Association of length of hospital stay with delay to surgical fixation of hip fracture

Does early surgery within 48 hours improve clinical outcomes in elderly hip fractures? A matched cohort study of 1776 hip fractures

PURPOSE

The aim of this study was to determine if a delay to surgery of more than 48 h was associated with poorer functional outcomes and increased 1-year mortality rates for elderly hip fractures.

METHODS

A retrospective review of surgically treated elderly (≥ 60 years old) hip fracture patients in a single institution was conducted. Patients were divided into 2 groups depending on hours from admission to surgery: Group 1 ( ≤ 48 h) and Group 2 (> 48 h); these groups were 1:1 matched for the initial Modified Barthel's Index (MBI) and Charlson Comorbidity Index (CCI).

RESULTS

2562 patients were eligible for the study. The cut-point value in a receiver operating curve analysis for 12-month MBI against time to surgery was not robust enough to determine an optimal time for surgery. Group 1 (n = 888) had significantly better MBI scores at 6-months [mean 78.7 (± 19.9) vs. mean 75.5 (± 20.6)] and 1-year [mean 80.4 (± 20.1) vs. mean 76.9 (± 22.3)] (p < 0.001). This difference in MBI scores between the groups did not meet the minimal clinically important difference of 10  points. There was no significant difference in 1-year mortality (3.7% vs. 4.4%) (p = 0.427). Delayed surgery past 48 h significantly increased the risk of post-operative complications. (Urinary tract infection, acute retention of urine and pneumonia) (p < 0.001).

CONCLUSION

Delayed surgery for elderly hip fractures after 48 h increases the risk of acute post-operative complications. There is no increase in 1-year mortality and no clinically important deterioration of MBI if operated on after 48 h.

LEVEL OF EVIDENCE

III.

Age-stratified analysis of delayed fixation outcomes of femoral neck fracture among adults: A retrospective study at a tertiary care trauma center

ObjectiveThis study investigated the delayed fixation outcomes of femoral neck fractures stratified by age and surgical delay in adult patients at a tertiary care trauma center.MethodA retrospective study was conducted involving patients with femoral neck fractures admitted to the orthopedic ward of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma between January 2019 and March 2023. Participants aged 18-60 years who underwent delayed surgery (>48 h) were included. Data on patient demographics, fracture and surgical characteristics, and outcomes were analyzed. This study utilized chi-square or Fisher's exact tests to compare outcomes between patients stratified by surgical delays as well as age.ResultsAmong 108 participants, 63.9% were aged 18-30 years and 36.1% were aged 31-60 years. Avascular necrosis was predominantly observed in older patients who underwent surgery within 7 days (P  = 0.001), whereas other complications such as nonunion and infection were more prevalent in patients aged 18-30 years whose surgery was delayed by >7 days (P  = 0.303). Patients who underwent surgery within 7 days had shorter length of hospital stay and faster return to work in both age groups (P < 0.05), whereas those aged 18-30 years experienced the opposite when surgery was delayed beyond 7 days.ConclusionsSurgical fixation within 7 days leads to better recovery and fewer complications in adults with femoral neck fractures, whereas delayed surgery provides acceptable outcomes. Age-specific protocols are key to optimizing results.

Three-dimensional printed anatomical models as an educational tool for orthopaedic surgical trainees - A single institution experience

Objective

To evaluate the utility of three-dimensional (3D) anatomical models as an educational tool among Orthopaedic surgical trainees.

Methods

Seven types of 3D anatomical models - humerus, elbow, ankle, calcaneum, knee, femur, and pelvis- based on patients' computational tomography (CT) scans were printed in the study institution and used by surgical trainees preoperatively. Responses were collected in the form of a Likert scale questionnaire. Descriptive statistics of participants' ratings were calculated. Non-parametric analysis using Wilcoxon test and Kruskal-Wallis test was performed to determine if effectiveness varied with gender, clinical experience, and anatomical model type.

Design

Observational cross-sectional study.

Setting

Single center study.

