Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair

Risk Factors of Postoperative Acute Heart Failure in Elderly Patients After Hip Fracture Surgery

Background Postoperative acute heart failure (AHF) in elderly patients after hip fracture surgery is a common complication. Therefore, this study aimed to identify the risk factor of AHF after hip fracture surgery among the older population. Methods This retrospective cohort study was performed on 88 admitted patients whose hip fractures were fixed via internal fixation surgery in a tertiary care hospital in Rawalpindi, Pakistan, from January 2022 to March 2023. Recruitment of patients was made through established inclusion and exclusion criteria. Ethical approval and informed consent were also gained before the data collection. A self-designed form was used to collect data. Data analysis was carried out in the IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). Both descriptive and inferential statistics were applied to compare the attributes of the patients with AHF and patients without AHF. Multivariate logistic regression was used to evaluate the association between the postoperative AHF and its potential risk factors. Results Out of 88 enrolled patients, 12 (13.64%) had developed postoperative AHF. Age ≥ 65 years (OR = 2.606, 95% CI = 1.035~4.160, p = 0.010), anemia (OR = 3.178, 95% CI = 1.847~5.990, p = 0.029), hypertension (OR = 2.019, 95% CI = 1.110~4.034, p = 0.012), diabetes mellitus (OR = 2.003, 95% CI = 1.115~4.012, p = 0.015), hypoalbuminemia (OR = 2.486, 95% CI = 1.218~4.619, p = 0.030), and operation time ≥ 120 minutes (OR = 1.702, 95% CI = 1.099~2.880, p = 0.018), were the risk factors of postoperative AHF in elderly patients after hip fracture surgery. Conclusions In the study population, the incidence of postoperative heart failure was significant and age ≥ 65 years, anemia, hypertension, diabetes mellitus, hypoalbuminemia, and operation time ≥ 120 were significantly involved in the development of it. Preoperative identification and management of AHF risk factors could lead to the prevention of postoperative complications.

Association between sedation during spinal anesthesia and mortality in older patients undergoing hip fracture surgery: A nationwide retrospective cohort study in Japan

STUDY OBJECTIVE

Intraoperative sedation plays an important role in the management of regional anesthesia. Few studies have investigated the association of sedation during spinal anesthesia with postoperative mortality in older patients as a primary outcome. This study aimed to test the hypothesis that sedation during spinal anesthesia increases postoperative mortality in older patients undergoing hip fracture surgery.

DESIGN

Retrospective, cohort study.

SETTING

Acute and subacute care hospitals in Japan.

PATIENTS

Patients aged 65 years and older who received hip fracture surgery under spinal anesthesia between April 2014 and May 2022.

EXPOSURE

Sedation during spinal anesthesia.

MEASUREMENTS

Postoperative in-hospital all-cause mortality within 30 days.

MAIN RESULTS

In total, 25,554 eligible patients were identified. Propensity score matching created 4735 pairs, and baseline patient characteristics were acceptably balanced between the sedation and non-sedation groups. There was no significant difference in 30-day postoperative mortality between the two groups (hazard ratio [95% CIs]: 0.92 [0.59-1.44]).

CONCLUSIONS

There was no association between sedation during hip fracture surgery in older patients under spinal anesthesia and postoperative mortality. However, these results are limited to our population, and further prospective studies are needed to determine the safety of sedation.

Functional outcome in patients with hip fracture from 2008 to 2018, and the significance of hand-grip strength - a cross-sectional comparative study

BACKGROUND

Incidence of hip fracture is estimated to rise, increasing demands on healthcare. Our objective was to compare patients with hip fracture, a decade apart, regarding surgical characteristics and functional outcome in relation to morbidity. A secondary aim was to analyse postoperative hand-grip strength (HGS) in relation to walking ability 4 months postoperatively.

