, 3.99; 95% CI, 1.19-13.4; p = 0.025), hip T score (HR, 0.64; 95% CI, 0.44-0.93; p = 0.021), and β-crosslaps (HR, 1.98; 95% CI, 1.02-3.84; p = 0.042) all predicted a higher mortality.

CONCLUSIONS

Neurologic disease and chronic obstructive pulmonary disease may increase the risk of subsequent fracture after a hip fracture. Male sex, age, autonomy degree, femur bone mass density/T score, fracture type, Charlson score, diabetes mellitus, heart failure, and β-crosslaps had significant impact on survival. The authors highlight β-crosslaps as a potential serological marker of increased mortality in clinical practice.

Management of pertrochanteric fractures in patients over 90 years: In-hospital mortality rate, complications and associated risk factors

PURPOSE

This study aims primarily to investigate the outcome following surgical management of pertrochanteric fractures of patients over 90 years compared to the outcome of a control group below 90 years under special consideration of the timing of surgery. The second aim was to analyze potential risk factors for early deaths in very old patients. This study allows us to draw conclusions to minimize complications linked to this particular age segment.

METHODS

The study group consisted of very old patients aged 90 years and older. Geriatric patients aged between 60 and 89 years of age were part of the control group. Type A1 pertrochanteric fractures were typically treated by dynamic hip crews, type A2 and A3 fractures by femoral nails. Full weight bearing physiotherapy was initiated on the day after surgery to improve mobility and muscle strength.

RESULTS

A total of 71 patients belonged to the study group (mean age: 92.5 years ±2.3 years), whereas 223 patients formed the control group (mean age: 79.9 ± 7.4 years). The mortality rate and the number of detected and documented complications were significantly higher in the study group (p = 0.001; p = 0.009, respectively). Despite the significantly higher complication rate in the > 90-year-old patients, there was no significant difference in the mean length of in-hospital-stay between the both groups (> 90 yrs.: 12.1d; < 90 yrs.: 13.1 d) and the timing of surgery.

CONCLUSION

The number of co-morbidities, number of daily-administered medications and the time between admission and surgery have no impact on the outcome. We noticed a longer period between admission and surgery in very old patients who survived. Patients with pertrochanteric fractures should be screened for multimorbidity and cognitive disorders in a standardized manner.

Effects of Anesthesia Techniques on Outcomes after Hip Fracture Surgery in Elderly Patients: A Prospective, Randomized, Controlled Trial

The superiority of distinct anesthesia methods for geriatric hip fracture surgery remains unclear. We evaluated high mobility group box-1 (HMGB1) and interleukin-6 (IL-6) with three different anesthesia methods in elderly patients undergoing hip fracture surgery. Routine blood test findings, postoperative morbidity, and mortality were assessed as secondary outcome. In total, 176 patients were randomized into desflurane (n = 60), propofol (n = 58), or spinal groups (n = 58) that received desflurane-based balanced anesthesia, propofol-based total intravenous anesthesia (TIVA), or spinal anesthesia, respectively. The spinal group required less intraoperative vasopressors (p < 0.001) and fluids (p = 0.006). No significant differences in HMGB1 (p_group×time = 0.863) or IL-6 (p_group×time = 0.575) levels were noted at baseline, postoperative day (POD) 1, or POD2. Hemoglobin, albumin, creatinine, total lymphocyte count, potassium, troponin T, and C-reactive protein were comparable among groups at all time-points. No significant differences in postoperative hospital stay, intensive care unit (ICU) stay, and ventilator use among groups were observed. Postoperative pulmonary, cardiac, and neurologic complications; and in-hospital, 30-day, and 90-day mortality were not significantly different among groups (p = 0.974). In conclusion, HMGB1 and IL-6, and all secondary outcomes, were not significantly different between desflurane anesthesia, propofol TIVA, and spinal anesthesia.

Evaluation of Risk Factors for Falls in Patients with Rheumatoid Arthritis

Background

The aim of our study was to investigate the risk factors for falls in the rheumatoid arthritis (RA) patient population in Poland. This would be a major step towards the development of new fall prevention programs.

Material/Methods

There were 450 RA patients who met the criteria of the American College of Rheumatology who participated in this study. The average age of patient participants was 54.2 years; the average RA duration was 15.1 years. All patients filled out the study questionnaire regarding falls, medications, and diseases, and they filled out the Polish version of the Health Assessment Questionnaire (HAQ).

Results

Of the 400 patients, 203 patients (51%) experienced falls. Out of the 268 falls experienced by study patients, 113 falls (42%) were due to an environmental cause, the remainder 155 falls were caused by health conditions. The number of falls positively correlated with HAQ scores (r=0.42, P<0.01) and the duration of RA (r=0.39, P<0.05). For individuals who had fallen 3 or more times, there was a stronger positive correlation between the number of falls and the total HAQ score (r=0.61, P<0.01). The main risk factors for falls in the study group were dizziness (odds ratio [OR]=3.42), the use of hypotensive medication (OR=2.82), foot deformities (OR=4.09), and a high HAQ score (OR=2.59). Other factors such as drug use (e.g., glucocorticoids), pain, and duration of RA were measured using a visual analogue scale, and were found not to have increased the risk for falls and fractures (P>0.05).