Participant selection criteria

All participants within a period of 16 months who were Orthopaedic surgical trainees within the study institution and utilised 3D anatomical models preoperatively were selected for this study.

Outcome measures and comparisons

Primary outcome was Likert scale ratings for three aspects - understanding of patients' anatomy, learning of a patient-specific orthopaedic condition, retention of anatomical knowledge.

Results

This study revealed that 3D anatomical models were well-received as an educational tool among Orthopaedic surgical trainees. There were no significant differences between gender, clinical experience or anatomical model type regarding 3D models in improving understanding of patient anatomy and retention of anatomical knowledge (p < 0.05). There were significant differences among participants based on clinical experience regarding the use of 3D models in learning of the patient-specific orthopaedic condition (p = 0.0106).

Conclusions

Preliminary results from this study demonstrate overall effectiveness of 3D models as an educational tool in Orthopaedic surgery, but is limited by the qualitative nature of data collected. Higher quality evidence is required to demonstrate that 3D anatomical models are effective tools to impart critical knowledge of anatomy to surgical trainees.

Level of evidence

IV.

Admission Hemoglobin Associated with Increased Mortality in Hip Fracture Surgical Patients: An Observational Study

In hip fracture patients, who are mostly elderly, preexisting anemia can be worsened when combined with trauma and surgery. To this date, there is no unequivocal approach about transfusion thresholds. We analyzed hemoglobin (Hb) and hematocrit (Hct) levels at three time points in surgical patients with proximal femoral fractures (PFF) to see which levels were triggers for transfusions and whether transfusions were related to mortality after hospital discharge. A total of 956 patients were operated on from 1 January 2021 to 31 December 2022 at the University Hospital of Split and included in the study. There were more women (74%); 47% patients had admission Hb < 120 g/L. Transfusion was given preoperatively to 88, intraoperatively to 74 and postoperatively to 309 patients. Transfusion thresholds were as follows: Hb 84 g/L preoperatively, 99 intraoperatively and 83 postoperatively. After hospital discharge, 10.79% of patients died within the 1st month and 23% within 6 months. In the group of non-survivors, 60% of patients had admission Hb ≤ 117 g/L and the proportion of patients transfused preoperatively was two times higher. Preoperative transfusion thresholds could be set to higher levels for patients with surgically treated PFF. However, that could increase mortality even more. Further investigation is necessary.

Health Outcomes of Older Adults after a Hospitalization for a Hip Fracture

Background

Hip fractures in older adults often lead to adverse health outcomes, which may be related to time to surgery and longer hospital stays. The experience of older adults with hip fractures in New Brunswick is not known.

Methods

This was a retrospective observational study. All hip fracture patients 65 years of age and older admitted to one hospital designated as a Level One Trauma Centre between April 1, 2015 and March 31, 2019 comprised the sample.

Results

The majority (86.5%) received surgery within 48 hours and those who had surgery beyond this time frame had a significantly longer stay in acute care (OR: 3.79, 95% CI: 2.05-7.15). The mean total length of stay (Total-LOS) for patients discharged after their acute care needs were met was 9.8 days (SD=8.1) compared to patients experiencing delays in discharge for nonmedical reasons which was 26.3 days (SD=33.7). An extended stay in acute care (OR: 1.93, 95% CI: 1.09-3.43) and increasing age (OR: 1.03, 95% CI: 1.001-1.06) were associated with a higher likelihood of death at one year post-discharge. Time to surgery beyond 24 hours (OR: 2.80, 95% CI: 1.13-7.38) was associated with a higher likelihood of death 30 days post-discharge.

Conclusions

Most patients had surgery within the national benchmark of less than 48 hours. The Total-LOS increased 2.5-fold in patients who remained in hospital after their acute care needs were met. A better understanding of patient characteristics, such as frailty, may better predict patients at risk for longer hospital stays and adverse health outcomes.

