Long-term survival of surgically treated hip fracture in an Australian regional hospital

Predictive factors for refractory stage I and II anti-resorptive agent-related osteonecrosis of the jaw

OBJECTIVES

We aimed to predict the possibility of patients with stage I and II anti-resorptive agent-related osteonecrosis of the jaw (ARONJ) developing resistance to our treatment protocol by evaluating their clinical and imaging factors.

MATERIALS AND METHODS

We enrolled 58 patients with ARONJ who underwent imaging modality. As objective variables, we considered the healing, stage-down, and stable stages as successful outcomes, and the stage-up stage as resistant-to-treatment. As explanatory variables, we investigated the clinical and imaging factors. Furthermore, we examined stage-down as an improvement outcome to compare with the stable and stage-up stages, which were considered as no-improvement outcomes. We conducted unpaired between-group comparisons on all explanatory variables using χ² tests for independence.

RESULTS

Among 58 patients, the treatment was successful in 53 (91.4%); however, the disease was resistant in five (8.6%). Among the clinical factors, the resistant patients had a longer duration of administration of bone-modifying agents (BMAs) (cut-off: 1251 days, p = 0.032, odds ratio = 11.2, 95% confidence interval 1.115-122.518). In addition, the target disease that was being treated bone metastasis of malignant tumor was the only significant refractory factor (p = 0.024, OR: 3.667 95% CI 1.159-11.603) CONCLUSIONS: A combination of metabolic and morphological imaging modalities may be useful for oral surgeons to evaluate the disease activity and predict course of refractory ARONJ.

Banding with lesser trochanter fragment using nonabsorbable tape in trochanteric femoral fractures

Introduction: Trochanteric femoral fracture is one of the most common fractures in the elderly. Trochanteric femoral fracture with involvement of the lesser trochanter is considered unstable and recognized as having a poor prognosis. However, fixation of lesser trochanter fragment is scarce because of technical difficulties. In this study, we reported the simple surgical procedure and the effect of using nonabsorbable tape in lesser trochanter fixation. Methods: From January 2014 to December 2017, 114 patients treated with proximal intramedullary nailing for trochanteric fractures with the lesser trochanter fragment were reviewed. Among patients enrolled in this study, 73 were followed up until radiographic bone union, of which 26 were treated with lesser trochanter fragment banding (group B) and 47 without banding (group N). Radiographs and/or computed tomography images were used to evaluate bone union of the lesser trochanter fragment at three months postoperatively. Results: The bone union of the lesser trochanter fragment was achieved in 24 cases (92%) in group B and 30 cases (64%) in group N. Compared with group N, group B showed a significantly increased number of mild and moderate deformities but decreased number of severe deformity and nonunion (P < 0.001). Postoperative complications were not observed in both groups. Conclusions: From the viewpoint of increasing lesser trochanteric bone union ratio, fixation of the lesser trochanter fragment using nonabsorbable tape in the treatment of trochanteric fractures could be an effective procedure.

Association of normalized protein catabolic rate (nPCR) with the risk of bone fracture in patients undergoing maintenance hemodialysis: The Q-Cohort Study

BACKGROUND & AIMS

Normalized protein catabolic rate (nPCR) is used as a surrogate for daily dietary protein intake and nutritional status in patients receiving maintenance hemodialysis. It remains uncertain whether the nPCR level is associated with the incidence of bone fracture.

METHODS

A total of 2869 hemodialysis patients registered in the Q-Cohort Study, a multicenter, prospective, observational study, were followed up for 4 years. The primary outcome was bone fracture at any site. The main exposure was the nPCR level at baseline. Patients were assigned to four groups based on their baseline nPCR levels (G1: <0.85, G2: 0.85≤, <0.95, G3: 0.95≤, <1.05 [reference], G4: ≥1.05 g/kg/day). We examined the relationship between the nPCR levels and the risk for bone fracture using Cox proportional hazards models.

RESULTS

During the follow-up period, 136 patients experienced bone fracture at any site. In the multivariable analyses, the risk for bone fracture was significantly higher in the lowest (G1) and highest (G4) nPCR groups than the reference (G3) group (hazard ratio [95% confidence intervals]: G1, 1.93 [1.04-3.58]; G2, 1.27 [0.67-2.40]; G3 1.00 (reference); G4, 2.21 [1.25-3.92]). The association remained almost unchanged, even when patients were divided into sex-specific nPCR quartiles, when analysis was limited to patients with a dialysis vintage ≥2 years, assumed to have lost residual kidney function, or when a competing risk model was applied.