Conclusions

Knowledge about risk factors can help identify high-risk patients to help decrease their risk of falling, thus preventing fall-related injuries.

Lumbar Plexus Block as an Effective Alternative to Subarachnoid Block for Intertrochanteric Hip Fracture Surgeries in the Elderly

Background and Aims:

Elderly patients with hip fractures pose a medical challenge for the anesthesiologist and are often associated with a high incidence of perioperative morbidity and mortality. We aimed to compare the efficacy of lumbar plexus block (LPB) with subarachnoid block (SAB) in elderly patients undergoing closed reduction and internal fixation for hip fractures.

Methods:

In this observational study, 50 patients with femoral intertrochanteric fracture were divided into LPB group and SAB group of 25 each by convenient sampling. Patients in the LPB group were given 20–25 ml of 0.5% bupivacaine to block the ipsilateral lumbar plexus with nerve stimulator assistance, whereas the patients in the SAB group received 0.5% bupivacaine intrathecally. Student's t-test was used for comparing the time for performing block, the time to achieving block, the time to the first request for analgesia, and the hemodynamic variables.

Results:

Lumbar plexus blockade took a longer time for performing and achieving block (P < 0.001). The time for the first request for analgesia was significantly longer in the LPB group (P < 0.001). A statistically significant reduction in blood pressures was noted in the SAB group.

Conclusions:

Lumbar plexus blockade offered more stable intraoperative hemodynamics and longer duration of postoperative analgesia in elderly patients undergoing hip fracture surgery.

The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.

Comparing prophylactic effect of phenylephrine and ephedrine on hypotension during spinal anesthesia for hip fracture surgery

BACKGROUND

Spinal anesthesia is an accepted technique in hip fracture surgery and prevention of this complication by sympathomimetic agents is of potential clinical significance. The aim of this study is to compare the effect of prophylactic phenylephrine versus ephedrine in the prevention of hypotension during spinal anesthesia in hip fracture surgery.

MATERIALS AND METHODS

Ninety-two patients undergoing hip fracture surgery with the American Society of Anesthesiologists I and II were randomized to receive prophylaxis with ephedrine or phenylephrine immediately before the spinal anesthesia. Patients in the ephedrine group received an intravenous (IV) bolus of 10 mg ephedrine, and patients in the phenylephrine group received an IV bolus of 50 μg phenylephrine. We recorded mean arterial pressure (MAP), systolic and diastolic blood pressure, heart rate every 3 min in the first 10 min and then every 5 min until 30 min after spinal anesthesia, nausea and vomiting, additional vasopressor, and atropine administration.

RESULTS

The frequency of hypotension was significantly lower in MAP, systolic and diastolic pressure in group phenylephrine in 3, 6, and 9 min after spinal anesthesia (P = 0.002, P = 0.001). There were no significant differences between two groups in heart rate at different time of study. In the phenylephrine group, lower additional vasopressor was used (8.7% and 23.9%) (P = 0.04). There were no significant differences between two groups in the use of atropine (P = 0.24), nausea and vomiting.

CONCLUSION

At the doses of ephedrine and phenylephrine administered in this trial, phenylephrine was better to prevent hypotension during hip fracture surgery with spinal anesthesia. Higher frequency of hypotension was observed in the ephedrine group.

[Pertrochanteric femoral fractures in the elderly]

Pertrochanteric fractures are one of the most common injuries in the elderly and due to the demographic changes the incidence and importance of this fracture entity will even increase in the future. The dynamic hip screw (DHS) has been used as the gold standard implant in the treatment of pertrochanteric femoral fractures for many years but recent studies have shown that cephalomedullary nails have some advantages. Due to the high incidence, operative treatment of these fractures is part of the standard repertoire of trauma surgeons and this article therefore provides an overview of existing knowledge and new trends in the treatment of pertrochanteric femoral fractures.

Anaesthesia for hip fracture surgery in adults

BACKGROUND

The majority of people with hip fracture are treated surgically, requiring anaesthesia.

OBJECTIVES

The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014).

SELECTION CRITERIA

We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I(2) < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group.

MAIN RESULTS

In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I(2) = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I(2) = 0%. Based on four studies that included 559 participants, we did not find a difference in the risk of myocardial infarction: RR 0.89, 95% CI 0.22 to 3.65; I(2) = 0%. Based on six studies that included 729 participants, we did not find a difference in the risk of cerebrovascular accident: RR 1.48, 95% CI 0.46 to 4.83; I(2) = 0%. Based on six studies that included 624 participants, we did not find a difference in the risk of acute confusional state: RR 0.85, 95% CI 0.51 to 1.40; I(2) = 49%. Based on laboratory tests, the risk of deep vein thrombosis was decreased when no specific precautions or just early mobilization was used: RR 0.57, 95% CI 0.41 to 0.78; I(2) = 0%; (number needed to treat for an additional beneficial outcome (NNTB) = 3, 95% CI 2 to 7, based on a basal risk of 76%) but not when low molecular weight heparin was administered: RR 0.98, 95% CI 0.52 to 1.84; I(2) for heterogeneity between the two subgroups = 58%. For neuraxial blocks compared to general anaesthesia, we rated the quality of evidence as very low for mortality (at 0 to 30 days), pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, decreased rate of deep venous thrombosis in the absence of potent thromboprophylaxis, and return of patient to their own home. The number of studies comparing other anaesthetic techniques was limited.