The Impact of Hospital Transfers on Surgical Delay and Associated Postoperative Outcomes for Hip Fracture Patients in Scotland: A Cohort Study

Background/Objectives: Hip fractures exert a substantial burden on hospital systems. Within Scotland 20% of the population resides rurally, warranting investigation of how this impacts prompt access to surgical care. This study aims to determine whether indirect hospital admission via hospital transfer affects the likelihood of surgical management within 36 h for hip fracture patients. Methods: A retrospective cohort study was performed. This used Scottish Hip Fracture Audit data including patients aged ≥50 split into two propensity matched groups based on their transfer status. Descriptive analysis compared patient characteristics. Regression assessed achieving surgery within 36 h of admission in the unmatched and matched cohorts. Secondary outcomes included time to surgery, mortality, mobilization, returning to residence and length of stay. A sensitivity analysis was undertaken to assess for residual confounding effects. Results: The unmatched analysis included 20,132 patients. Transfer patients were younger (p = 0.007) and less-comorbid (p < 0.001). In the matched population, 711 (63.6%) transfer patients had surgery with 36 h of presentation to hospital, compared to 852 (75.3%) non-transfer patients. Transfer patients had 43% reduced odds of timely surgery (OR (95% CI) 0.57 (0.48 to 0.69); p < 0.001). No disparities emerged in mortality, mobilisation or returning to residence., Transfer patients experienced a significant increase in length of stay in hospital (median (IQR) 16 (8 to 33) vs. 13 (8 to 30); p = 0.024). Conclusions: Hospital transfer is associated with significantly reduced odds of timely surgery, a longer time to surgery and longer length of stay. Development of structured network pathways that minimize delay to transfer are required to potentially optimize outcomes and reduce associated cost.

Association of the Number of Teeth With Physical Function and Length of Hospital Stay After Hip Fracture Surgery: A Prospective Observational Study at a Tertiary Hospital in Japan

OBJECTIVES

Although lower-extremity muscle strength is associated with physical function, there are challenges in assessing the muscle strength of patients after hip surgery due to pain or limited cognitive function. The number of teeth is a characteristic that can be easily examined. Although the relationship between the number of teeth and physical function has been reported in recent years, there are no reports examining the relationship with prognosis in patients with hip fractures. Therefore, this study aimed to investigate the relationship between the number of teeth and physical function and length of hospital stay after hip fracture surgery and to evaluate the predictive efficacy of the number of teeth on postoperative prognosis.

METHODS

This prospective cohort study was conducted in a tertiary clinical care facility. Patients aged ≥65 years who underwent hip surgery were included. A total of 101 patients (mean age: 85.1±8.0 years) were included. The factor analyzed was the number of teeth at admission. Patients were divided into two groups according to the number of teeth: those with ≥20 and those with ≤19 teeth. The outcomes were knee extension muscle strength-to-weight ratio at two weeks postoperatively and the length of hospital stay. A multiple regression analysis was performed to determine the association between the two groups.

RESULTS

Of 101 patients, 79 (78.2%) had ≤19 teeth, whereas 22 (21.8%) had ≥20 teeth. The mean muscle strength-to-weight ratio and length of hospital stay were 0.26±0.11 kgf/kg and 57.5±31.4 days, respectively. Multiple regression analysis revealed that the number of teeth was significantly associated with the muscle strength-to-weight ratio (β=-0.26, p=0.04) but not with the duration of hospitalization (β=0.17, p=0.09).

CONCLUSIONS

We suggest that assessment of the number of teeth at admission may be a useful predictor of patient physical function.

Does Time to Surgery for Distal Radius Fractures Impact Clinical and Radiographic Outcomes? A Systematic Literature Review

Distal radius fractures are one of the most common upper extremity fractures across all age groups. Although the American Academy of Orthopaedic Surgery (AAOS) Clinical Practice Guidelines have defined recommendations for the treatment of distal radius fractures, the optimal time to surgery was not included. There remains relatively little guidance or consensus regarding the optimal timing of surgical intervention for distal radius fractures and the impact of time to surgery on outcomes. As such, the purpose of this investigation is to systematically review clinical and radiographic outcomes associated with time to surgical management of distal radius fractures.