CONCLUSIONS

Our results suggest that both lower and higher nPCR levels are associated with an increased risk for bone fracture in hemodialysis patients.

Geriatric Nutritional Risk Index and Controlling Nutritional Status Score can predict postoperative 180-day mortality in hip fracture surgeries

BACKGROUND

The Geriatric Nutritional Risk Index (GNRI) based on serum albumin level and body weight and the Controlling Nutritional Status Score (CONUT) based on serum albumin level, total cholesterol level, and total lymphocyte count were created to evaluate objectively a patient's nutritional status in 2005. Here we validated the usefulness of the GNRI and the CONUT as a prognostic factor of the 180-day mortality in patients who underwent hip fracture surgeries. We retrospectively collected data from patients with hip surgeries performed from January 2012 to December 2018. The variables required for the GNRI and the CONUT and the factors presumably associated with postoperative mortality including the patients' characteristics were collected from the medical charts. Intergroup differences were assessed with the χ² test with Yates' correlation for continuity in category variables. The Mann-Whitney U test was used to test for differences in continuous variables. We validated the power of the GNRI and the CONUT values to distinguish patients who died ≤ 180 days post-surgery from those who did not, by calculating the area under the receiver operating characteristic curve (AUC). The correlation between these two models was analyzed by Spearman's rank correlation (ρ).

RESULTS

We retrospectively examined the cases of 607 patients aged 87 ± 6 (range 70-102) years old. The 180-day mortality rate was 5.4% (n = 33 non-survivors). The GNRI value in the non-survivors was 83 ± 9 (range 66-111), which was significantly lower than that in the survivors at 92 ± 9 (range 64-120). The CONUT value in the non-survivors was 6 ± 3 (range 1-11), which was significantly higher than that in the survivors at 4 ± 2 (range 0-11). The AUC value to predict the 180-day mortality was 0.74 for the GNRI and 0.72 for the CONUT. The ρ value between these two models was 0.61 in the total of 607 patients and was 0.78 in the 33 non-survivors.

CONCLUSIONS

Our results suggest that the GNRI and the CONUT are a simple and useful tool to predict the 180-day mortality in patients who have undergone a hip surgery.

Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review

OBJECTIVE

Older patients with hip fractures who are undergoing surgery are at high risk of significant mortality and morbidity including postoperative delirium. It is unclear whether different types of anaesthesia may reduce the incidence of postoperative delirium. This systematic review will investigate the impact of anaesthetic technique on postoperative delirium. Other outcomes included mortality, length of stay, complications and functional outcomes.

DESIGN

Systematic review of randomised controlled trials and non-randomised controlled studies.

DATA SOURCES

Bibliographic databases were searched from inception to June 2018. Web of Science and ZETOC databases were searched for conference proceedings. Reference lists of relevant articles were checked, and clinical trial registers were searched to identify ongoing trials.

ELIGIBILITY CRITERIA

Studies were eligible if general and regional anaesthesia were compared in patients (aged 60 and over) undergoing hip fracture surgery, reporting primary outcome of postoperative delirium and secondary outcomes of mortality, length of hospital stay, adverse events, functional outcomes, discharge location and quality of life. Exclusion criteria were anaesthetic technique or drug not considered current standard practice; patients undergoing hip fracture surgery alongside other surgery and uncontrolled studies.

RESULTS

One hundred and four studies were included. There was no evidence to suggest that anaesthesia type influences postoperative delirium or mortality. Some studies suggested a small reduction in length of hospital stay with regional anaesthesia. There was some evidence to suggest that respiratory complications and intraoperative hypotension were more common with general anaesthesia. Heterogeneity precluded meta-analysis. All findings were described narratively and data were presented where possible in forest plots for illustrative purposes.

CONCLUSIONS

While there was no evidence to suggest that anaesthesia types influence postoperative delirium, the evidence base is lacking. There is a need to ascertain the impact of type of anaesthesia on outcomes with an adequately powered, methodologically rigorous study.

PROSPERO REGISTRATION NUMBER

CRD42015020166.