METHODS

This is a cross-sectional comparative study of patients with hip fracture, included in 2008 (n = 78) and 2018 (n = 76) at Örebro University Hospital. Patient-data (age, gender, morbidity, fall-circumstances, fracture, surgical characteristics, and length of stay) were collected from medical records. HGS was measured postoperatively. Data on functional outcome in terms of housing, walking ability and need of walking aids at 4 months postoperatively was collected from the Swedish Hip Fracture Register RIKSHÖFT. Statistical analyses adapted were hypothesis tests and regression analysis.

RESULTS

Patients in 2018 presented a significantly higher morbidity than patients in 2008 and there were significant differences in adapted surgical methods. Functional outcome at 4-months postoperatively was analysed by logistic regression where Cohort 2018 was associated with higher odds of independent walking ability (OR 5.7; 95%CI 1.9-17.2) and not needing any walking aids (OR 5.1; 95%CI 1.9-17.2). Postoperative HGS was higher among patients in 2018 and a multiple regression analysis revealed a significant association between HGS and walking ability at 4 months postoperatively.

CONCLUSIONS

This study supports the since previously reported development in hip fracture surgery in Sweden while also presenting that functional outcome seems to have improved despite a concomitant increase in morbidity. Results suggest an improvement in postoperative HGS, predicting walking ability at 4 months postoperatively.

Incidence and predictors of postoperative acute kidney injury in older adults with hip fractures

OBJECTIVES

Main Purpose: To clarify the incidence and predictors of acute kidney injury (AKI) after hip fracture surgery; Secondary Purpose: To investigate the impact of AKI on the length of stay (LOS) and mortality of patients.

METHODS

We retrospectively evaluated data from 644 hip fracture patients at Peking University First Hospital from 2015 to 2021, and divided the patients into AKI and Non-AKI groups according to whether AKI occurred after surgery. Logistic regression was used to clarify the risk factors for AKI, draw ROC curves, and analyze the odds ratio (OR) for LOS and death at 30 days, 3 months, and 1 year for patients with AKI.

RESULTS

The prevalence of AKI after hip fracture was 12.1%. Age, BMI, and postoperative brain natriuretic peptide (BNP) levels were risk factors for AKI after hip fracture surgery. The risk of AKI in underweight patients, overweight patients and obese patients was 2.24, 1.89, and 2.58 times. Compared to patients with BNP levels <800 pg/ml, the risk of AKI was 22.34-fold for postoperative BNP levels>1500 pg/ml. The risk of a one-grade increase in LOS was 2.84 times higher in the AKI group and the mortality of patients with AKI were higher.

CONCLUSION

The incidence of AKI after hip fracture surgery was 12.1%. Advanced age, low BMI, and postoperative high level BNP were risk factors for AKI. Surgeons need to pay more attention to patients with older age, low BMI and high postoperative BNP levels in order to proactively prevent the development of postoperative AKI.

Current Trends in Comorbidity Prevalence and Associated Mortality in a Population-Based Cohort of Hip Fracture Patients in Denmark

Background and Purpose

Patients with hip fractures often have comorbidities, but detailed data on comorbidity and its impact on prognosis are lacking. We described the current trends in the prevalence of comorbidity and the magnitude of the associated mortality.

Patients and Methods

From the Danish Multidisciplinary Hip Fracture Registry we included 31,443 hip fracture patients (diagnosed in 2014-2018). We calculated the prevalence of individual diseases and comorbidity measured with the Charlson Comorbidity Index (CCI), the Elixhauser Index, and the Rx-Risk Index. We calculated sex and age-adjusted odds ratios (aORs) for 30-day mortality and hazard ratios (aHRS) for one-year mortality with 95% confidence intervals (CI).

