30-day mortality after hip fracture surgery: Influence of postoperative factors

Fragility hip fractures among Nigerian older adults: a retrospective study of epidemiology, mobility and mortality outcomes at 3 and 12 months post-hospital discharge

Fragility hip fractures (FHFs) are a growing concern worldwide. Sub-Saharan Africa is no exception. Nigeria has limited data on FHFs. This study found that surgical treatment significantly enhances mobility and survival rates for older adults with FHFs. The findings can inform healthcare policies and practices in Nigeria and similar contexts.

PURPOSE

The global population, including that of sub-Saharan Africa, is rapidly ageing, resulting in a higher incidence of fragility fractures. This study investigates the epidemiology of fragility hip fractures (FHFs) at a Nigerian teaching hospital, focusing on the predictors of two key outcomes: (1) mobility and mortality 3 months post-discharge, and (2) mortality 12 months post-discharge.

METHODS

A retrospective study was conducted involving 102 older adults aged ≥ 60 who received treatment for femoral neck, intertrochanteric, and subtrochanteric fractures at a mission teaching hospital in Nigeria over 6 years. Data collected included demographics, causes of fractures, comorbidities, treatment methods, time-to-surgery, length of stay, mobility, and mortality rates. Univariate analyses were performed to identify mobility and mortality outcomes predictors at 3 and 12 months post-discharge.

RESULTS

The mean age was 78.0 years, with 49.0% of patients in the oldest-old category. 70.6% regained mobility 3 months post-discharge. The mortality rate was 3.9% at 3 months and 22.5% at 12 months. Predictors of better mobility and mortality outcomes included younger age, no/mild comorbidities, fractures due to community falls, femoral neck fractures, surgical treatment, and shorter time to surgery. Patients who regained mobility by 3 months had a lower 12-month mortality rate (p < 0.001).

CONCLUSION

This study emphasizes the importance of effective surgical management for FHFs in Nigeria's ageing population. The findings suggest that a multidisciplinary care approach, encompassing comprehensive management of comorbidities, age-friendly housing design, ongoing research, and investment in healthcare infrastructure, is essential to address the growing burden of FHFs.

Impact of Vitamin D Deficiency on Short- and Long-Term Mortality in Patients Receiving Hip Fracture Surgery Under General Anesthesia: A Matched Cohort Study

BACKGROUND

Although vitamin D deficiency (VDD) is common in patients who have hip fractures, the relationship between VDD and mortality risk remains unclear.

METHODS

Using a network database (2010 to 2023), we conducted a matched cohort study of adult patients undergoing hip fracture surgery under general anesthesia. Patients were stratified according to preoperative 25-hydroxyvitamin D levels into VDD (≤ 20 ng/mL) and control groups (≥ 30 ng/mL). After 1:1 propensity score matching, 4,736 pairs were analyzed. The primary outcome was 12-month all-cause mortality. Secondary outcomes included 30- and 90-day all-cause mortality.

RESULTS

The 12-month mortality rate was significantly higher in the VDD group than in the control group (13.6 versus 11.6%, hazard ratio [HR]: 1.23, 95% confidence interval [CI]: 1.09 to 1.37, P = 0.0005). Similar patterns were observed at 30 days (3.4 versus 2.3%, HR: 1.52, P = 0.0007) and 90 days (7.1 versus 5.2%, HR: 1.41, P < 0.0001). Subgroup analyses based on age (18 to 65 versus > 65 years) and sex revealed a consistent association between VDD and mortality at 12 months. Vitamin D insufficiency (20 to 30 ng/mL) showed no significant association with increased mortality compared to the control group. Among patients who had VDD, malnutrition, neoplasms, diabetes mellitus, and heart disease have been identified as risk factors for 12-month mortality.

CONCLUSIONS

Preoperative VDD was significantly associated with increased mortality risk after hip fracture surgery, with particularly pronounced effects in the early postoperative period. These findings highlight the importance of preoperative vitamin D screening and potential supplementation strategies for patients who have vitamin D levels below 20 ng/mL.

A simulation study showed that linear regression and Mann-Whitney test can be used to analyze the Days Alive and at Home by Day 30 outcome in a randomized controlled trial

BACKGROUND AND OBJECTIVES

The aims of the work were to consider the properties of the Days Alive and at Home by Day 30 (DAH30) from a statistical perspective, and to conduct a simulation study exploring the use of simple (unadjusted) linear regression and Mann-Whitney test as the method of analysis reflect realized analysis options.

STUDY DESIGN AND SETTING

The Days Alive and at Home by Day 30 (DAH30) has been proposed a patient-centric outcome, and clinically relevant outcome suitable for clinical trials. It has unusual statistical properties, and suitability of standard statistical analysis methods is unclear. The properties of DAH30 were reviewed. Simulations based upon 1:1 allocation in an randomized controlled trial (RCT) based upon empirical data were conducted reflecting different additive and realized (reflecting the DAH30) treatment effects, sample sizes and distributions with varying and central locations and zero value level. A variety of metrics were used to assess performance (including bias, coverage, and rejection rate).

RESULTS

Linear regression provided a valid estimate of the unadjusted average treatment effect with an additive treatment. This was confirmed in terms of bias, estimation of variance, rejection rate in the absence of an effect, and coverage of the 95% confidence interval for the true realized effect. Mann-Whitney provided greater (power) than linear regression in some situations.

CONCLUSION

Simple linear regression is a reasonable analytic option for the DAH30 for estimating the average treatment effect in the RCT cohort (ie, an intention to treat, or "treatment policy" estimand) where zero-inflation is relatively low. Mann-Whitney test in some circumstances (small effects and smaller samples sizes) provides better ability (like for like) to detect a difference between the groups.

PLAIN LANGUAGE SUMMARY

Simple linear regression can be used to analyze DAH30 outcome in a randomized trial for a range of scenarios which were considered in this study (including relatively proportions of zero values). The DAH30's properties affect the treatment effect than can be estimated. Mann-Whitney test offered better ability to detect a difference of a smaller magnitude for smaller samples sizes.

Multidimensional Approach for Predicting 30-Day Mortality in Patients with a Hip Fracture: Development and External Validation of the Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30)

BACKGROUND

The aim of this study was to develop an accurate and clinically relevant prediction model for 30-day mortality following hip fracture surgery.

METHODS

A previous study protocol was utilized as a guideline for data collection and as the standard for the hip fracture treatment. Two prospective, detailed hip fracture databases of 2 different hospitals (hospital A, training cohort; hospital B, testing cohort) were utilized to obtain data. On the basis of the literature, the results of a univariable analysis, and expert opinion, 26 candidate predictors of 30-day mortality were selected. Subsequently, the training of the model, including variable selection, was performed on the training cohort (hospital A) with use of adaptive least absolute shrinkage and selection operator (LASSO) logistic regression. External validation was performed on the testing cohort (hospital B).