The Surgical Apgar Score can help predict postoperative complications in femoral neck fracture patients: a 6-year retrospective cohort study

Introduction

The postoperative mortality rate following a femoral neck fracture remains high. The Surgical Apgar Score (SAS), based on intraoperative blood loss, the lowest mean arterial pressure, and the lowest heart rate, was created to predict 30-day postoperative major complications. Here, we evaluated the relationship between the SAS and postoperative complications in patients who underwent femoral neck surgeries.

Methods

We retrospectively collected data from patients with femoral neck surgeries performed in 2012–2017 at Kumamoto Central Hospital. The variables required for the SAS and the factors presumably associated with postoperative complications including the patients’ characteristics were collected from the medical charts. Intergroup differences were assessed with the χ² test with Yates’ correlation for continuity in category variables. The Mann-Whitney U test was used to test for differences in continuous variables. We assessed the power of the SAS value to distinguish patients who died ≤ 90 days post-surgery from those who did not, by calculating the area under the receiver operating characteristic curve (AUC).

Results

We retrospectively examined the cases of 506 patients (94 men, 412 women) aged 87 ± 6 (range 70–102) years old. The 90-day mortality rate was 3.4% (n = 17 non-survivors). There were significant differences between the non-survivors and survivors in body mass index (BMI), the presence of moderate to severe valvular heart disease, albumin concentration, the American Society of Anesthesiologists (ASA) classification, and the SAS. The 90-day mortality rate in the SAS ≤ 6 group (n = 97) was 10.3%, which was significantly higher than that in the SAS ≥ 7 group (n = 409), 1.7%. The AUC value to predict the 90-day mortality was 0.70 for ASA ≥ 3 only, 0.71 for SAS ≤ 6 only, 0.81 for SAS ≤ 6 combined with ASA ≥ 3, and 0.85 for SAS ≤ 6 combined with albumin concentration < 3.5 g/dl, BMI ≤ 20, and the presence of moderate to severe valvular heart disease.

Conclusions

Our results suggest that the SAS is useful to evaluate postoperative complications in patients who have undergone a femoral neck surgery. The ability to predict postoperative complications will be improved when the SAS is used in combination with the patient’s preoperative physical status.

Validity of routinely collected data in identifying hip fractures at a major tertiary hospital in Australia

OBJECTIVES

To examine the validity of routinely collected data in identifying hip fractures (HFs) and to identify factors associated with incorrect coding.

METHOD

In a prospective cohort study between January 2014 and June 2016, HFs were identified using physician diagnosis and diagnostic imaging and were recorded in a Registry. Records of HFs in the health information exchange (HIE) were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification/Australian Classification of Health Interventions/Australian Coding Standards codes. New HFs were estimated by episode of care, hospital admission and with an algorithm. Data from the HIE and the Registry were compared.

RESULTS

The number of HFs as the principal diagnosis (PD) recorded by episode (864) was higher than by admission (743), by algorithm (711) and in the Registry (638). The sensitivity was high for all methods (90-93%) but the positive predictive value was lower for episode (68%) than for admission (80%) or algorithm (81%). The number of HFs with surgery recorded in the PD by episode (639), algorithm (630) and in the Registry (623) was similar but higher than by admission (589). The episode and algorithm methods also had higher sensitivity (91-92%) than the admission method (84%) for HFs with surgery. Factors associated with coding errors included subsequent HF, long hospital stay, intracapsular fracture, younger age, male, HF without surgery and death in hospital.

CONCLUSIONS

When it is not practical to use the algorithm for regular monitoring of HFs, using PD by admission to estimate total HFs and PD by episode in combination with a procedure code to estimate HFs with surgery can produce robust estimations.

Mortality after hip fracture with vertebral compression fracture is poor

Due to the increasing elderly population, the prevalence of osteoporotic hip fractures in Japanese patients continues to rise. It is well established that patients with either hip fracture or both symptomatic and asymptomatic morphometric vertebral compression fracture (VCF) have a poor health prognosis compared with the general population. The purpose of this study was to retrospectively investigate vertebral fracture rates among patients with hip fracture and their influence on mortality. We examined 182 cases of osteoporotic hip fracture in patients admitted to our institution between January 2009 and May 2011. The average age at the time of fracture was 85 years. Radiographs of the lumbar spine were obtained from all of the participants and the lateral spinal radiographs were examined for evidence of VCF. The patients were classified into two groups, those with VCF and those without. A VCF was identified in approximately 78 % of the patients. The mortality rate 1 year after the hip fracture was approximately 22 % and it was significantly higher in patients with VCF. Through multivariate statistics we found that VCF, post-operative complication, loss of ambulation after operation and medication for osteoporosis were statistically significant. In other words, VCF, post-operative complication and loss of ambulation were considered to be poor prognostic factors and medication for osteoporosis was likely to improve the prognosis. We concluded that the risk of mortality after hip fracture is significantly greater in patients who also have VCF compared to patients without VCF, and that medication for osteoporosis is likely to improve prognosis.