Results

The most common diseases identified with the CCI were cerebrovascular diseases (18%), malignancies (17%), chronic pulmonary disease (14%), and dementia (11%). Using the Elixhauser Index, hypertension (37%), cardiac arrhythmias (21%), and fluid and electrolyte disorders (15%) were most prevalent, while ischemic heart disease (42%), hypertension (39%), and use of antiplatelets (37%) were most prevalent when using the Rx-Risk Index. Using the Rx-Risk Index, only 28% of patients had no comorbidity compared to 38% for CCI and 44% for the Elixhauser Index, and the prevalence was stable through the years. Compared to patients with no comorbidity, patients with very severe comorbidity had an aORs for 30-day mortality of 2.6 (CI: 2.4-2.9) using CCI, 2.6 (CI: 2.4-3.1) using the Elixhauser Index, and 3.1 (CI: 2.7-3.4) using the Rx-Risk Index.

Interpretation

More than 50% of the patients with hip fractures have moderate to very severe comorbidity, with considerable variation between indices. The prevalence of individual diseases varies considerably. All indices had comparable dose-response associations with mortality. These results are relevant for clinicians to amend prevention and target care, and for researchers to decide which comorbidity measure to use depending on the research question.

Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study

STUDY OBJECTIVE

Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects.

DESIGN

Retrospective study of population-based database.

PATIENTS

The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery.

INTERVENTIONS

None.

MEASUREMENTS

The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes.

MAIN RESULTS

In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP.

CONCLUSIONS

In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.

Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation

INTRODUCTION

Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery.

METHODS

This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO₂) values between the 4^th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs.

DISCUSSION

We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures.

ETHICS AND DISSEMINATION

This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals.

ETHICS APPROVAL NUMBER

2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021.

TRIAL STATUS

Recruiting. Recruitment is expected to be completed in December 2024.

Risk Factors Associated With Postoperative Pulmonary Infection in Elderly Patients With Hip Fracture: A Longitudinal Study

This study aimed to conduct a longitudinal study to explore the influencing factors of pulmonary infection in elderly patients with hip fracture after surgery, to provide evidence and reference for the early identification and nursing care of patients at high risk of postoperative pulmonary infection.A secondary analysis was conducted of electronic medical record data from elderly patients with hip fractures treated in a tertiary hospital from January 1, 2020 to June 30, 2021.A total of 526 patients were included. Age ≥70 years (odd ratio [OR] 2.042, 95% confidence interval [CI] [1.516-4.022]), history of smoking (OR 2.755, 95% CI [2.009-3.175]), time from fracture to operation ≥5 days (OR 3.117, 95% CI [1.925-3.911]), American Society of Anesthesiologists grade ≥II (OR 1.254, 95% CI [1.053-1.921]), chronic obstructive pulmonary disease (OR 2.832, 95% CI [1.775-3.808]), hypoproteinemia (OR 1.395, 95% CI [1.022-1.841]), red blood cell distribution width >15% (OR 3.142, 95% CI [2.104-4.172]), intensive care unit stay (OR 2.174, 95% CI [1.083-3.718]) and duration of mechanical ventilation ≥180 minutes (OR 3.117, 95% CI [2.199-4.807]) were the independent risk factors (all p < .05).Early nursing care should be taken for patients with risk factors to reduce the pulmonary infection.

Reoperation and revision rates at ten years after 1,312 cemented Thompson’s hemiarthroplasties

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Methods

Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries.

Results

In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%.

Conclusion

The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients.

Cite this article: Bone Jt Open 2022;3(9):710–715.

The Use of Critical Care Services After Orthopedic Surgery at a High-Volume Orthopedic Medical Center: A Retrospective Study

Background: With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. Purpose: We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. Methods: We retrospectively reviewed inpatient electronic medical record data (2016-2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Results: Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). Conclusions: This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery.

Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center

BACKGROUND

Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol.

METHODS

We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017.

RESULTS

A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups.

CONCLUSION

With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population.

LEVEL OF EVIDENCE

III, therapeutic.

A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial

Background

Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.

Methods

A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.

Results

Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.