RESULTS

A total of 3,523 patients were analyzed, of whom 302 (8.6%) died within 30 days after surgery. After the LASSO analysis, 7 of the 26 variables were included in the prediction model: age, gender, an American Society of Anesthesiologists score of 4, dementia, albumin level, Katz Index of Independence in Activities of Daily Living total score, and residence in a nursing home. The area under the receiver operating characteristic curve of the prediction model was 0.789 in the training cohort and 0.775 in the testing cohort. The calibration curve showed good consistency between observed and predicted 30-day mortality.

CONCLUSIONS

The Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30) was developed and externally validated, and showed adequate performance in predicting 30-day mortality following hip fracture surgery. The RHMP-30 will be helpful for shared decision-making with patients regarding hip fracture treatment.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

[Translated article] Hip fractures in Spain. How are we? Systematic review and meta-analysis of the published registries

OBJECTIVE

Spain is expected to be the country with the highest life expectancy in the coming years. In this context, it is important to improve the care of hip fractures. The objective of this work was to describe the results of the registries published on hip fractures in Spain.

MATERIAL AND METHODS

Systematic review and meta-analysis of the records published on hip fractures in Spain, the last 10 years. The characteristics of the study, characteristics of the patients, of the fractures, the type of surgery, as well as morbidity and mortality were analyzed.

RESULTS

A total of 55,680 patients with a mean age of 84.6 years were analyzed, of whom 75% were women. Extracapsular fractures were the most frequent (58%). It was found that conservative treatment was applied in an average of 3% of cases. The average surgical delay was 64.7h, with a mean percentage of patients operated on within 24h at 18%, and within 48h at 40%. A mean hospitalization time of 10.7 days was found. Delirium was found to be the most frequent postoperative complication (42%). The mean transfusion rate was 36%. Mean in-hospital mortality at one month and one year was 4%, 5% and 18%, respectively.

CONCLUSIONS

Less than half of patients with a hip fracture undergo surgery within 48h, despite being recommended by the majority of clinical practice guidelines. Delirium is the most frequently reported postoperative complication, and one in every 5 patients will die within a year after a hip fracture. Standardizing the management of hip fractures at the state level could improve healthcare quality and facilitate the establishment of common criteria for good clinical practice.

The hemoglobin, albumin, lymphocyte, and platelet score as a useful predictor for mortality in older patients with hip fracture

Objective

With a rapidly aging population, identifying effective prognostic predictors has always been a research hotspot in older patients with hip fracture. Recently, the score combining hemoglobin, albumin, lymphocyte and platelet (HALP) has been proposed as a novel biomarker for reflecting systemic inflammation and nutritional status. However, it is unclear whether the HALP score could be a potential prognostic indicator for mortality following hip fracture. Thus, the objective of this study was to explore the relationship between the HALP score and mortality risk in older patients with hip fracture, and further evaluate its predictive value.

Methods

Consecutive patients were identified from our institutional hip fracture database over the period from January 1, 2013 to December 31, 2022. Outcomes were 90-day all-cause mortality and overall mortality at the longest follow-up. Multivariate Cox proportional hazard models and restricted cubic spline (RCS) models were employed to assess this relationship. The incremental predictive performance of the HALP score was assessed using the c statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results

In total, 1707 patients were included with a median follow-up duration of 44.4 months, of whom 174 cases (10.2%) died within 90 days and 667 cases (39.1%) died at the longest follow-up. After multivariate adjustment, compared to tertile 1 group, tertile 2 and tertile 3 groups exhibited 0.676-fold (95% confidence interval [CI]: 0.471-0.972, p = 0.035) and 0.598-fold (95% CI: 0.390-0.918, p = 0.019) lower risks of 90-day mortality, as well as 0.681-fold (95% CI: 0.566-0.820, p < 0.001) and 0.618-fold (95% CI: 0.504-0.759, p < 0.001) decreased risks of overall mortality, respectively. For each unit increase in the HALP score, there was a significant decrease in 90-day mortality by 1.1% and in overall mortality by 1.0% (all p < 0.05). RCS analyses indicated nonlinear relationships between the HALP score and 90-day and overall mortality (all P for nonlinear <0.01). Moreover, adding the HALP score significantly improved the predictive ability for 90-day and overall mortality (all p < 0.05).

Conclusion

The HALP score was independently associated with mortality risk, highlighting its potential as a useful prognostic indicator for predicting mortality in older patients with hip fracture.

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.

To analyze the risk factors associated with mortality within 1 year after surgery in elderly patients with hip fracture and to assess the value of the age-corrected Charlson comorbidity index in predicting this mortality risk

To investigate the determining risk factors for 1-year postoperative mortality in elderly patients with hip fracture and to assess the efficacy of the age-adjusted Charlson comorbidity index (ACCI) in predicting the risk of death. This study adopted a retrospective analysis method to focus on 652 elderly patients who underwent hip fracture surgery between January 2018 and November 2022 in our hospital. By systematically combing the patients' medical records, relevant data were collected and analyzed in depth for their association with morbidity and mortality rates within 1 year. In the 1-year follow-up for 652 elderly patients who underwent hip fracture surgery, the proportion of deaths due to disease amounted to 21.5% (140/652). Univariate analysis using the Cox proportional hazard model revealed that age, number of hospital days, ACCI, and the occurrence of postoperative pneumonia were significantly associated with the rate of morbidity and mortality within 1 year. Further multivariate Cox regression analysis confirmed that age (hazard ratio [HR], 1.087 [95% confidence interval [CI], 1.060-1.114]), ACCI (HR, 1.645 [95% CI, 1.548-1.747]), and postoperative pneumonia (HR, 2.353 [95% CI, 1.624-3.408]) served as independent risk factors that significantly influenced the patients' 1-year survival. The ACCI excelled in predicting the risk of 1-year postoperative mortality, with an AUC of 0.912 for its prediction model and a specificity and sensitivity of 0.834 and 0.871, respectively, when the threshold was set at 5.5. The results of this study emphasize that age, ACCI, and postoperative pneumonia are key risk factors affecting the survival of elderly patients with hip fracture at 1-year postoperatively. ACCI, as an effective predictive tool, can provide an important reference for the clinical assessment of patients' postoperative risk and help precision medical decision-making.

Readmission and mortality before and after introduction of orthogeriatric home visits: A retrospective cohort study in hip fracture patients

INTRODUCTION

Orthogeriatric collaboration in hip fracture patients during admission is well established, however, orthogeriatric involvement after discharge is not common. The aim of this study was to explore the association of orthogeriatric home visits with 30-day and 120-day readmission and mortality in ≥ 65-year-old patients surgically treated for hip fractures.