HIP FRACTURE: POST-OPERATIVE EVALUATION OF CLINICAL AND FUNCTIONAL OUTCOMES

Objective: To evaluate the clinical and functional outcomes from patients undergoing surgery to treat hip fractures, with regard to the ASA score and time spent waiting for definitive surgical treatment. Method: Over a one-year period, 154 patients with hip fractures, aged 65 years and over, underwent operations. Data on the preoperative ASA score and the time spent waiting for the operation were obtained. Two years after the operation, Zuckerman‘s Functional Recovery Score (FRS) questionnaire was used to assess the patients' current functional capacity. Results: Mortality during the first postoperative year differed between patients with ASA 3 or 4 and those classified as ASA 1 or 2 (significant data; p < 0.05). Mortality up to the end of the second postoperative year was significantly higher (p < 0.05) in the ASA 3 or 4 group. The preoperative ASA score did not demonstrate any significant relationship with the patients' current functional capacity (p > 0.05). There was no significant difference between the group operated within 48 hours of admission and the group operated after 48 hours, in relation to mortality or current functional capacity (p > 0.05). The group aged 80 years and over showed significantly higher mortality (p < 0.05) than the group aged 65 to 79 years up to the end of the second postoperative year. Conclusion: The preoperative ASA score and an age of 80 years or over may be considered to be factors associated with higher mortality two years after hip fracture surgery. In isolation, time spent waiting for surgery was not significant.

Outcomes following fractured neck of femurin an Australian metropolitan teaching hospital

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

Methods

We performed a retrospective observational study of 185 consecutive adult patients admitted to an Australian metropolitan teaching hospital with fractured neck of femur between 2009 and 2010. The main outcome measures were 30-day and one-year mortality rates, major complications and factors influencing mortality.

Results

The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were observed, including pre-operative hypoxia (17%), post-operative delirium (25%), anaemia requiring blood transfusion (28%), representation within 30 days of discharge (18%), congestive cardiac failure (14%), acute renal impairment (12%) and myocardial infarction (4%). Mortality rates were 8.1% at 30 days and 21.6% at one year. Factors predictive of one-year mortality were American Society of Anesthesiologists (ASA) score (odds ratio (OR) 4.2 (95% confidence interval (CI) 1.5 to 12.2)), general anaesthesia (OR 3.1 (95% CI 1.1 to 8.5)), age > 90 years (OR 4.5 (95% CI 1.5 to 13.1)) and post-operative oliguria (OR 3.6 (95% CI 1.1 to 11.7)).

Conclusions

Results from an Australian metropolitan teaching hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and correction of pre-operative hypoxia. This study provides planning data for future interventional studies.

Cite this article: Bone Joint Res 2013;2:162–8.

Factors influencing mortality in patients on antiplatelet agents presenting with proximal femoral fractures

PURPOSE

To identify factors predicting one-year mortality in patients on clopidogrel presenting with proximal femoral fractures.

METHODS

9 men and 22 women aged 64 to 97 (mean, 81; standard deviation, 8) years who had been taking clopidogrel for ischaemic heart disease (n=15), cerebrovascular disease (n=6), or both (n=10) presented with proximal femoral fractures. The time from injury to operation, type of anaesthesia, treatment method, and postoperative complications were reviewed. One-year mortality was analysed using the Kaplan-Meier curve. Factors predicting one-year mortality were identified.

RESULTS

The fracture configurations of the 31 patients included intracapsular femoral neck fracture (n=17), intertrochanteric fracture (n=13), and subtrochanteric fracture (n=1). 30 of the patients underwent hemiarthroplasty (n=16), dynamic hip screw fixation (n=9) or intramedullary hip screw fixation (n=5). The remaining patient underwent conservative treatment owing to metastatic prostate cancer. Of the 30 patients who underwent surgery, clopidogrel was discontinued at least 7 days prior to surgery, with the mean delay to surgery being 8.4 (range, 2-16) days. No patient had excessive blood loss at operation, although 7 patients received a blood transfusion postoperatively. 13 (43%) patients developed postoperative complications. The one-year mortality was 26% (8/31). Univariate analysis showed that factors predicting one-year mortality were spinal anaesthesia (p=0.04), postoperative blood transfusion (p=0.03), postoperative complications (p=0.03), and delay to surgery (p=0.03). Multiple regression analysis showed that delay to surgery (p=0.03) was the only independent predictor of one-year mortality, with a hazard ratio of 1.357 (95% confidence interval, 1.03-1.79).