AUTHORS' CONCLUSIONS

We did not find a difference between the two techniques, except for deep venous thrombosis in the absence of potent thromboprophylaxis. The studies included a wide variety of clinical practices. The number of participants included in the review is insufficient to eliminate a difference between the two techniques in the majority of outcomes studied. Therefore, large randomized trials reflecting actual clinical practice are required before drawing final conclusions.

[Early complication rate of fractures close to the hip joint. Dependence on treatment in on-call services and comorbidities]

BACKGROUND

Guidelines advocate early surgery for proximal femoral fractures so that operations are frequently performed in on-call duty times. Multimorbid patients also suffer more frequently from postoperative complications. Does on-call duty or night shift services correlate with higher postoperative complication rates and what influence do comorbidities have?

PATIENTS AND METHODS

In 300 patients (> 65 years) postoperative surgical and non-surgical complications were documented and correlated with comorbidities, on-call duty and night shift service times.

RESULTS

Postoperative complications were observed in 10.7 % of surgical and 62 % of non-surgical cases. Surgery in on-call duty and night shift times did not increase the postoperative complication rate. Comorbidities, age and ASA classification correlated with postoperative complications which significantly prolonged hospital stay.

CONCLUSION

Surgery of proximal femoral fractures in on-call duty and night shift times is justified because postoperative complications are not increased. Comorbidities and higher age correlated with postoperative complications. Postoperative complications should be avoided because they result in prolonged hospital stay.

Propensity Score–matched Comparison of Postoperative Adverse Outcomes between Geriatric Patients Given a General or a Neuraxial Anesthetic for Hip Surgery

Background:

The effects of the mode of anesthesia on major adverse postoperative outcomes in geriatric patients are still inconclusive. The authors hypothesized that a neuraxial anesthetic (NA) rather than a general anesthetic (GA) would yield better in-hospital postoperative outcomes for geriatric patients undergoing hip surgery.

Methods:

The authors used data from Taiwan’s 1997–2011 in-patient claims database to evaluate the effect of anesthesia on in-hospital outcomes. The endpoints were mortality, stroke, transient ischemic stroke, myocardial infarction, respiratory failure, and renal failure. Of the 182,307 geriatric patients who had hip surgery, a GA was given to 53,425 (29.30%) and an NA to 128,882 (70.70%). To adjust for baseline differences and selection bias, patients were matched on propensity scores, which left 52,044 GA and 52,044 NA patients.

Results:

GA-group patients had a greater percentage and higher odds of adverse in-hospital outcomes than did NA-group patients: death (2.62 vs. 2.13%; odds ratio [OR], 1.24; 95% CI, 1.15 to 1.35; P &lt; 0.001), stroke (1.61 vs. 1.38%; OR, 1.18, 95% CI, 1.07 to 1.31; P = 0.001), respiratory failure (1.67 vs. 0.63%; OR, 2.71; 95% CI, 2.38 to 3.01; P &lt; 0.001), and intensive care unit admission (11.03 vs. 6.16%; OR, 1.95; 95% CI, 1.87 to 2.05; P &lt; 0.001), analyzed using conditional logistic regression. Moreover, patients given a GA had longer hospital stays (10.77 ± 8.23 vs. 10.44 ± 6.67 days; 95% CI, 0.22 to 0.40; P &lt; 0.001) and higher costs (New Taiwan Dollars [NT$] 86,606 ± NT$74,162 vs. NT$74,494 ± NT$45,264; 95% CI, 11,366 to 12,859; P &lt; 0.001).

Conclusion:

For geriatric patients undergoing hip surgery, NA was associated with fewer odds of adverse outcomes than GA.

Gotfried percutaneous compression plating (PCCP) versus dynamic hip screw (DHS) in hip fractures: blood loss and 1-year mortality

BACKGROUND

Intertrochanteric fractures are among the most common fracture in elderly and are correlated with an average 1-year mortality of 25 %. Increased mortality after hip fracture could be related to blood loss and comorbidities.

AIMS

We compared two groups of patients treated with percutaneous compression plating (PCCP) and dynamic hip screw (DHS) with the hypothesis that treatment with PCCP can reduce blood loss and 1-year mortality. We furthermore investigated the role of several surgical-related and patient-related factors on mortality of all the enrolled patients.

