Combination of measures of handgrip strength and red cell distribution width can predict in-hospital complications better than the ASA grade after hip fracture surgery in the elderly

Intra-operative blood transfusions raise the risk of postoperative delirium and impede functional recovery in elderly hip fracture patients: a propensity score-matched study

BACKGROUND

This retrospective analysis was performed to investigate the potential influence of intra-operative blood transfusion (IBT) in patients aged 65 years or older with intertrochanteric fractures (IF) who underwent intramedullary fixation.

METHODS

The outcomes of interest included the incidence of postoperative delirium (POD), pain score at discharge, length of hospital stay (LOS), functional outcomes, and mortality. The study included all surgically treated patients with IF between Jan. 2018 and Dec. 2021. Data on patient demographics, injury-related factors, surgical procedures, intraoperative details, in-hospital information, and postoperative outcomes were collected. In order to mitigate potential confounding and selection bias, the researchers employed the propensity score matching (PSM) technique using a 1:1 ratio via the caliper matching method. Following PSM, the association between IBT and outcome analyses was assessed using McNemar's Chi-square tests. Additionally, the Spearman correlations between IBT, POD and postoperative functional outcomes were computed.

RESULTS

Out of the initial 2159 consecutive patients screened, a final sample of 1681 individuals was included, consisting of 1278 in the non-IBT group and 403 in the IBT group. After PSM, each group comprised 298 participants. The disparities in POD rate and functional outcomes became significant after employing propensity score-based matching (P < 0.001 and 0.029, respectively), despite their lack of significance prior to matching. There were no notable distinctions observed in other operation-related data, LOS, and crude mortality rates at 30-day, 90-day, and 12-month intervals before and after PSM. Furthermore, incidence of POD (P = 0.006) and functional outcomes (P = 0.013) were significantly associated with IBT.

CONCLUSION

In conclusion, IBT significantly increases the incidence of POD and hinders postoperative functional recovery in elderly patients with hip fracture.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis

BACKGROUND

The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications.

METHODS

A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes.

RESULTS

The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11).

CONCLUSION

The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Deformability of Heterogeneous Red Blood Cells in Aging and Related Pathologies

Aging is interrelated with changes in red blood cell parameters and functionality. In this article, we focus on red blood cells (RBCs) and provide a review of the known changes associated with the characterization of RBC deformability in aging and related pathologies. The biophysical parameters complement the commonly used biochemical parameters and may contribute to a better understanding of the aging process. The power of the deformability measurement approach is well established in clinical settings. Measuring RBCs' deformability has the advantage of relative simplicity, and it reflects the complex effects developing in erythrocytes during aging. However, aging and related pathological conditions also promote heterogeneity of RBC features and have a certain impact on the variance in erythrocyte cell properties. The possible applications of deformability as an early biophysical biomarker of pathological states are discussed, and modulating PIEZO1 as a therapeutic target is suggested. The changes in RBCs' shape can serve as a proxy for deformability evaluation, leveraging single-cell analysis with imaging flow cytometry and artificial intelligence algorithms. The characterization of biophysical parameters of RBCs is in progress in humans and will provide a better understanding of the complex dynamics of aging.

Does Red Cell Distribution Width Predict Hip Fracture Mortality Among the Arab Population? A Single-Center Retrospective Cohort Study

BACKGROUND

Hip fractures impose significant morbidity and mortality. Red cell distribution width (RDW) appears to be an emerging tool in predicting mortality following hip fractures. Several factors can influence the RDW value including genetic factors and ethnicity. The purpose of the study was to assess the relation between RDW level at admission and hip fracture mortality within 6 months among Arab/Middle East populations.

METHODS

We conducted a single-center retrospective cohort study including 549 patients (274 female and 275 male) diagnosed with a hip fracture undergoing surgery from February 2016 to December 2019. All included patients shared the same country of origin which is Arab Middle East country. Statistical analysis, including binary regression, was performed to assess the relationship between RDW and mortality within 6 months of admission. Other predictors of mortality following hip fracture surgery were also assessed.