CONCLUSION

Surgery should be performed as soon as possible in medically fit patients having proximal femoral fractures who are taking clopidogrel, as delay to surgery is associated with increased one-year mortality.

Does timing of surgery matter in fragility hip fractures?

The effect of delay of surgery on the geriatric hip fractures has been a subject of interest in the past two decades. While the elderly patients will not tolerate long periods of immobilization, it is still unclear how soon these surgeries need to be performed. A review of existing literature was performed to examine the effect of timing of surgery on the different outcome parameters of these patients. Although there is conflicting evidence that early surgery would improve mortality, there is widespread evidence in the literature that other outcomes including morbidity, the incidence of pressure sores, and the length of hospital stay could be improved by shortening the waiting time of hip fracture surgery. We concluded that it is beneficial to the elderly patients to receive surgical treatment as an urgent procedure as soon as the body meets the basic anesthetic requirements.

Effects of socioeconomic position on 30-day mortality and wait for surgery after hip fracture

OBJECTIVE

In countries where the National Health Service provides universal health coverage, socioeconomic position should not influence the quality of health care. We examined whether socioeconomic position plays a role in short-term mortality and waiting time for surgery after hip fracture.

DESIGN

Retrospective cohort study.

SETTING

and participants From the Hospital Information System database, we selected all patients, aged at least 65 years and admitted to acute care hospitals in Rome for a hip fracture between 1 January 2006 and 30 November 2007. The socioeconomic position of each individual was obtained using a city-specific index of socioeconomic variables based on the individual's census tract of residence.

MAIN OUTCOME MEASURES

Three different outcomes were defined: waiting times for surgery, mortality within 30 days and intervention within 48 h of hospital arrival for hip fracture. We used a logistic regression to estimate 30-day mortality and a Cox proportional hazard model to calculate hazard ratios of intervention within 48 h. Median waiting times were estimated by adjusted Kaplan-Meyer curves. Analyses were adjusted for age, gender and coexisting medical conditions.

RESULTS

Low socioeconomic level was significantly associated with higher risk of mortality [adjusted relative risk (RR) = 1.51; P < 0.05] and lower risk of early intervention (adjusted RR = 0.32; P < 0.001). Socioeconomic level had also an effect on waiting times within 30 days.

CONCLUSIONS

Individuals living in disadvantaged census tracts had poorer prognoses and were less likely than more affluent people to be treated according to clinical guidelines despite universal healthcare coverage.

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.

[Independence in activities of daily living 6 months after surgery in previously independent elderly patients with hip fracture caused by a fall]

OBJECTIVE

To measure recovery of independence in activities of daily living (ADL) 6 months after surgery in elderly patients (previously independent and without cognitive impairment) with hip fracture caused by a fall.

METHOD

We performed a longitudinal, prospective cohort study of patients who were previously independent for ADL, or had mild dependence, and who showed no cognitive impairment. Consecutive sampling was performed. The variables studied were age, sex, habitual residence, type of hip fracture, mental status (SPMSQ Pfeiffer), and independence in ADL (according to Barthel Index [BI]) prior to the fall and 6 months after the fall.

RESULTS

The study included 207 patients. There was a predominance of female sex (74.4%) and pertrochanteric fractures (45.9%). The mean age was 80.17 years old (SD = 6.95), and 7.7% were institutionalized. Six months after surgery, the mean BI score was 73.37 (SD = 26.76) (versus 90.05 before the fall), 16.8% showed urinary incontinence (versus 5.9%), 59.2% walked without assistance (versus 82.4%) and 24.6% climbed stairs unaided (versus 50.7%). The ability to walk down the street was regained in 64.6% (versus 82.1% before the fall). Recovery of autonomy for ADL was statistically significantly lower in patients unable to walk outdoors, who were institutionalized or who had mild cognitive impairment before the fall.

CONCLUSIONS

Only 33.6% of patients regained prior levels of autonomy 6 months after surgery.