MATERIALS AND METHODS

A cohort of patients who underwent acute hip fracture surgery in an usual care period from January 2018 to December 2018 was compared with a cohort of patients in an intervention period from June 2020 to June 2021. During the intervention period, patients were offered orthogeriatric home visits at day 2 and 9 after discharge. The home visits were performed by orthogeriatric nurses, in close collaboration with geriatricians and orthopedic surgeons based in the local hospital. Readmission was defined as ≥ 12 h hospital stay, regardless of reason. For the main analysis, we applied Cox-regression models adjusted for age, sex, New Mobility Score, Cumulated Ambulation Score regained, cognitive function, Charlson Comorbidity Index, complications, medication, discharge destination and emergency department visits.

RESULTS

In total, 292 patients were included during the usual care period, and 308 patients during the intervention period. Thirty- and 120-day readmission rates were 27.7 % and 41.4 % in the usual care cohort vs. 21.8 % and 35.1 % in the home visit cohort. Adjusted Hazard Ratios for readmission in the intervention cohort after 30 and 120 days were 0.67 (CI95 %: 0.48-0.93) and 0.71 (CI95 %: 0.54-0.93) respectively. Thirty- and 120-day mortality rates were 7.2 % and 20.9 % in the usual care cohort versus 5.8 % and 13.3 % in the intervention cohort. Adjusted Hazard Ratios for mortality in the intervention cohort after 30 and 120 days were 0.68 (CI95 %: 0.35-1.31) and 0.56 (CI95 %: 0.37-0.84) respectively.

CONCLUSIONS

In a period where hip fracture patients were offered two home visits after discharge, we observed lower 30- and 120- day readmission, and lower 120-day mortality, calling for more studies with a randomized design.

Mortality, perioperative complications and surgical timelines in hip fracture patients: Comparison of the Spanish with the non-Spanish Cohort of the HIP ATTACK-1 trial

BACKGROUND

Hip fractures carry a substantial risk of complications and death. This study aimed to report the 90-day incidence of mortality, major perioperative complications and in-hospital timelines after a hip fracture in the Spanish HIP ATTACK-1 trial cohort, comparing with the non-Spanish cohort.

METHODS

Prospective cohort study of Spanish patients nested in the HIP ATTACK-1 trial. The HIP ATTACK-1 was an international, randomized, controlled trial (17 countries, 69 hospitals, 7 in Spain, highest recruiting country). Patients were randomized to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. Participants were ≥45 years of age who presented with a low-energy hip fracture requiring surgery.

RESULTS

Among 534 patients in the Spanish cohort, 69 (12.9 %) patients died at 90 days follow-up, compared to 225 (9.2 %) in the non-Spanish cohort (p = 0.009), mostly due to higher nonvascular related mortality. A composite of major postoperative complication occurred in 126 patients (23.6 %). The most common perioperative complications were myocardial injury (189 patients, 35.4 %), infection with no sepsis (86 patients, 16.1 %) and perioperative delirium (84 patients, 15.7 %); all these complication rates in Spain were significantly higher than the non-Spanish patients (29.2 % p = 0.005; 11.9 % p = 0.008 and 9.2 % p < 0.0001, respectively). Spanish cohort patients were older and had more comorbidities than the non-Spanish cohort, evidencing their greater frailty at baseline. Among Spanish patients, the median time from hip fracture diagnosis to surgery was 30.0 h (IQR 21.1-53.9) in the standard-care group, with 68.8 % of patients receiving surgery within 48 h of diagnosis. This median time was lower in the non-Spanish cohort (22.8 h, IQR 9.5-37.0), where 82.1 % of patients were operated within 48 h.

CONCLUSIONS

In the HIP ATTACK-1 trial, 1 in 8 patients died 90 days after a hip fracture in Spain. The most common complication after a hip fracture was myocardial injury, followed by infection and delirium. Spanish patients had worse outcomes than non-Spanish patients. Research needs to focus on new interventions such as accelerated surgery and perioperative troponin measurement with the appropriate investment of resources, to prevent and identify early these complications with a goal of improving mortality for this high-risk population.

LEVEL OF EVIDENCE

II.

Hip fractures in Spain. How are we? Systematic review and meta-analysis of the published registries

OBJECTIVE

Spain is expected to be the country with the highest life expectancy in the coming years. In this context, it is important to improve the care of hip fractures. The objective of this work was to describe the results of the registries published on hip fractures in Spain.

MATERIAL AND METHODS

Systematic review and meta-analysis of the records published on hip fractures in Spain, the last 10 years. The characteristics of the study, characteristics of the patients, of the fractures, the type of surgery, as well as morbidity and mortality were analyzed.

RESULTS

A total of 55,680 patients with a mean age of 84.6 years were analyzed, of whom 75% were women. Extracapsular fractures were the most frequent (58%). It was found that conservative treatment was applied in an average of 3% of cases. The average surgical delay was 64.7hours, with a mean percentage of patients operated on within 24hours at 18%, and within 48hours at 40%. A mean hospitalization time of 10.7 days was found. Delirium was found to be the most frequent postoperative complication (42%). The mean transfusion rate was 36%. Mean in-hospital mortality at one month and one year was 4%, 5% and 18%, respectively.

CONCLUSIONS

Less than half of patients with a hip fracture undergo surgery within 48hours, despite being recommended by the majority of clinical practice guidelines. Delirium is the most frequently reported postoperative complication, and one in every 5 patients will die within a year after a hip fracture. Standardizing the management of hip fractures at the state level could improve healthcare quality and facilitate the establishment of common criteria for good clinical practice.

The use of minimum common data set in the development of the Greek Fragility Hip Fracture Registry in the Greek health care setting: the first year of its pilot implementation

The first Fragility Hip Fracture Registry has been established in Greece. The in-hospital length of stay was 10.8 days and was significantly influenced by the delayed surgical fixation. The increased age, the higher ASA grade, and the male gender influenced negatively the 30-day mortality, which reached 7.5%.

BACKGROUND

The increased incidence of fragility hip fractures constitutes a great challenge to the health care professionals and causes a significant burden on national health care systems around the globe. Fragility hip fracture registries have been used in many countries in order to document the cotemporary situation in each country and to identify potential weaknesses of the local health care systems.

AIM

The aim of the herein study is to present the results of the pilot implementation of the first fragility hip fracture registry in Greece, which was developed by the Greek Chapter of Fragility Fracture Network (FFN Gr), and use the neural networks in the analysis of the results.

MATERIALS AND METHODS

Seven orthopaedic departments from six different hospitals in Greece participated in the present pilot study. All fragility hip fractures from September 2022 until December 2023 were prospectively collected and documented using a central database. For this purpose, the 22 points of minimum common data set, proposed by the Global Fragility Fracture Network, with the addition of the 30-day mortality was used.