Conclusion

Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

Functional Application of Tricks for Super Obese Patient Positioning: A Technical Guide for Hip Fractures on a Fracture Table With a Case Example

Obese patients with hip fractures are at increased risk of perioperative complications due to both their size and associated medical conditions. The purpose of this report is to describe a technique for intraoperative positioning of obese patients who sustain a hip fracture. A 62-year-old female with a history of morbid obesity (BMI 48.06kg/m²), type II diabetes mellitus, and hypertension presented with a right intertrochanteric fracture and was admitted for operative fixation on a fracture table. A standardized approach for systematic patient positioning and abdominal panniculus taping is described, which facilitates operative repair of the hip fracture using a cephalomedullary nail. This report describes the intraoperative positioning technique of a morbidly obese patient with an intertrochanteric hip fracture in order to highlight specific techniques used to deal with the physical aspects of obesity that can improve the surgical efficiency of the procedure. By positioning obese patients in a standardized way, intraoperative time and complications will be decreased, potentially mitigating some of the risks associated with this patient population.

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study

BACKGROUND

Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients.

METHODS

After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated.

RESULTS

Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35).

CONCLUSIONS

Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Trends in Comorbidities and Postoperative Complications of Geriatric Hip Fracture Patients from 2000 to 2019: Results from a Hip Fracture Cohort in a Tertiary Hospital

Objective

To describe the secular trends in comorbidities and postoperative complications of geriatric hip fracture patients from the Chinese People's Liberation Army General Hospital Hip Fracture Cohort between 2000 and 2019.

Methods

We included 2,805 hip fracture patients aged 65 years or older and received surgical treatment from 25 January 2000 to 19 December 2019. Demographic characteristics, comorbidities, postoperative complications, length of hospital stay, and the time to surgery were extracted and examined in each 5‐year period based on the admission year, namely 2000–2004, 2005–2009, 2010–2014, and 2015–2019. Categorical data were analyzed by chi‐squared or Fisher's exact test, with ordinal data by row mean scores difference test and continuous data by one‐way analysis of variance. Trends in comorbidities and postoperative complications were examined by the Cochran–Armitage trend test.

Results

The average age of the included population was 79.1 ± 7.3 years (mean ± standard deviation), and 69.1% were female. From 2000 to 2019, the proportion of females increased from 59.8% to 73.0% (P for trend <0.05). Hypertension (51.8%), type 2 diabetes (23.6%), coronary heart disease (20.9%), stroke (18.7%), and arrhythmia (11.2%) were the most prevalent five comorbidities. The proportion of hypertension was 27.0%, 45.4%, 53.0%, and 57.2% in each 5‐year period with an increasing trend (P for trend <0.05). The proportion of type 2 diabetes was 9.8%, 22.8%, 23.5%, and 26.0% in each 5‐year period (P for trend <0.05). Similar increasing trends were found in myocardial infarction, arrhythmia, and tumor. On the contrary, the proportion of patients with major postoperative complications decreased from 2000 to 2019, with 23.0%, 14.6%, 6.5%, and 5.6% in each 5‐year period (P for trend <0.05). For each specific postoperative complication, i.e. pneumonia, cardiovascular event, respiratory failure, and in‐hospital death, similar decreasing trends were found (all P for trend <0.05).

Conclusion

This descriptive analysis sheds light on the fact that the health status of the hip fracture population tends to shift gradually. Improving concepts and practices of clinical interventions may help reduce postoperative complications, whereas challenges in the management of comorbidities increase.

Impact of multiple nerves blocks anaesthesia on intraoperative hypotension and mortality in hip fracture surgery intermediate-risk elderly patients: A propensity score-matched comparison with spinal and general anaesthesia

BACKGROUND

A Hip fracture in the intermediate-risk elderly patient is common and associated with a high rate of postoperative morbidity and mortality. There is a lack of consensus on the optimal anaesthetic technique but there is a clear association between intraoperative hypotension and postoperative morbidity and mortality. We aimed to compare the haemodynamic stability of three anaesthesia techniques: general anaesthesia (GA), continuous spinal anaesthesia (CSA), and multiple nerve blocks (MNB).

