Cerebrovascular accidents associated with hip fractures: morbidity and mortality-5-year survival

Prevalence of complications in older adults after hip fracture surgery : a systematic review and meta-analysis

Aims

Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery.

Methods

MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery.

Results

A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%.

Conclusion

Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence.

Association between postoperative thromboembolic and hemorrhagic complications and clinical outcomes after surgery for chronic subdural hematoma in patients with anticoagulation therapy for atrial fibrillation

PURPOSE

A substantial proportion of patients undergoing surgery for chronic subdural hematoma (CSDH) use anticoagulation medication due to atrial fibrillation (AF). We assessed the risk of postoperative thromboembolic and hemorrhagic complications in CSDH surgery patients with a history of anticoagulation for AF and their association with outcome.

METHODS

This posthoc analysis of a nationwide multicenter randomized controlled trial conducted during 2020-2022 included CSDH patients undergoing surgery with a history of preoperative anticoagulation use for AF. We assessed the incidence of thromboembolic and hemorrhagic complications and their associations with functional outcomes and mortality.

RESULTS

Of 589 patients, 128 patients (median age 83 years, 24% females) were on anticoagulation medication due to AF. The incidences of postoperative thromboembolic and hemorrhagic complications were 8% and 6%, respectively. A significantly higher proportion of patients with a thromboembolic complication had unfavorable functional outcome (70% vs. 21%, p < 0.001) and higher mortality (50% vs. 14%) than those without. After adjusting for risk factors, a thromboembolic complication was independently associated with a higher risk for unfavorable outcome (OR 16.8, 95% CI 3.0-94.2) and death (OR 11.1, 95% CI 2.4-52.0). Similarly, hemorrhagic complications associated independently with unfavorable outcome, although the effect size was smaller than for thromboembolic complications.

CONCLUSION

The risk for thromboembolic complications seemed to be slightly higher than the risk for postoperative hemorrhagic complications after CSDH surgery in patients with a history of preoperative anticoagulation medication use due to AF. The occurrence of a thromboembolic complication was detrimental for patient prognosis, underscoring the importance of strategies to prevent thromboembolic events. There is an urgent need for a trial assessing the optimal timing of restarting anticoagulation medication after CSDH surgery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04203550.

Cervical Degenerative Myelopathy is an Unexpected Risk Factor for Hip Fractures

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To assess the potential role of degenerative myelopathy as a risk factor for major fragility fractures in older patients.

BACKGROUND

Degenerative cervical myelopathy (DCM) stands as the foremost spinal disorder affecting adults, significantly impacting patients' quality of life. However, it is often underdiagnosed, with its prevalence traditionally considered low (0.06%-0.112%). Despite the rising prevalence of hip fractures with an aging population and the identification of numerous risk factors, DCM is not typically regarded as a primary risk factor for such fractures. In 2015, an American study revealed an unexpectedly high rate of 18% of undiagnosed DCM in patients with hip fractures within a small cohort. We sought to replicate this study in a larger cohort of a European population.

MATERIALS AND METHODS

Our cross-sectional study targeted patients older than 65 years with hip fractures and aimed to identify cases of DCM at the time of fracture. Exclusions were made for patients with preexisting DCM diagnoses, neurological disorders, prior cervical surgeries, and instances of high-energy trauma. Comprehensive demographic, clinical, and radiologic data were collected, followed by descriptive and statistical analysis.

RESULTS

In our study, 147 patients (mean age: 82.9 y) were included. Through a combination of clinical assessment and physical examination, 23 patients (15.6%) were identified as indicative of myelopathy. Confirmation through magnetic resonance imaging led to an estimated overall prevalence of DCM at 10.5%. Logistic regression analysis revealed that the presence of hypertonic reflexes, cervical pain, or cervicobrachialgia were specific and valuable indicators for diagnosing myelopathy.

CONCLUSION

This study marks the first investigation of its kind in a European population, highlighting the notably high prevalence of undiagnosed DCM among older patients who have experienced hip fractures. This underscores DCM as a potential risk factor for hip fractures in the elderly, despite its underdiagnosis and undertreatment.

LEVEL OF EVIDENCE

Level III.

Pulmonary Embolism Post-Femoral Neck Fracture Surgery: A Critical Predictor of Five-Year Mortality

Objectives

This study examines the impact of pulmonary embolism (PE) on mortality among patients with femoral neck fractures, exploring the predictive value of preoperative PE for postoperative occurrences and associated mortality over a 5-year follow-up period.