RESULTS

A total of 1009 patients who sustained a fragility hip fracture were included in the study. The mean age of the cohort was 82.2 ± 8.6 years with the majority of patients being female (72%). Sixty percent (60%) of the patients had an extracapsular hip fracture, with a mean ASA grade 2.6 ± 0.8. Intramedullary nailing and hip hemiarthroplasty were the surgical treatments of choice in the majority of extra- and intra-capsular hip fractures respectively. The mean hospital length of stay of the patients was 10.8 ± 8.5 days, and the 30-day mortality was 7.5%. The multivariant analysis revealed that the age, the ASA grade and the male gender had a significant contribution to the 30-day mortality. The neural network model had a significant under-the-curve predictive value (0.778), with age being the most important predictive factor. The length of stay was significantly influenced only by the delayed surgical fixation (more than 36 h from admission).

CONCLUSIONS

The present pilot study provides evidence that establishing a fragility hip fracture registry in Greece is feasible and demonstrates that the minimum common data set can be used as the base of any new registry. In Greece, patients with a fragility hip fracture stay in the hospital for approximately 11 days and have 7.5% 30-day mortality. Unfortunately, due to the logistics of the public healthcare system, they do not receive surgical fixation in a timely manner, which is a factor that negatively affects their length of in-hospital stay.

Development and validation of a prognostic scoring system for 1-year mortality in older patients with hip fractures

BACKGROUND

Hip fractures in older people result in increased mortality.

OBJECTIVE

We developed and validated an accurate and simple prognostic scoring system for hip fractures that can be used preoperatively.

DESIGN

Retrospective study.

SETTING

Multicenter.

PARTICIPANTS

Patients aged ≥65 years with hip fractures who underwent surgery between 2011 and 2021 were enrolled.

METHODS

The significant factors were determined with logistic regression analysis, and a scoring system was developed. The patients were classified into three groups, and a log-rank test was performed to evaluate 1-year survival rates. The model was internally and externally validated using the 5-fold cross-validation and data from another hospital, respectively.

RESULTS

We included 1026 patients. The analysis revealed eight significant prognostic factors: sex, body mass index, history of chronic heart failure and malignancy, activities of daily living (ADLs) before injury, hemoglobin and the prognostic nutritional index (PNI) at injury, and the American Society of Anesthesiologists Physical Status. The area under the receiver operating characteristic curve (AUC) after internal validation was 0.853. The external validation data consisted of 110 patients. The AUC of the model for the validation data was 0.905, showing outstanding discrimination. Sensitivity and specificity were 88.7% vs. 100% and 93.3% vs. 95.2% for the development and validation data, respectively.

CONCLUSIONS

We developed and validated an accurate and simple prognostic scoring system for hip fractures using only preoperative factors. Our findings highlight PNI as an important predictor of prognosis in hip fracture patients.

Systematic review of multivariable prognostic models for outcomes at least 30 days after hip fracture finds 18 mortality models but no nonmortality models warranting validation

OBJECTIVES

Prognostic models have the potential to aid clinical decision-making after hip fracture. This systematic review aimed to identify, critically appraise, and summarize multivariable prediction models for mortality or other long-term recovery outcomes occurring at least 30 days after hip fracture.

STUDY DESIGN AND SETTING

MEDLINE, Embase, Scopus, Web of Science, and CINAHL databases were searched up to May 2023. Studies were included that aimed to develop multivariable models to make predictions for individuals at least 30 days after hip fracture. Risk of bias (ROB) was dual-assessed using the Prediction model Risk Of Bias ASsessment Tool. Study and model details were extracted and summarized.

RESULTS

From 5571 records, 80 eligible studies were identified. They predicted mortality in n = 55 studies/81 models and nonmortality outcomes (mobility, function, residence, medical, and surgical complications) in n = 30 studies/45 models. Most (n = 46; 58%) studies were published since 2020. A quarter of studies (n = 19; 24%) reported using 'machine-learning methods', while the remainder used logistic regression (n = 54; 68%) and other statistical methods (n = 11; 14%) to build models. Overall, 15 studies (19%) presented 18 low ROB models, all predicting mortality. Common concerns were sample size, missing data handling, inadequate internal validation, and calibration assessment. Many studies with nonmortality outcomes (n = 11; 37%) had clear data complexities that were not correctly modeled.

CONCLUSION

This review has comprehensively summarized and appraised multivariable prediction models for long-term outcomes after hip fracture. Only 15 studies of 55 predicting mortality were rated as low ROB, warranting further development of their models. All studies predicting nonmortality outcomes were high or unclear ROB. Careful consideration is required for both the methods used and justification for developing further nonmortality prediction models for this clinical population.

Should patients with exceptional longevity be treated for osteoporosis after a hip fracture?

BACKGROUND

There are no studies focusing on treatment for osteoporosis in patients with exceptional longevity after suffering a hip fracture.

OBJECTIVE

To assess the advisability of initiating treatment for osteoporosis after a hip fracture according to the incidence of new fragility fractures after discharge, risk factors for mortality and long-term survival.

DESIGN

Retrospective review.

SETTING

A tertiary university hospital serving a population of ~425 000 inhabitants in Barcelona.

SUBJECTS

All patients >95 years old admitted with a fragility hip fracture between December 2009 and September 2015 who survived admission were analysed until the present time.

METHODS

Pre-fracture ambulation ability and new fragility fractures after discharge were recorded. Risk factors for 1-year and all post-discharge mortality were calculated with multivariate Cox regression. Kaplan-Meier survival curve analyses were performed.

RESULTS

One hundred and seventy-five patients were included. Median survival time was 1.32 years [95% confidence interval (CI) 1.065-1.834], with a maximum of 9.2 years. Male sex [hazard ratio (HR) 2.488, 95% CI 1.420-4.358] and worse previous ability to ambulate (HR 2.291, 95% CI 1.417-3.703) were predictors of mortality. After discharge and up to death or the present time, 10 (5.7%) patients had a new fragility fracture, half of them during the first 6 months.

CONCLUSIONS

Few new fragility fractures occurred after discharge and half of these took place in the first 6 months. The decision to start treatment of osteoporosis should be individualised, bearing in mind that women and patients with better previous ambulation ability will have a better chance of survival.

AtoG: A simple score to predict complications and death after hip fractures, in line with the comprehensive geriatric assessment

INTRODUCTION

Proximal Femur Fractures (PFFs) are a significant public health issue and occur in the context of global frailty and aging. Recent literature identifies new patient-related prognostic factors that focus on socioeconomic environment, patient well-being, or nutrition status. Specific scores have been developed, but in most cases, they fail to be in line with the comprehensive geriatric assessment, or do not assess the newly identified prognostic factors, contain multitude collinearities, or are too complex to be used in the daily practice. Hypothesis A comprehensive score with equal representation of the patient's dimensions does at least as good as the Charlson score (CCI), to predict complications and mortality.