METHODS

We performed a comparative retrospective study of 280 patients with type 31A1 or 31A2 hip fractures treated in our department from January 2004 to May 2008. Exclusion criteria were age <60 years, multiple injuries and pathological fractures. A total of 194 patients were treated with DHS, and 86 patients were treated with PCCP.

RESULTS

No statistical differences were found in term of blood loss, blood transfusion and 1-year mortality between the two groups, whereas we found a significant incidence of gender, age, American Society of Anaesthesiologists score and preoperative haemoglobin on mortality.

DISCUSSION

Both plates seem to be comparable in terms of blood loss and blood transfusion rate, and mortality was rather correlated with some patient-related factors reflecting the global health status.

CONCLUSION

Emerging mortality in this kind of patient should encourage us to improve preventative orthogeriatric health care.

Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture

AIM

To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture.

METHODS

An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12-month follow-up period, functional recovery and mortality outcomes were measured.

RESULTS

Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140-0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197-0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020-2.635, P = 0.04).

CONCLUSIONS

We observed higher 12-month mortality and less functional recovery with increasing severity of dementia.

Biofeedback therapy for functional constipation: Long-term efficacy and nursing measures

AIM: To assess the long-term efficacy of biofeedback treatment (BF) for functional constipation (FC) and to discuss the nursing measures.

METHODS: One hundred and fifty FC patients who underwent BF were retrospectively analyzed. The clinical symptoms and anorectal manometry results before and after BF were compared. The long-term efficacy of biofeedback treatment and the related nursing measures were assessed.

RESULTS: The numbers of patients with typical clinical symptoms decreased significantly 3 and 6 mo after treatment compared with before treatment (P < 0.05). There were no significant differences in the rectal resting pressure and the maximum constriction pressure between before and after treatment. However, the initial defecation perception threshold and the anorectal inhibitory reflex threshold were significantly higher after treatment than before treatment (41.65 mL ± 6.74 mL vs 29.41 mL ± 4.97 mL, 67.12 mL ± 9.55 mL vs 47.25 mL ± 8.34 mL, P < 0.05). Univariate and multivariate analyses showed that the long-term efficacy of BF treatment was positively correlated with patient compliance and utilization of social support, and negatively correlated with age, disease course and other diseases.

CONCLUSION: BF therapy can improve clinical symptoms of FC patients and correct physiological dysfunction, having satisfactory long-term efficacy.

Retrospective Evaluation of Anaesthesia Techniques for Hip Replacement Operations

OBJECTIVE

In this retrospective study, we evaluated the demographic characteristics of patients that underwent hip replacement surgery in our orthopedic clinic. Associated diseases, preoperative laboratory findings, intraoperative findings, and the effect of admission or refusal to the intensive care unit on postoperative mortality and morbidity were recorded. Furthermore, we tried to identify surgical and anaesthetic methods applied, intraoperative hemodynamic changes, length of stay in the post-anaesthesia care unit, and postoperative complications.

METHODS

Demographic characteristics, co-morbidities, preoperative laboratory findings, intraoperative findings, and admission or refusal to the intensive care unit of patients who underwent hip replacement surgery between January 2008-December 2010 were enrolled.

RESULTS

Out of 500 patients, 33.4% (n=164) were operated under general anaesthesia, 34% (n=170) under combined spinal-epidural anaesthesia, 22.2% (n=111) under spinal anaesthesia, 6.4% (n=32) under combined lomber plexus block and sciatic nerve block, and 4% (n=20) under epidural anaesthesia. Mean hospital stay was 7 days in the general anaesthesia group and 5 days in the regional anaesthesia group.

CONCLUSION

American Society of Anesthesiologists (ASA) scores and incidence of co-morbidities were higher in the partial hip replacement group. Admission to the intensive care unit was lower in the total hip replacement group. Hospital stay was shorter in the partial hip replacement group. Mortality rates on the 7(th) and 30(th) days were higher in the partial hip replacement group.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

BACKGROUND

Various beneficial effects derived from neuraxial blocks have been reported. However, it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications.

OBJECTIVES

Our primary objective was to summarize Cochrane systematic reviews that assess the effects of neuraxial blockade on perioperative rates of death, chest infection and myocardial infarction by integrating the evidence from all such reviews that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various populations. Our secondary objective was to summarize the evidence on adverse effects (an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility) of neuraxial blockade. Within the reviews, studies were selected using the same criteria.

METHODS

A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have (1) included all Cochrane systematic reviews that examined participants of any age undergoing any type of surgical (open or endoscopic) procedure, (2) compared neuraxial blockade versus general anaesthesia alone for surgical anaesthesia or neuraxial blockade plus general anaesthesia versus general anaesthesia alone for surgical anaesthesia and (3) included death, chest infection, myocardial infarction and/or serious adverse events as outcomes. Neuraxial blockade could consist of epidural, caudal, spinal or combined spinal-epidural techniques administered as a bolus or by continuous infusion. Studies included in these reviews were selected on the basis of the same criteria. Reviews and studies were selected independently by two review authors, who independently performed data extraction when data differed from one of the selected reviews. Data were analysed by using Review Manager Version 5.1 and Comprehensive Meta Analysis Version 2.2.044.