Methods

We analyzed 2256 patients over 60 years old admitted with femoral neck fractures, focusing on those who developed DVT or PE postoperatively. Surgical intervention aimed within 48 hours without pharmacological thromboprophylaxis, utilizing mechanical prophylaxis instead. Postoperative management included Enoxaparin administration. Data analysis employed SPSS 21, with chi-squared tests, T-tests, and multivariate logistic regression to explore mortality and PE incidence.

Results

PE was diagnosed in 1.4% of patients, with a notable mortality contrast between patients with PE (87%) and those without (59.7%) over 5 years. A history of preoperative PE emerged as a significant risk factor for postoperative PE. Despite surgical variations, no significant correlation was found between surgery type and PE incidence. Early postoperative weight-bearing and institutional rehabilitation did not significantly alter PE incidence rates.

Conclusions

The study underscores the significant mortality risk associated with preoperative PE in femoral neck fracture patients. It highlights the necessity for vigilant PE risk assessment and management, challenging assumptions about the protective role of early mobility and rehabilitation in PE incidence. Further research is essential to refine patient care strategies and improve outcomes.

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures

PURPOSE

Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates.

METHODS

A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission.

RESULTS

The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss.

CONCLUSION

This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Incidence and risk factors for stroke after hip fracture: a meta-analysis

Hip fractures represent a high burden and are associated with mortality in up to 30% of the cases. Stroke complications can be devastating and increase mortality and disability in elderly patients. This study aimed to determine the overall incidence and risk factors for stroke in patients with hip fractures. A systematic search of the literature using PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases was carried out. Studies have reported the incidence of stroke in patients > 50 years of age with hip fractures. Data were extracted according to PRISMA guidelines (PROSPERO: CRD42023384742). Data were combined using Review Manager version 5.4. A random-effects model was adopted if a significant heterogeneity was observed. The primary outcome was the incidence of stroke in patients with hip fractures. The secondary outcomes of interest included the influence on the incidence of demographic factors, associated conditions, habits, and analytical parameters. Of the 635 initially retrieved studies, 18 were included, with 256,197 patients. The mean age of the patients ranged from 55 to 84 years old. The overall incidence of stroke in patients with hip fracture was 6.72% (95% CI 4.37-9.07%. The incidence of stroke by region was highest in the American continent (8.09%, 95% CI 3.60-12.58%; P > 0.001). Regarding associated conditions diabetes significantly increased the risk of stroke (OR 1.80, 95% CI 1.41-2.30). Respect to patient characteristics, BMI greater than 24.4 and female gender did not significantly increase the risk of stroke: (OR 1.07, 95% CI 0.74-1.56) and (OR 1.15, 95% CI 0.91-1.46). Lastly, lower albumin concentrations were a risk factor for stroke in patients with hip fracture (MD - 3.18, 95% CI - 4.06 to 2.31). In conclusion, the incidence of stroke after hip fracture was 6.72%. The incidence of stroke increases over time, and the closely associated risk factors are diabetes and low albumin level.

The Effect of Warfarin Use on Postoperative Outcomes after Femoral Neck Surgery

Introduction: Anticoagulation use in the elderly is common for patients undergoing femoral neck hip surgery. However, its use presents a challenge to balance it with associated comorbidities and benefits for the patients. As such, we attempted to compare the risk factors, perioperative outcomes, and postoperative outcomes of patients who used warfarin preoperatively and patients who used therapeutic enoxaparin. Methods: From 2003 through 2014, we queried our database to determine the cohorts of patients who used warfarin preoperatively and the patients who used therapeutic enoxaparin. Risk factors included age, gender, Body Mass Index (BMI) > 30, Atrial Fibrillation (AF), Chronic Heart Failure (CHF), and Chronic Renal Failure (CRF). Postoperative outcomes were also collected at each of the patients' follow-up visits, including number of hospitalization days, delays to theatre, and mortality rate. Results: The minimum follow-up was 24 months and the average follow-up was 39 months (range: 24-60 months). In the warfarin cohort, there were 140 patients and 2055 patients in the therapeutic enoxaparin cohort. Number of hospitalization days (8.7 vs. 9.8, p = 0.02), mortality rate (58.7% vs. 71.4%, p = 0.003), and delays to theatre (1.70 vs. 2.86, p < 0.0001) were significantly longer for the anticoagulant cohort than the therapeutic enoxaparin cohort. Warfarin use best predicted number of hospitalization days (p = 0.00) and delays to theatre (p = 0.01), while CHF was the best predictor of mortality rate (p = 0.00). Postoperative complications, such as Pulmonary Embolism (PE) (p = 0.90), Deep Vein Thrombosis (DVT) (p = 0.31), and Cerebrovascular Accidents (CVA) (p = 0.72), pain levels (p = 0.95), full weight-bearing status (p = 0.08), and rehabilitation use (p = 0.34) were similar between the cohorts. Conclusion: Warfarin use is associated with increased number of hospitalization days and delays to theatre, but does not affect the postoperative outcome, including DVT, CVA, and pain levels compared to therapeutic enoxaparin use. Warfarin use proved to be the best predictor of hospitalization days and delays to theatre while CHF predicted mortality rate.