RESULTS

The mean age was 76.42 (±9.19) years. Seventy (12.8%) of participants died within 6 months. No statistically significant association (P=0.053) between RDW level at admission and mortality within 6 months of surgery was found. Binary regression demonstrated that the only independent predictors of mortality were age (P= 0.003, odds ratio 1.048 with 95% CI 1.016 to 1.080) and male gender (P= 0.021, odds ratio 1.872 with 95% CI 1.100 to 3.185).

CONCLUSION

Although the previous studies reported that RDW is one of the predictors of mortality in hip fracture patients, our study found no relation in the Arab population. This finding may confirm the influence of genetic factors and ethnicity on RDW value. We recommend further large-scale multicenter studies to solidly establish the relationship between RDW and hip fracture mortality among the Arab/Middle East population.

The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - A nationwide cohort study

This study examines the association between the ASA physical status classification score at hip fracture surgery and severe postoperative complications in patients aged 60 and older. Among both men and women, ASA scores consistently predict a wide range of complications including infections, cardiovascular complications, hospital readmissions, and death.

INTRODUCTION

Hip fractures are common in aging populations and associated with poor prognosis. This study examines how the American Society of Anaesthesiologists (ASA) physical status classification is related to severe complications among hip fracture patients including infections, cardiovascular diseases, hospital readmissions, and death.

METHODS

Based on a linkage of the Swedish National Inpatient Register with the Swedish National Registry for Hip Fractures (RIKSHÖFT), this study includes patients aged 60+ with first hip fracture between 1998 and 2017. We estimated associations between ASA score and complications during the hospital stay and during 1 year after hip fracture using multivariable-adjusted logistic regression and Cox proportional hazard regression.

RESULTS

The study population included 170,193 hip fracture patients of which 24% died and 39% were readmitted to hospital within 1 year. The most common complications were urinary tract infections, pneumonia, second hip fractures, and heart failure. Among both men and women, higher ASA scores were consistently associated with higher risks for all complications included in this study. The strongest associations were observed for heart failure, myocardial infarction, pneumonia, and death.

CONCLUSION

ASA scores are routinely assessed in clinical practice and predict a wide range of postoperative complications among hip fracture patients. Since many complications may be preventable through adequate drug treatment, rehabilitation, and risk awareness, future studies should examine the mechanisms linking ASA scores to complication risk in order to improve preventive strategies. Particularly, the high risk of cardiovascular complications among patients with high ASA scores deserves clinical and scientific attention.

Handgrip strength: a reliable predictor of postoperative early ambulation capacity for the elderly with hip fracture

Backgrounds

A common sequela of hip fracture is loss of ambulation capacity. Prediction of postoperative ambulation capacity is important for surgical and rehabilitation decision making. Handgrip strength is a quick and convenient tool for evaluating postoperative functional ability and outcome in variety of clinical conditions for the elderly and is associated with the use of walking aids. We propose that handgrip strength may be a good predictor for postoperative early ambulation. The purpose of our study was to investigate the contribution of handgrip strength in the prediction of postoperative early ambulation capacity in elderly hip fracture patients.

Methods

Clinical data of patients with low-energy hip fractures who received surgery from Jan 2018 to Dec 2019 were prospectively collected. The correlations of ambulation time with complication rate, age, gender, injured side, fracture classifications, surgical procedure, body mass index (BMI), and handgrip strength were analyzed.

Results

Sixty-three hip fracture patients were included in this study. Patients whose ambulation time was less than 3 days after the operation had significantly fewer postoperative complications (P = 0.006). Handgrip strength showed the strongest correlation with postoperative early ambulation capacity (P = 0.004). The handgrip strength threshold value for early ambulation was found to be 20.5 kg for male patients and 11.5 kg for female patients.