MAIN RESULTS

Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from four to six of a maximal possible score of seven. Compared with general anaesthesia, neuraxial blockade reduced the zero to 30-day mortality (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53 to 0.94; I(2) = 0%) based on 20 studies that included 3006 participants. Neuraxial blockade also decreased the risk of pneumonia (RR 0.45, 95% CI 0.26 to 0.79; I(2) = 0%) based on five studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the two techniques (RR 1.17, 95% CI 0.57 to 2.37; I(2) = 0%) based on six studies with 849 participants. Compared with general anaesthesia alone, the addition of a neuraxial block to general anaesthesia did not affect the zero to 30-day mortality (RR 1.07, 95% CI 0.76 to 1.51; I(2) = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial blockade-general anaesthesia and general anaesthesia alone (RR 0.69, 95% CI 0.44 to 1.09; I(2) = 0%) based on eight studies that included 1580 participants. The addition of a neuraxial block to general anaesthesia reduced the risk of pneumonia (RR 0.69, 95% CI 0.49 to 0.98; I(2) = 9%) after adjustment for publication bias and based on nine studies that included 2433 participants. The quality of the evidence was judged as moderate for all six comparisons.No serious adverse events (seizure or cardiac arrest related to local anaesthetic toxicity, prolonged central or peripheral neurological injury lasting longer than one month or infection secondary to neuraxial blockade) were reported. The quality of the reporting score of complications related to neuraxial blocks was nine (four to 12 (median range)) of a possible maximum score of 14.

AUTHORS' CONCLUSIONS

Compared with general anaesthesia, a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk (level of evidence, moderate). Further research is required.

Mortality and quality of life after proximal femur fracture-effect of time until surgery and reasons for delay

INTRODUCTION

Studies yield conflicting results from the effect of early surgery on mortality. Some observed a positive, others a negative and some did not find any effect of early operation. In this study, mortality and quality of life in relation to time until surgery as well as reasons for delay were observed prospectively.

MATERIAL AND METHODS

Data of 138 patients (>65 years) with proximal femoral fractures and consecutive surgery were observed. Demographic data as well as mortality rate, survival time and Barthel Index up to 1 year in relation to different time frames were observed. Reasons for operative delay were divided into being administrative or patient-related.

RESULTS

Three-month mortality was 10.1% and 1-years was 23.9%. Neither time from injury until hospital admission nor from injury until surgery or from hospital admission until surgery up to 48 hours had any effect on mortality and survival time. The age of patients dying in the follow-up period was significantly higher than the age of patients surviving (86.8 vs. 84.4 years). No influence of any delay in time until surgery on the Barthel Index was observed.

CONCLUSION

In proximal femoral fractures, a delay of surgery up to 48 hours did not influence mortality and Barthel Index negatively, nor did other associating factors. Only the patients age at the time of injury influences mortality rate, survival time, and Barthel Index significantly. The older the patient at the time of injury; the higher the mortality rate, the shorter the survival time and the lower the Barthel Index.

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials

CONTEXT AND OBJECTIVE

Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery.

DESIGN AND SETTING

Systematic review at Universidade Federal de Alagoas.

METHODS

We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included.

RESULTS

Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167).

CONCLUSION

So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia.

Mortality after low trauma hip fracture: a prospective cohort study

BACKGROUND

Various risk of mortality due to hip fracture has been reported by different studies. There is scarce controlled study on hip fracture mortality from developing countries and no data from Middle East region. The objective of this study is to determine mortality and its risk factors one year after low trauma hip fracture.

METHODS

One hundred and two patients after hip fracture not caused by high impact injuries or local bone diseases followed up prospectively for one year. Control group consisted of sex and age matched patients admitted to ophthalmology ward for eye surgery. Data about comorbidity obtained from both groups at baseline. Functional state and health-related quality of life for the participants were measured using RDRS-2 and SF-36 questionnaires, respectively.

RESULTS

The overall survival was 83% in cases and 92% in controls (log rank test 3.62, df = 1, P = 0.057). Early mortality within the first 6 months of observation was significantly higher in patients than controls (13 in patients vs. 2 in controls) (log rank test 8.84, df = 1, P = 0.003). The risk of mortality in the first year after fracture was significantly and independently associated with age and baseline RDRS score. By the end of follow-up, in the patient group, 55.4% of survivors were able to walk without any assistance and 10.8% were not able to walk.

CONCLUSIONS

The risk of mortality within the first 6 months of observation was significantly and independently associated with low trauma hip fracture. However, age and baseline RDRS score were independent predictors of mortality in the first year following hip fracture.

The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients

BACKGROUND

Delayed surgery (ie, >48 hours from arrival in hospital) and pre-fracture disability are thought to be long-term risk factors for mortality in patients with hip fracture (HF). However, the combined effect on mortality of these two conditions has not been satisfactorily assessed in previous studies.