OBJECTIVE

To develop a new comprehensive prognostic score, predicting inpatient complications and mortality up to 5-year after PFF.

MATERIAL AND METHODS

The patients treated surgically for PFF on a native hip, between 2005 and 2017 were selected from a French national database. The variables were the gender, age, the type of treatment (osteosynthesis or arthroplasty), and the CCI. The outcomes were the medical and surgical complications as inpatient and the mortality (up to 5-year). Variables were grouped into dimensions with similar clinical significance, using a Principal Component Analysis, for instance, bedsores and malnutrition. The dimensions were tested for 90-day mortality and complications, in regressions models. Two scores were derived from the coefficients: SCOREpond (strict ponderation), and SCORE (with loose ponderation: 1 point/risk factors, -1 point/protective factors). Calibration, discrimination (ROC curves with Area Under Curves AUC), and cross-validation were assessed for SCOREpond, SCORE, and CCI.

RESULTS

Analyses were performed on 7756 fractures. The factorial analysis identified seven dimensions: age; brain-related conditions (including dementia): 1738/7756; severe chronic conditions (for instance, organ failures) 914/7756; undernutrition: 764/7756; environment, including social issues or housing difficulties: 659/7756; associated trauma: 814/7756; and gender. The seven dimensions were selected for the prognostic score named AtoG (ABCDEFG, standing for Age, Brain, Comorbidities, unDernutrition, Environment, other Fractures, Gender). The median survival rate was 50.8 months 95% CI [49-53]. Anaemia and urologic complications were the most prevalent medical complications (1674/7756, 21%, and 1109/7756, 14.2%). A total of 149/7756 patients (1.9%) developed a mechanical inpatient complication (fractures or dislocations), with a slightly higher risk for arthroplasties. The AUCs were 0.69, 0.68, and 0.67 for AtoGpond, AtoG, and CCI, respectively, for 90-day mortality, and 0.64, 0.63, and 0.56 for complications. Compared to patients with AtoG=0, Hazard Ratios for 90-day mortality were 2.3 95% CI [1.7-2.9], 4.2 95% CI [3.1-5.4], 6 95% CI [4.5-8.1], 8.3 95% CI [6.5-12.9], and 13.7 95% CI [8-24], from AtoG=1 to AtoG≥5, respectively (p<10-4); the 90-day survival decreased by 5%/point, roughly. The sur-risk of mortality associated with AtoG was up to 5-year: HR=1.51 (95% CI [1.46-1.55], p<10-4). Compared to AtoG=0, from AtoG=1 to AtoG≥5, the pooled Odd Ratios were 1.14 95% CI [1.06-1.2], 1.53 95% CI [1.4-1.7], 2.17 95% CI [1.9-2.4], 2.9 95% CI [2.4-3.4], and 4.9 95% CI [3.3-7.4] for any complication (p<10-4).

CONCLUSION

AtoG is a multidimensional score in line with the concept of comprehensive geriatric assessment. It had good discrimination and performance in predicting 90-day mortality and complications. Performances were as good as CCI for 90-day mortality, and better than it for the complications.

LEVEL OF PROOF

IV; retrospective cohort study.

Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study

Purpose

The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery.

Patients and methods

A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis.

Results

8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001).

Conclusion

A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

Risk prediction models of mortality after hip fracture surgery in older individuals: a systematic review

OBJECTIVE

This study aimed to critically assess existing risk prediction models for postoperative mortality in older individuals with hip fractures, with the objective of offering substantive insights for their clinical application.

DESIGN

A comprehensive search was conducted across prominent databases, including PubMed, Embase, Cochrane Library, SinoMed, CNKI, VIP, and Wanfang, spanning original articles in both Chinese and English up until 1 December 2023. Two researchers independently extracted pertinent research characteristics, such as predictors, model performance metrics, and modeling methodologies. Additionally, the bias risk and applicability of the incorporated risk prediction models were systematically evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST).

RESULTS

Within the purview of this investigation, a total of 21 studies were identified, constituting 21 original risk prediction models. The discriminatory capacity of the included risk prediction models, as denoted by the minimum and maximum areas under the subject operating characteristic curve, ranged from 0.710 to 0.964. Noteworthy predictors, recurrent across various models, included age, sex, comorbidities, and nutritional status. However, among the models assessed through the PROBAST framework, only one was deemed to exhibit a low risk of bias. Beyond this assessment, the principal limitations observed in risk prediction models pertain to deficiencies in data analysis, encompassing insufficient sample size and suboptimal handling of missing data.

CONCLUSION

Subsequent research endeavors should adopt more stringent experimental designs and employ advanced statistical methodologies in the construction of risk prediction models. Moreover, large-scale external validation studies are warranted to rigorously assess the generalizability and clinical utility of existing models, thereby enhancing their relevance as valuable clinical references.

Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study

INTRODUCTION

Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy.

Increasing serum miR-409-3p predicts the major adverse cardiac adverse events in elderly patients after hip fracture surgery

BACKGROUND

Major adverse cardiovascular events (MACE) are critical complications responsible for the morbidity and mortality of elderly hip fracture patients. There was an urgent need to explore an effect biomarker for predicting MACE in elderly patients receiving hip fracture surgery.

OBJECTIVE

This study focused on an age-related miRNA, miR-409-3p, and assessed its significance in elderly hip fracture patients.

METHODS

A total of 267 hip fracture patients were enrolled in this study including 104 elderly patients (age ≥ 60 years). All patients were followed up for 1 year to monitor the occurrence of MACE. The risk factors for the occurrence of MACE were evaluated by the logistic regression analysis.

RESULTS

Elderly age and reduced cardiac and renal function were identified as risk factors for MACE in hip fracture patients. Elderly patients also showed a high incidence of MACE. In elderly hip fracture patients, significant upregulation of miR-409-3p was observed, which was associated with patients' elderly age, higher level of revised cardiac risk index (RCRI), lower left ventricular ejection fraction (LVEF), and higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), creatine kinase-MB (CK-MB), and high sensitivity troponin I (hsTnI). Additionally, miR-409-3p was identified as an independent factor for the MACE in elderly patients received hip fracture surgery.

CONCLUSION

Upregulated miR-409-3p was an age-related miRNA and could predict the occurrence of MACE in elderly hip fracture patients.

[Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.

Association between admission hyperglycemia and postoperative pneumonia in geriatric patients with hip fractures

BACKGROUND

Admission hyperglycemia is a common phenomenon in the early stages of injury. This study aimed to determine the relationship between admission hyperglycemia and postoperative pneumonia in geriatric patients with hip fractures.