Conclusion

Handgrip strength testis a quick and convenient tool for predicting postoperative early ambulation capacity. In elderly Asians, male patients with a handgrip strength above 20.5 kg and female patients with a handgrip strength above 11.5 kg suggest a high likelihood of early postoperative ambulation and a lower risk of complications after the hip surgery.

Grip strength in men and women aged 50-79 years is associated with non-vertebral osteoporotic fracture during 15 years follow-up: The Tromsø Study 1994-1995

In 50-79-year-olds who participated in the Tromsø Study (1994-1995), the risk of non-vertebral osteoporotic fractures during 15 years follow-up increased by 22% in men and 9% in women per 1 SD lower grip strength. The strongest association was observed in men aged 50-64 years.

INTRODUCTION

We aimed to explore whether low grip strength was associated with increased risk of non-vertebral osteoporotic fracture in the population-based Tromsø Study 1994-1995.

METHODS

Grip strength (bar) was measured by a Martin Vigorimeter and fractures were retrieved from the X-ray archives at the University Hospital of North Norway between 1994 and 2010. At baseline, weight and height were measured, whereas information on the other covariates were obtained through self-reported questionnaires. Cox regression was used to estimate the hazard ratio (HR) of fracture in age- and gender-specific quintiles of grip-strength, and per 1 SD lower grip strength. Similar analyses were done solely for hip fractures. Adjustments were made for age, height, body mass index (BMI), marital status, education, smoking, physical activity, use of alcohol, self-perceived health, and self-reported diseases.

RESULTS

In 2891 men and 4002 women aged 50-79 years, 1099 non-vertebral osteoporotic fractures-including 393 hip fractures-were sustained during the median 15 years follow-up. Risk of non-vertebral osteoporotic fracture increased with declining grip strength: hazard ratios per SD decline was 1.22 (95% CI 1.05-1.43) in men and 1.09 (95% CI 1.01-1.18) in women. HR for fracture in lower vs. upper quintile was 1.58 (95% CI 1.02-2.45) in men and 1.28 (95% CI 1.03-1.59) in women. The association was most pronounced in men aged 50-64 years with HR = 3.39 (95% CI 1.76-6.53) in the lower compared to the upper quintile.

CONCLUSIONS

The risk of non-vertebral osteoporotic fracture increased with declining grip-strength in both genders, particularly in men aged 50-64 years.

Handgrip strength predicts length of stay and quality of life in and out of hospital

BACKGROUND

Handgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS.

METHODOLOGY

HGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed.

RESULTS

The mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X² = 7.85, p < 0.05; female X² = 14.9, p < 0.0001). The average quality of life scores were as follows: in hospital PCS: 34.66, MCS: 46.49; post discharge PCS: 36.17; MCS: 51.22. HGS predicted PCS during hospitalization (male X² = 36.22, p < 0.0001; female X² = 19.87, p < 0.0001) and post hospitalization (male X² = 6.98, p < 0.01; female X² = 10.99, p < 0.01). Various reference cut-points for HGS were tested against LOS, with none being considered appropriate (e.g., SE and SP both < 70) when adjusting for age and sex.

CONCLUSION

Admission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.

A New Threshold for Appendicular Lean Mass Discriminates Muscle Weakness in Women With Hip Fracture: A Cross-Sectional Study

OBJECTIVE

The aim of the study was to investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass, appendicular lean mass/body mass index ratio and appendicular lean mass/height to separate weak and nonweak women. Secondly, we aimed to explore alternative thresholds for the three measures of muscle mass to discriminate weakness.

DESIGN

This is cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed appendicular lean mass by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength of less than 16 kg.

RESULTS

Weakness was not significantly associated with appendicular lean mass of less than 15.02 kg, appendicular lean mass/body mass index ratio of less than 0.512 or appendicular lean mass/height of less than 5.67 kg/m. For appendicular lean mass (but not for the other 2 measures of muscle mass), an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ (1, n = 160) = 10.77 (P = 0.001). The association between appendicular lean mass of less than 11.87 kg and grip strength of less than 16 kg persisted after adjustment for age and body mass index (odds ratio = 2.50, 95% confidence interval = 1.17-5.34, P = 0.018).