OBJECTIVE

To assess the combined effect of pre-fracture disability and delayed surgery on 12-month mortality in a population of elderly patients after HF surgical treatment.

DESIGN

Retrospective cohort study with 12-month follow-up.

SETTING

An orthogeriatric unit (OGU) in a university hospital in Italy.

METHODS

All patients (n = 390) admitted to an OGU from March 2007 to December 2010 who underwent proximal HF surgery and who were not transferred to other hospitals were considered for the analyses. Pre-fracture disability was defined as having an impairment in more than one activity of daily living (ADL). The 12-month mortality was assessed by a Kaplan-Meyer analysis and by a Cox proportional hazards regression models adjusting for relevant potential confounders.

RESULTS

After adjusting for potential confounders, patients with both delayed surgery and pre-fracture disability had a significantly higher 12-month mortality (hazard ratio [HR] = 5.80; 95% confidence interval [CI] = 2.11-15.92) than patients with neither delayed surgery nor disability (reference group). Patients with disability but not delayed surgery had a nearly 4-fold increased mortality risk (HR, 3.98; 95% CI 1.41-11.27) than patients in the reference group.

CONCLUSIONS

Patients with both pre-fracture disability and delayed HF surgical treatment had a nearly six-fold increased 12-month mortality risk than did patients with neither disability nor delayed surgery.

Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis

BACKGROUND

Hip fractures are always associated with a high postoperative mortality, the preoperative predictors for mortality have neither been well identified or summarised. This systematic review and meta-analysis was performed to identify the preoperative non-interventional predictors for mortality in hip fracture patients, especially focused on 1 year mortality.

METHODS

Non-interventional studies were searched in Pubmed, Embase, Cochrane central database (all to February 26th, 2011). Only prospective studies and retrospective studies with prospective collected data were included. Qualities of included studies were assessed by a standardised scale previous reported for observational studies. The effects of individual studies were combined with the study quality score using a previous reported model of best-evidence synthesis. The hazard ratios of strong evidence predictors were combined only by high quality studies.

RESULTS

75 included studies with 94 publications involving 64,316 patients were included and the available observations was a heterogeneous group. The overall inpatient or 1 month mortality was 13.3%, 3-6 months was 15.8%, 1 year 24.5% and 2 years 34.5%. There were strong evidence for 12 predictors, including advanced age, male gender, nursing home or facility residence, poor preoperative walking capacity, poor activities of daily living, higher ASA grading, poor mental state, multiple comorbidities, dementia or cognitive impairment, diabetes, cancer and cardiac disease. We also identified 7 moderate evidence and 12 limited evidence mortality predictors, and only the race was identified as the conflicting evidence predictor.

CONCLUSION

Whilst there is no conclusive evidence of the preoperative predictors for mortality following hip fractures, special attention should be paid to the above 12 strong evidence predictors. Future researches were still needed to evaluate the effects of these predictors.

[Optimal timing of operations to treat fractures of the femoral neck with endoprotheses : CRP as a parameter of postoperative immunologic reaction]

BACKGROUND

The optimal time to perform endoprosthesis of hip fractures in the elderly is still under discussion. CRP as an objective marker of postoperative inflammatory reaction should give an indication if early or late surgery is favored.

METHODS

CRP values from 122 patients with no complications after hip arthroplasty of femoral neck fractures were analyzed in context with the time between the trauma and the operation.

RESULTS

In early surgery within 24 h after trauma the CRP values were significantly lower than in delayed surgery.

CONCLUSION

The lower postoperative inflammatory reaction after early surgery of hip fractures provides a better outcome when treated with arthroplasty.

Hip fracture management, before and beyond surgery and medication: a synthesis of the evidence

INTRODUCTION

The geriatrician and orthopedic surgeon's roles are well defined in hip fracture management, yet other health-care providers contribute significantly toward care, as well as maximizing rehabilitation potential and decreasing readmissions. We examine evidence concerning pre-hospital care, pain management, multidisciplinary rehabilitation and secondary prevention strategies.

METHODS

Cochrane reviews and randomized controlled trials were identified through PubMed to synthesize current evidence in the role of multidisciplinary management of the patient with a hip fracture from injury to secondary prevention. The well-recognized roles of the geriatrician, anesthetist and orthopedic surgeon were not evaluated for the purpose of this review.

RESULTS

Transport of patients with a hip fracture can be eased through non-pharmaceutical simple, inexpensive techniques. Nerve blockade appears effective and easily administered in the emergency department. In-hospital multidisciplinary rehabilitation programs are effective in both earlier discharge and reducing falls, morbidity and mortality. Fall prevention programs are effective in nursing home patients, but not community dwellers. Osteoporosis prevention is primarily a medical endeavor; however, exercise and education may contribute to increased bone mineral density, compliance and better results of treatment.

CONCLUSION

Multidisciplinary medical management of patients with hip fractures is being improved within the hospital environment resulting in earlier discharge with decreased morbidity. There is evidence to show the benefits to patients with hip fractures from peripheral modalities within the hospital; however unless resident in a facility, multidisciplinary management is not clearly of benefit.

Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter?

The influence of the mode of anaesthesia on outcome of geriatric patients with hip fractures is a controversial issue in the medical literature. In the light of an ageing society, a conclusive answer to this question is of growing importance. The purpose of this review was to assess the effect of neuroaxial and general anaesthesia on mortality and morbidity in geriatric patients sustaining a hip fracture. Following a current literature search within the Pubmed and Cochrane database (1967-2010), 34 randomised controlled trials, 14 observational studies and eight reviews/meta-analysis publications were included. Potentially outcome-influencing factors such as mortality, deep vein thrombosis, pulmonary embolism, postoperative confusion and other anaesthesia-related outcomes were evaluated. After analysing the current literature with 56 references, covering 18,715 patients with hip fracture, it can be concluded that spinal anaesthesia is associated with significantly reduced early mortality, fewer incidents of deep vein thrombosis, less acute postoperative confusion, a tendency to fewer myocardial infarctions, fewer cases of pneumonia, fatal pulmonary embolism and postoperative hypoxia. General anaesthesia has the advantages of having a lower incidence of hypotension and a tendency towards fewer cerebrovascular accidents compared to neuroaxial anaesthesia. Otherwise, general anaesthesia and respiratory diseases were significant predictors of morbidity in hip fracture patients. These data suggest that regional anaesthesia is the preferred technique, but the limited evidence available does not permit a definitive conclusion to be drawn for mortality or other outcomes. For hip fracture surgery, the choice of anaesthesia (general or neuroaxial) is made by the anaesthesiologist and is based on the patient's preference, comorbidities, potential general postoperative complications and the clinical experience of the anaesthesiologist. The overall therapeutic approach in hip fracture care should be determined jointly by the orthopaedic surgeon, the geriatrician and the anaesthesiologist (multidisciplinary approach).

Peri-operative management of anti-platelet agents and anti-thrombotic agents in geriatric patients undergoing semi-urgent hip fracture surgery

Hip fractures are common events in the geriatric population and are often associated with significant morbidity and mortality. Over the coming decades, the size of the greying population is forecast to increase and hence, the annual incidence of hip fracture is expected to rise substantially. Several studies have shown that hip fracture surgery performed within 24 to 48 h of hospitalisation significantly reduces mortality. Medical specialists including cardiologists are often involved in the care of these geriatric patients as most of them have comorbid conditions that must be managed concomitantly with their fracture. Cardiovascular and thromboembolic complications are among some of the commonest adverse events that could be experienced by these elderly patients during hospitalisation. We review in this article the current recommendations and controversies on the peri-operative management of anti-platelet agents and anti-thrombotic agents in geriatric patients undergoing semi-urgent hip fracture surgery.

Impact of organisational changes on fracture neck of femur management

INTRODUCTION

In 2005, University Hospitals of Leicester formed a Fracture Neck of Femur (#NOF) project group to improve care of this group of patients.

SUBJECTS AND METHODS

The salient changes effected by the group were the appointment of designated orthogeriatricians, trauma co-ordinators, clinical aides, and discharge nurses.

RESULTS

As a result of these measures, the number of patients going to theatre within 48 h of admission rose from 38.5% in 2005/6 to 90% in 2007/8. In-hospital mortality decreased from 16.5% in 2005/6 to 10.9% in 2007/8. The 30-day mortality dropped from 13% in 2005/6 to 10.9% in 2007/8. Hospital stay reduced from 29 days in 2005/06 to 17 days in 2007/8.

CONCLUSIONS

Re-organisation of available resources has a positive impact on reducing mortality and in-hospital stay of fracture neck of femur patients.

A multicenter survey on profile of care for hip fracture: predictors of mortality and disability

Because delay in time to surgery beyond 24-48 h has been observed in many studies to be associated with adverse outcomes, a survey in nine centers in Italy was undertaken to examine the impact of time to surgery on mortality and disability at 6 months after hospitalization.

INTRODUCTION

Delays in surgery for hip fracture have been reported to be associated with negative outcomes. However, most studies are based on retrospective analysis of hospital discharge data, which cannot determine functional status or general health status of patients prior to the fracture.

METHODS

Using a prospective cohort design, data were collected on 3,707 patients aged >50 years during hospitalization for hip fracture and in a 6-month postdischarge follow-up. Baseline information included age, gender, living arrangement, prefracture walking ability, walking aid, ASA grade, type and reason of fracture, time to surgery, type of surgery, date and destination at discharge, and osteoporosis treatment. Follow-up data included living arrangement, walking ability, and mortality.

RESULTS

Six-month mortality was positively associated with increasing age, comorbidity, prefracture functional disability, and having surgery more than 48 h after admission. Higher levels of functional status at 6 months were independently associated with surgery occurring within 24 h of the fracture and with osteoporosis therapy at discharge. Walking disability was associated with older age, comorbidity, disability before fracture, and time to surgery after 24 h.

CONCLUSIONS

Delay in surgery is a major cause of mortality and disability at 6 months, and interventions to modify this pattern of care are urgently needed.