METHODS

A total of 600 geriatric patients admitted to Dandong Central Hospital with hip fractures were included. Patients were divided into four groups based on quartiles of admission blood glucose levels: Q1- Q4. Multivariable logistic regression and propensity score-matched analyses were conducted to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative pneumonia. Receiver operating characteristic (ROC) curves were used to determine the cut-off value of admission hyperglycemia for predicting postoperative pneumonia.

RESULTS

The incidence of postoperative pneumonia was significantly higher among hyperglycemic patients than those with normal glucose levels (OR = 2.090, 95% CI: 1.135-3.846, p = 0.016). Admission hyperglycemia showed moderate predictive power, with an area under the ROC curve of 0.803. Furthermore, propensity score-matched analyses demonstrated that patients in the Q3 (OR = 4.250, 95% CI: 1.361-13.272, p = 0.013) and Q4 (OR = 4.667, 95% CI: 1.251-17.405, p = 0.022) quartiles had a significantly higher risk of postoperative pneumonia compared to patients in the Q1 quartile.

CONCLUSIONS

Admission hyperglycemia in elderly hip fracture patients increases the risk of postoperative pneumonia. This biomarker can aid clinical assessment and perioperative management.

Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.

The Rising Problem of Hip Fractures in Geriatric Patients-Analysis of Surgical Influences on the Outcome

BACKGROUND

Hip fractures in geriatric patients often have a poor outcome in terms of mortality, mobility as well as independence. Different surgical influence factors are known that improve the outcome.

METHODS

In this observational cohort study, 281 patients of a geriatric trauma unit were analyzed prospectively. Demographic factors, as well as data regarding the trauma mechanism and perioperative treatment, were recorded. The nutritional status was also analyzed. The follow-up was set to 120 days.

RESULTS

The key conclusion of this study is that a high ASA classification, the use of anticoagulatory medicine and malnutrition are significantly associated with higher mortality together with worse independence (p < 0.05). There is no significant difference in outcome concerning the time to surgery within the first 24 h.

CONCLUSIONS

Malnutrition seems to be an important risk factor for an adverse outcome of geriatric patients and therefore warrants a focus in multidisciplinary treatment. The risk factor ASA cannot be improved during the pre-surgery phase, but requires intensified care by a multidisciplinary team specialized in orthogeriatrics.

Health Care for Inpatients with a Proximal Humeral Fracture - an Analysis of Health Insurance Data

The proximal humeral fracture is one of the most common fractures in the elderly. While epidemiological factors have been well studied, the influence of a proximal humeral fracture on morbidity, mortality and associated costs has not yet been adequately analysed.On a basis of 4.1 million insurance holders of the German public health insurance (GKV), patients with (study population, SP) and without (comparison group, VG) a proximal humeral fracture (pHF) were compared with regard to comorbidity, rehospitalisation, mortality, drug and aid needs as well as number of physician contacts. Study period was between 2012 and 2016.6068 patients of the SP met the inclusion and exclusion criteria (age 69.4 ± 14.3 years; male : female = 28.2% : 71.8%). 4781 patients (78.8%) received surgical, 1287 patients (21.2%) conservative treatment of the pHF. Rehospitalisations and visits to the general practitioner occurred more frequently in the SP vs. VG (p < 0.01). Contacts with specialists after pHF varied according to specialty, as did newly occurring diseases. Typical specialities for preventive examinations were significantly less common (gynaecology p < 0.01, pathology p < 0.01, dermatology p < 0.01). According to pHF, the costs of SP for drugs (2490.76 ± 1395.51 € vs. 2167.86 ± 1314.43 €; p = 0.04), medical therapies (867.01 ± 238.67 € vs. 393.26 ± 217.55 €; p < 0.01) and aids (821.02 ± 415.73 € vs. 513.52 ± 368.76 €; p < 0.01) were significantly above the VG. The two-year survival after pHF is lower in the SP than in the VG (p < 0.01).The results show increased morbidity and mortality as well as medical costs after a proximal humeral fracture. Preventive examinations and treatments are rarer. In the future, care concepts for patients with proximal humeral fractures should not only be optimised with regard to functional scores and reduced complication rates, but also with regard to quality of life and preservation of general health.

Predictive Validity of Mortality after Surgically Treated Proximal Femur Fractures Based on Four Nutrition Scores-A Retrospective Data Analysis

BACKGROUND

Hip fractures are becoming a growing concern due to an aging population. The high costs to the healthcare system and far-reaching consequences for those affected, including a loss of independence and increased mortality rates, make this issue important. Poor nutritional status is a common problem among geriatric patients and is associated with a worse prognosis. Nutritional screening tools can help identify high-risk patients and enable individualized care to improve survival rates.

MATERIAL AND METHODS

This retrospective study investigates four nutritional scores and laboratory parameters' predictive significance concerning postoperative mortality after surgical treatment of proximal femur fractures at 1, 3, 6, and 12 month/s for patients over 60 years using the chi-square test, Cox regression analysis, and receiver operating characteristics (ROC). The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines were used as part of the screening of the respective nutritional status of the patients, in particular to filter out malnutrition.

RESULTS

A total of 1080 patients were included in this study, whereas 8.05% suffered from malnutrition, defined as a body mass index (BMI) below 18.5 kg/m2. The Mini Nutritional Assessment (MNA) screening tool identified the highest proportion of malnourished patients at 14.54%. A total of 36.39% of patients were at risk of malnutrition according to three nutrition scores, with MNA providing the most significant proportion at 41.20%. Patients identified as malnourished had a higher mortality rate, and MNA screening was the only tool to show a significant correlation with postoperative mortality in all survey intervals. The MNA presented the best predictive significance among the screening tools, with a maximum area under the curve (AUC) of 0.7 at 12 month postoperatively.

CONCLUSIONS

MNA screening has a solid correlation and predictive significance regarding postoperative mortality-therefore routine implementation of this screening in orthopedic/traumatology wards is recommended. Moreover, nutritional substitution therapy can offer a relatively inexpensive and easy-to-implement measure. The Graz malnutrition screening (GMS) shows moderate predictive power and could be considered as an alternative for patients under 60 years of age. A higher albumin level is associated with improved survival probability, but cannot be indicative of nutritional status.

Impact of oral anticoagulation on inhospital mortality of patients with hip fracture - Analysis of nationwide hospitalization data

OBJECTIVES

Oral anticoagulation (OAC) may have an impact on mortality in cases hospitalized for hip fracture (HF). We studied nationwide time trends of OAC prescriptions and compared time trends of inhospital mortality of HF cases with and without OAC in Germany DESIGN: Retrospective cohort study SETTING: Nationwide German hospitalization, Diagnosis-Related Groups Statistic PATIENTS/PARTICIPANTS: All hospital admissions for HF 60 years and older in the years 2006 through 2020.