CONCLUSIONS

Data suggest that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For appendicular lean mass, an alternative cutoff point actually separated weak and nonweak women.

Red Cell Distribution Width: An Unacknowledged Predictor of Mortality and Adverse Outcomes Following Revision Arthroplasty

BACKGROUND

Revision total joint arthroplasties (TJAs) have been empirically associated with significant postoperative morbidity and mortality. Red blood cell distribution width (RDW), a frequently measured hematological parameter, has been shown to predict mortality in hip fracture patients. However, its utility in risk-stratifying patients before revision TJA remains unknown. The aim of this study was to investigate the possible relationship between preoperative RDW levels and outcome of revision arthroplasty in terms of mortality, adverse outcomes, and length of hospital stay.

METHODS

A single-institution retrospective study was conducted on 4633 patients who underwent revision TJA (3289 hips and 1344 knees) between 2000 and September 2016. Of those, 656 (14.1%) surgeries were performed due to periprosthetic joint infection, and 3977 (85.9%) were aseptic revisions. The association between preoperative RDW and various outcomes, including 1-year mortality, in-hospital medical complications, length of hospital stay, and 90-day all-cause readmission, was examined.

RESULTS

The average age of patients in the cohort was 65.4 ± 12.9 years. The average Charlson comorbidity index was 0.6 (standard deviation = 1.0), with 691 patients (14.9%) having 2 or more comorbidities. Mean preoperative RDW level was 14.4% (standard deviation = 1.8). After adjusting for covariates, higher RDW levels were statistically significantly associated with mortality (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), any in-hospital medical complications (adjusted OR, 1.12; 95% CI, 1.07-1.18; P < .001), and readmission (adjusted OR, 1.07; 95% CI, 1.02-1.13; P < .001).

CONCLUSION

Higher levels of preoperative RDW appeared to be associated with less optimal outcomes after revision TJA. Adult reconstruction orthopedic surgeons should be aware of this predictive factor and exercise caution with TJA revision patients with high values of preoperative RDW. RDW could be included in the routine perioperative workup and used to counsel patients on their postoperative risk.

Hip fracture patients who experience a greater fluctuation in RDW during hospital course are at heightened risk for all-cause mortality: a prospective study with 2-year follow-up

This study aims to detect whether there remains valuable prognostic information in fluctuation of red cell distribution width (RDW) in hip fracture patients. Results show that this readily available parameter may provide a more effective strategy for assessment of mortality risk, therefore providing a reference for clinical planning and decision-making.

INTRODUCTION

Prognostic values have been found in the fluctuation of some hematologic parameters. The red cell distribution width (RDW) routinely reported with all complete blood cell counts (CBC) has proven to be associated with poor outcomes in various diseases. However, whether the fluctuation in RDW is predictive of long-term mortality in hip fracture patients treated with surgery remains unknown.

METHODS

One thousand three hundred thirty hip fracture patients who underwent surgery from January 1, 2000 to November 18, 2012 were recruited in this prospective cohort study. Fluctuation in the RDW between admission and discharge was measured, and a Kaplan-Meier (KM) analysis and multivariable Cox regression model were applied to evaluate the relationship between this fluctuation and mortality. Risk factors for a larger fluctuation were detected by using Logistic regression analyses.

RESULTS

In addition to the admission RDW, a high RDW level at the time of discharge was also associated with an increased risk of death, while no significant difference was found in the postoperative RDW. Fluctuation in the RDW between admission and discharge was an independent risk predictor for 2-year mortality (HR 1.45 95%CI 1.06-2.00, p = 0.022). Factors affecting the change in the RDW between admission and discharge included both the demographic characteristics of the patients and clinical interventions.

CONCLUSION

Hip fracture patients who experience a greater fluctuation in RDW during the hospital course are at a heightened risk for 2-year all-cause mortality.