METHODS

The primary outcome was the occurrence of intraoperative hypotension defined by a 30% decrease in mean arterial pressure (MAP) from baseline. Secondary outcomes included incidence of hypotension under 50 mmHg of MAP, time spent below MAP 50 mmHg, use of vasopressors, in-hospital and 30-day mortality. A propensity score-matched analysis was performed.

RESULTS

After screening and application of the exclusion criteria, 593 patients undergoing hip fracture surgery between the 1^st of January 2015 and the 31^st of December 2016 were included. The propensity score match analysis selected 43 patients in each group. The incidence of hypotension was significantly higher in the GA group than in the MNB and CSA groups: 39 (90%), 22 (51%), and 23 (53.5%), respectively; p < 0.0001. The incidence of MAP < 50 mmHg (59.5%, 23.3%, and 16.3%; p < 0.0001) and the use of vasopressors (93%, 39.5%, and 25.6%; p < 0.0001) were increased significantly in the GA group. With the GA group as a reference, odds ratios were reported in the MNB group at 0.08 [0.022-0.30] (p = 0.0002) for hypotension episodes; 0.17 [0.04-0.66] (p = 0.01) for hypotension < 50 mmHg for more than 3 min and 0.049 [0.013-0.018] (p < 0.0001) for use of vasopressors. The duration of hospital stay, postoperative complications, in-hospital and 30-day mortality rates did not differ significantly between the groups.

CONCLUSION

CSA and MNB provide better haemodynamic stability than GA. However, whatever the anaesthesia technique used, the mortality rates do not change even if MNB leads to less hypotension. IRB contact information: CERAR IRB 00010254-2016-118. Clinical Trial Number: ClinicalTrials.gov. ID: NCT03356704.

A Comparison of Patients with Hip Fracture, Ten Years Apart: Morbidity, Malnutrition and Sarcopenia

OBJECTIVES

To investigate possible differences in morbidity, malnutrition, sarcopenia and specific drug use in patients with hip fracture, ten years apart. To analyse 1-year mortality and possible associations with variables.

DESIGN

A prospective, observational study.

SETTING

Örebro University Hospital, Sweden.

PARTICIPANTS

Two cohorts of patients with hip fracture, included in 2008 (n=78) and 2018 (n=76).

MEASUREMENTS

Presence of comorbidity according to the Elixhauser comorbidity measure, multimorbidity defined as ≥3 comorbidities, preoperative American Society of Anaesthesiologists Classification (ASA-class), malnutrition according to the definition by the Global Leadership Initiative on Malnutrition (GLIM), sarcopenia according to the most recently revised definition by the European Working Group on Sarcopenia in Older People (EWGSOP), polypharmacy defined as ≥5 prescribed medications, use of Potentially Inappropriate Medications (PIM) and Fall-Risk-Increasing-Drugs (FRID) and postoperative 1-year mortality.

RESULTS

When comparing the cohorts, significant increases over time was seen for mean comorbidity-count (Difference -1; p=0.002), multimorbidity (Difference -15%; 95%CI -27;-2), ASA-class 3-4 (Difference -25%; 95%CI -39;-9) and polypharmacy (Difference -17%; 95%CI -32;-2). Prevalence of malnutrition and sarcopenia coherently decreased with 22% (95%CI 5;37) and 14% (95%CI 1;29) respectively. One-year mortality remained unchanged and a significant association was found for a higher ASA-class in 2008 (OR 3.5, 95%CI 1.1;11.6) when adjusted for age. Results on PIM exposure suggest a decrease while exposure to FRID remained high.

CONCLUSION

Our findings support an increasing morbidity within the population over time. However, also presented is a coherent decrease in malnutrition and sarcopenia, suggesting a decrease in frailty as a possible explanation for the observed unaltered mortality, in turn suggesting advances in treatment of comorbidities.