INTERVENTION

Additional diagnosis with a personal history of long-term use of anticoagulants (ICD code Z92.1).

MAIN OUTCOME MEASUREMENTS

Inhospital mortality RESULTS: Cases hospitalized for HF 60 years and older increased by 29.5%. In 2006, 5.6% had a documented history of long-term use of OACs. This proportion rose to 20.1% in 2020. Age-standardized hospitalization mortality in HF cases without long-term use of OACs in males decreased steadily from 8.6% (95% confidence intervals 8.2 - 8.9) in 2006 to 6.6% (6.3 - 6.9) in 2020 and in females from 5.2% (5.0 - 5.3) to 3.9% (3.7 - 4.0). Mortality of HF cases with long-term use of OACs remained unchanged: males 7.0% (5.7 - 8.2) in 2006 and 7.3% (6.7 - 7.8) in 2020, females 4.8% (4.1 - 5.4) and 5.0% (4.7 - 5.3).

CONCLUSION

Inhospital mortality of HF cases with and without long-term OAC show different trends. In HF cases without OAC, mortality decreased from 2006 to 2020. In cases with OAC such a decrease could not be observed.

The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90)

The AHFS90 was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS90 has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%.

PURPOSE

Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS90).

METHODS

Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS90, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks.

RESULTS

One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS90 includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS90 had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS90 overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS90 had a maximal prediction of early mortality of 64.5% in this study population.

CONCLUSION

The AHFS90 accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%.

Predictability of Neutrophil to Lymphocyte Ratio in preoperative elderly hip fracture patients for post-operative short-term complications: a retrospective study

PURPOSE

Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population.

METHODS

We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality.

RESULTS

After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications.

CONCLUSIONS

Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context.

Risk factors for postoperative medical morbidity and 3-month mortality in elderly patients with hip fracture following hip arthroplasty during COVID-19 pandemic

BACKGROUND

The purpose of the current study was to investigate the incidence of postoperative medical complications and 3-month mortality in patients  ≥ 70 years old with hip fracture following hip arthroplasty (HA) and independent risk factors associated with postoperative medical complications and 3-month mortality during the Coronavirus Disease 2019 (COVID-19) pandemic.

METHODS

A multicenter retrospective study was conducted, patients  ≥ 70 years old with HA for hip fracture under general anesthesia were included during COVID-19 and before COVID-19 pandemic. The outcome was defined as postoperative medical complications and 3-month mortality. The baseline characteristics and risk factors were collected, multivariable logistic regression was used to identify independent risk factors for postoperative medical complications and 3-month mortality.

RESULTS

A total of 1096 patients were included during COVID-19 pandemic and 1149 were included before COVID-19 pandemic in the study. Patients  ≥ 70 years with hip fracture for HA had longer fracture to operation duration (7.10 ± 3.52 vs. 5.31 ± 1.29, P < 0.001), and the incidence of postoperative medical complications (21.90% vs. 12.53%, P < 0.001) and 3-month mortality (5.20% vs. 3.22%, P = 0.025) was higher during COVID-2019 pandemic. Multivariate logistic regression analysis showed that dementia (OR 2.73; 95% CI 1.37-5.44; P = 0.004), chronic obstructive pulmonary disease (COPD) (OR 3.00; 95% CI 1.92-4.71; P < 0.001), longer fracture to operation duration (OR 1.24; 95% CI 1.19-1.30; P < 0.001) were associated with increased risk for postoperative medical complications. COPD (OR 2.10; 95% CI 1.05-4.17; P = 0.035), dementia (OR 3.00; 95% CI 1.11-7.94; P = 0.031), postoperative medical complications (OR 4.99; 95% CI 2.68-9.28; P < 0.001), longer fracture to operation duration (OR 1.11; 95% CI 1.04-1.19; P = 0.002) were associated with increased risk for 3-month mortality.

CONCLUSIONS

In conclusion, we found that postoperative medical morbidity and 3-month mortality in patients with hip fracture underwent HA were 21.90% and 5.20%, respectively, during the COVID-19. COPD, dementia and longer fracture to operation duration were associated with negative outcome in patients with hip fracture underwent HA during the COVID-19.

No Excess Mortality in Geriatric Patients With Femoral Neck Fractures Due to Shorter Intensive Care Caused by COVID-19

Background

Since March 2020, increasing numbers of hospitalized patients with coronavirus disease-2019 (COVID-19) infections have been registered. The first and the second waves necessitated the extensive restructuring of hospital infrastructure with prioritization of intensive care capacity. Elective surgeries in all surgical disciplines were postponed to preserve intensive care capacity for COVID-19 patients. However, emergency care for trauma patients had to be maintained. Especially, geriatric patients with hip fractures often require intensive care.

This study sought to investigate the possible excess mortality of geriatric patients with femoral neck fractures due to shorter intensive care unit stays because of COVID-19.

Material and methods

All patients over the age of 70 between March 2019 and February 2020 who underwent surgical treatment for femoral neck fractures were included. This cohort (group 1) was compared with all patients over 70 who received surgical treatment for hip fractures during the period of the pandemic between March 2020 and February 2021 with attention to potential excess mortality due to low intensive care capacity (group 2). Demographic data, American Society of Anesthesiologists (ASA) score, surgical modality, ICU stay, complications, and mortality were analyzed and compared.

Results

A total of 356 patients with 178 in each cohort with a mean age of 82.7 in group 1 and 84.8 in group 2 (p<0.05) were included. No significant difference was seen in sex and ASA scores. During the pandemic, patients with hip fractures had a significantly shorter stay in ICU (0.4 ± 0.9 vs 1.2 ± 2.8 days; p<0.05), shorter time to surgery (29.9 ± 8.2 vs 16.8 ± 5.3 h; p<0.05) and operations were significantly more often performed out-of-hour (4 pm-12 am 47.8% vs 56.7%; 12 am-8 am 7.9% vs 13.5%, p<0.05). Interestingly, mortality was lower during the pandemic, but the difference did not reach significance (6.7% vs 12.4%, p=0.102).

Conclusion

During the pandemic, ICU capacity was reserved for COVID patients. Due to a change in the law of the Joint Federal Committee with effect from January 1, 2021, all patients with proximal femur fractures had to be operated on within the first 24 hours, which is why a significantly shorter time to surgery was observed during the pandemic period. As a consequence, a lower mortality rate was observed, although no significance could be reached.

The impact of COVID-19 on mortality after hip fracture : a population cohort study from England

AIMS

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

METHODS

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.

RESULTS

Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days.

CONCLUSION

COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J 2022;104-B(10):1156-1167.