Loss of life years after a hip fracture

BACKGROUND

Patients with a hip fracture have a high mortality; however, it is not clear how large the loss of life-years is over an extended observation period.

SUBJECTS AND METHODS

This was a cohort study involving all patients in Denmark who suffered a hip fracture between 1977 and 2001 (n = 169,145). The survival rate for these patients was compared to that for age- and sex-matched subjects without a hip fracture (n = 524,010).

RESULTS

There was a substantial degree of excess mortality, with a pronounced variation in age and sex. The absolute number of life-years lost compared to age-matched subjects without a hip fracture was larger in younger subjects than in older subjects (men aged 51-60 years lived 7.5 years less on average while men over 80 years of age lived 3 years less). Expressed as a percentage, however, older subjects had the largest relative loss of expected remaining years of life. Men < or = 50 years of age lost 18% of their expected remaining years of life, as opposed to men > 80 years of age who lost as much as 58% of their expected remaining years of life. In women, the trend was similar but less pronounced (27% loss in women < or = 50 years of age vs. 38% in women > 80 years of age).

INTERPRETATION

A large proportion of the estimated remaining life is lost after a hip fracture, even in younger patients. Prevention may save life years, although not all of the years lost after a hip fracture may be due to the hip fracture per se.

Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home. We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. In conclusion early surgery (within 48h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.

The burden of hospitalized hip fractures: patterns of admissions in a level I trauma center over 20 years

BACKGROUND

To describe trends over 20 years in (1) number of admissions for hip fracture, (2) patients' demographics, type of fractures sustained by the patients, and their health status at admission, (3) surgical delays, and (4) acute care outcomes.

METHODS

This trend was a study conducted in a Level I trauma center in Quebec, Canada. All patients (n = 3174) aged 65 and older, admitted with a hip fracture between 1985 and 2005 were included. Outcome measures were: number of admissions, age, gender, comorbidities at admission, surgical delays, postsurgical complications, inpatient mortality, discharge destinations.

RESULTS

From 1985 to 2005, the number of admissions increased from 56 to 271, age at admission has increased by 2 years both in men and women (p < 0.01), women/men proportion has remained stable (3.2) over time. The adjusted proportions of minor and severe comorbidities at admission increased by 13% and 5% yearly (p < 0.01). Surgical delays decreased from 4.7 days +/- 16.5 days to 0.9 days +/- 1.9 days (p < 0.01). Acute care length of stay has drastically decreased from 37.0 days +/- 70.9 days to 16.7 days +/- 14.2 days (p < 0.01). Although severe postsurgical complications did not increase over time, the proportion of patients suffering from minor postsurgical complications increased by 22%. Inpatient death has decreased by 4% each year.

CONCLUSION

The tremendous increase in the volume of older and sicker patients admitted for hip fracture has put an enormous demand on our Level I trauma center. The changes in clinical management implemented to face this challenge have helped improve acute care outcomes.

Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?

INTRODUCTION

Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.

PATIENTS AND METHODS

The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.

RESULTS

A total of 883 patients were included in the audit (35-126 per hospital). Overall, 5-15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5-19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).

CONCLUSIONS

Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.

Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality?

This study aims to analyze whether the interval from hospital admission to surgery may be used as a surrogate of the actual gap from fracture to surgery when investigating in-hospital hip fracture mortality. After analyzing 3,754 hip fracture admissions, we concluded that those intervals might be used interchangeably without misinterpretation bias.

INTRODUCTION

The debate regarding the influence of time to surgery in hip fracture (HF) mortality is one of the most controversial issues in the HF medical literature. Most previous investigations actually analyzed the time from hospital admission to surgery as a surrogate of the less easily available gap from fracture to surgery. Notwithstanding, the assumption of equivalency between those intervals remains untested.

METHODS

We analyzed 3,754 hospital admissions of elderly patients due to HF in Quebec, Canada. We compared the performance as predictors of in-hospital mortality of the delay from admission to surgery and the actual gap from fracture to surgery using univariate and multiple logistic regression analysis.

RESULTS

The mean times from fracture to surgery and from admission to surgery were 1.84 and 1.02 days (P < 0.001), respectively. On univariate logistic regression, both times were slightly significant as mortality predictors, yielding similar odds ratios of 1.08 (P < 0.001) for time from fracture to surgery and 1.11 (P < 0.001) for time from admission to surgery. After accounting for other covariates, neither times remained significant mortality predictors.

CONCLUSION

The gap from admission to surgery may be used as a surrogate of the actual delay from fracture to surgery when studying in-hospital HF mortality.

[Thromboembolic disease in orthopedic surgery]

Thromboembolic complications are frequent after orthopaedic surgery of the limbs. Strategies to minimize these complications go from recognize the risk factors of the patient to introduce new antithrombotic drugs, and including general medical care, regional anaesthesia and early mobilization. Based in epidemiological studies, prophylaxis must be extended 4-6 weeks in total hip and knee arthroplasty and in surgery of the hip fracture.