Characteristics and perioperative complications of hip fracture in the elderly with acute ischemic stroke: a cross-sectional study

BACKGROUND

Patients with acute ischemic stroke (AIS) after hip fracture in the elderly have worse prognosis. We aimed to describe the characteristics and complications of hip fracture with AIS in the elderly.

METHODS

This cross-sectional study selected patients with hip fracture (age ≥65 years) from January 2018 to September 2020. The collected data included age, sex, fracture types, comorbidities. In above screened patients, we further collected cerebral infarction related information of AIS patients. The least absolute shrinkage and selection operator (LASSO) logistic regression was performed to identify the strongest predictors of AIS after hip fracture. Multivariate logistic regression analysis was conducted to find independent risk factors for AIS after hip fracture.

RESULTS

Sixty patients (mean age 79.7 years;female 56.7%) occurred AIS after hip fracture in 1577 cases. The most common infarction type was partial anterior circulation infarction (PACI) (70.0%). The majority of these infarction lesions were single (76.7%) and most infarction lesions(65.0%) were located in the left side. 81.7% of AIS patients had mild (Health stroke scale NIHSS <4) AIS. Older patients with AIS after hip fracture were more frequently complicated by hypertension(73.3%), prior stroke (46.7%), diabetes(35.0%) and were more likely to have hypoproteinemia(68.3%), electrolyte disorders ( 66.7%), anemia (65.0%), deep vein thrombosis (51.6%), pneumonia (46.6%),cardiac complications (45.0%). Combined with hypertension (OR 2.827, 95%CI 1.557-5.131) and male sex(OR 1.865, 95%CI 1.095-3.177) were associated with the increased risk of AIS after hip fracture.

CONCLUSIONS

Older patients combined with hypertension are more likely to have AIS after hip fracture. For these patients, early preventions should be administered. AIS patients after hip fracture are prone to have multiple complications under traumatic stress, and we should enhance the management of these patients to reduce the stress and avoid occurrence of complications.

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery

INTRODUCTION

Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.

METHODS

We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold.

RESULTS

There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively).

CONCLUSION

We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

Bipolar hemiarthroplasty may reduce cerebrovascular accidents and improve early weight-bearing in the elderly after femoral neck fracture

Cerebrovascular accidents (CVA) in the elderly population after femoral neck fracture remain great concern for physicians. Specifically, surgical fixation techniques, such as bipolar hemiarthroplasty (HA) and internal fixation play a significant role in influencing the occurrence of postoperative CVA in the elderly population.In order to identify 2 cohorts, we used a rigid selection process based on our institution's database. The cohorts were comprised of a HA cohort and a cannulated screw cohort, of which underwent femoral neck surgery, performed by 3 fellowship trained surgeons from 2003 to 2014. Risk factors were documented and measured, including Coumadin use and hypertension, and postoperative complications such as CVA and death rate were also recorded. A P-value of <.05 was determined to be statistically significant.A power analysis was performed and achieved a power of 0.95. We found a non-significant reduction in CVA for bipolar HA (3.6% CVA vs 0.0% in the non-CVA group, P = .48) and a non-significant increase in CVA for cannulated screw use (7.6% CVA vs 14.4% in the non-CVA group, P = .11). In addition, we found a significant difference in terms of weight-bearing status at 6-weeks postoperatively (0.95 vs 2.0, P < .0001), favoring the bipolar HA group.Among the advantages of bipolar HA surgery, surgeons should consider its value in reducing the occurrence of postoperative CVA. Furthermore, patients who underwent bipolar HA had improved weight-bearing status postoperatively compared with cannulated screw fixation.

Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data

A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option.

PURPOSE

Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM).

METHODS

This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically.

RESULTS

From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%).

CONCLUSION

Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.