A risk scoring system integrating postoperative factors for predicting early mortality after major non-cardiac surgery

We aimed to develop a risk scoring system for 1-week and 1-month mortality after major non-cardiac surgery, and assess the impact of postoperative factors on 1-week and 1-month mortality using machine learning algorithms. We retrospectively reviewed the medical records of 21,510 patients who were transfused with red blood cells during non-cardiac surgery and collected pre-, intra-, and postoperative features. We derived two patient cohorts to predict 1-week and 1-month mortality and randomly split each of them into training and test cohorts at a ratio of 8:2. All the modeling steps were carried out solely based on the training cohorts, whereas the test cohorts were reserved for the evaluation of predictive performance. Incorporation of postoperative information demonstrated no significant benefit in predicting 1-week mortality but led to substantial improvement in predicting 1-month mortality. Risk scores predicting 1-week and 1-month mortality were associated with area under receiver operating characteristic curves of 84.58% and 90.66%, respectively. Brain surgery, amount of intraoperative red blood cell transfusion, preoperative platelet count, preoperative serum albumin, and American Society of Anesthesiologists physical status were included in the risk score predicting 1-week mortality. Postoperative day (POD) 5 (neutrophil count × mean platelet volume) to (lymphocyte count × platelet count) ratio, preoperative and POD 5 serum albumin, and occurrence of acute kidney injury were included in the risk score predicting 1-month mortality. Our scoring system advocates the importance of postoperative complete blood count differential and serum albumin to better predict mortality beyond the first week post-surgery.

Trends in Hip Fracture Incidence, Length of Hospital Stay, and 30-Day Mortality in Sweden from 1998-2017: A Nationwide Cohort Study

In this nationwide cohort study, we investigated trends in hip fracture incidence, hospital length of stay (LOS), and 30-day mortality after admission in Sweden. The cohort included all individuals in Sweden aged ≥ 50 years with a first hip fracture diagnosis during 1998-2017 (N = 313,761). The outcomes were hip fracture incidence and 30-day mortality. The results showed that the incidence of hip fracture decreased from 79.2 to 46.7/10,000 population in women and from 35.7 to 26.5/10,000 population in men. In contrast, 30-day mortality increased from 4.3% to 6.2% in women (P < 0.001) and from 8.4% to 11.1% in men (P < 0.001). Strong risk factors (P < 1 × 10^-25 for all) for 30-day mortality were older age, male sex, and shorter LOS. From 1998 to 2017, LOS decreased by on average 4 days and was shorter in both male and female aged ≥ 90 years compared to those aged 80-89 (P < 0.001 for comparisons). In conclusion, despite population aging, hip fracture incidence in Sweden has decreased over the last 20 years. However, short-term mortality has increased, which to some extent may partly be explained by the fact that LOS has decreased without being adapted to important risk factors.

Can C-reactive protein-based biomarkers be used as predictive of 30-day mortality in elderly hip fractures?A retrospective study

BACKGROUND

C-reactive protein-to-lymphocyte ratio (CLR), C-reactive protein/albumin (CRP/ALB), and CRP are prognostic factors for outcome and survival in oncology and digestive surgery. CLR has not been studied for the prediction of mortality in hip fracture. The aim of this study is to investigate whether there is an association between pre-operative CLR, CRP/ALB, and CRP levels in patients with hip fracture and patient survival.

METHODS

The medical reports of the patients who underwent surgery with a diagnosis of hip fracture in our hospital between January 2016 and December 2019 were retrospectively reviewed. The patients were divided into two groups (Group E: Those who died within 1 month and Group S: Those who died after the 1st month or those who survived). A total of 19 parameters, namely, included ' blood parameters including hemoglobin, C-reactive protein, albumin, lymphocytes, neutrophils, monocytes, platelets, PLR, NLR, LMR, CLR CRP/ALB ratios, gender, American Society of Anesthesiologists, Charlson Comorbidity Index, delirium, infections, repeated surgeries, and type of anesthesia were evaluated preoperatively and on the post-operative 2nd and 5th days and 1 month.

RESULTS

A total of 165 patients with the mean age of 83.09±8.52 years who met the inclusion criteria were studied. The pre-op-erative means of CRP, neutrophil count, CLR ratio, and CRP/ALB ratio were statistically significantly higher in Group E than in Group S (p=0.016, p=0.023, p=0.035, and p=0.044, respectively). The univariate regression analysis showed that age, pre-operative Hb level, CRP, and CRP/ALB ratio were significant predictors of the 1-month mortality (ß=-0.335, p=0.049; ß=0.411, p=0.028; ß=3.632, p=0.007; and ß=-3.280, p=0.008; respectively). When we performed the ROC curve analysis, the CRP/ALB ratio had the highest AUC, with the highest sensitivity and specificity. The cutoff value of CRP/ALB ratio was found to be 12.42.

CONCLUSION

We found that the pre-operative CRP/ALB ratio is an important parameter for predicting the first 30-day mortality in elderly patients with intertrochanteric femur fractures. For this reason, we recommend that CRP and albumin be checked in prepa-ration for routine pre-operative anesthesia.

Development and internal validation of a clinical prediction model using machine learning algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above

Purpose

Preoperative prediction of mortality in femoral neck fracture patients aged 65 years or above may be valuable in the treatment decision-making. A preoperative clinical prediction model can aid surgeons and patients in the shared decision-making process, and optimize care for elderly femoral neck fracture patients. This study aimed to develop and internally validate a clinical prediction model using machine learning (ML) algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above.

Methods

A retrospective cohort study at two trauma level I centers and three (non-level I) community hospitals was conducted to identify patients undergoing surgical fixation for a femoral neck fracture. Five different ML algorithms were developed and internally validated and assessed by discrimination, calibration, Brier score and decision curve analysis.

Results

In total, 2478 patients were included with 90 day and 2 year mortality rates of 9.1% (n = 225) and 23.5% (n = 582) respectively. The models included patient characteristics, comorbidities and laboratory values. The stochastic gradient boosting algorithm had the best performance for 90 day mortality prediction, with good discrimination (c-statistic = 0.74), calibration (intercept = − 0.05, slope = 1.11) and Brier score (0.078). The elastic-net penalized logistic regression algorithm had the best performance for 2 year mortality prediction, with good discrimination (c-statistic = 0.70), calibration (intercept = − 0.03, slope = 0.89) and Brier score (0.16). The models were incorporated into a freely available web-based application, including individual patient explanations for interpretation of the model to understand the reasoning how the model made a certain prediction: https://sorg-apps.shinyapps.io/hipfracturemortality/

Conclusions

The clinical prediction models show promise in estimating mortality prediction in elderly femoral neck fracture patients. External and prospective validation of the models may improve surgeon ability when faced with the treatment decision-making.

Level of evidence

Prognostic Level II.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.