Outcome after surgery for the treatment of hip fracture in the extremely elderly

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection

BACKGROUND

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood.

METHODS

A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05.

RESULTS

A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts.

CONCLUSIONS

Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission?

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022

INTRODUCTION

Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture.

METHODS

Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination.

RESULTS

The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications.

DISCUSSION

In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

Risk Factors of the 2-Year Mortality after Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture

Purpose

This study investigates the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), albumin, and 2-year mortality in elderly patients having hemiarthroplasty for displaced femoral neck fracture (FNF).

Materials and Methods

We retrospectively reviewed 284 elderly patients who underwent hemiarthroplasty for Garden type IV FNF from September 2014 to September 2020. Using the receiver operating characteristic curve, optimal cutoff values for LCR, NLR, and albumin were established, and patients were categorized as low or high. Associations with 2-year mortality were evaluated through univariate and multivariate Cox regression analyses.

Results

Of the 284 patients, 124 patients (45.9%) died within 2 years post-surgery. The optimal cutoff values were: LCR at 7.758 (specificity 58.5%, sensitivity 25.0%), NLR at 3.854 (specificity 39.2%, sensitivity 40.0%), and albumin at 3.750 (specificity 65.9%, sensitivity 21.9%). Patients with low LCR (<7.758), high NLR (≥3.854), and low albumin (<3.750) had a statistically significant reduced survival time compared to their counterparts.

Conclusion

Lower preoperative LCR and albumin levels, along with higher NLR, effectively predict 2-year mortality and 30-day post-surgery complications in elderly patients with Garden type IV FNF undergoing hemiarthroplasty.

Hip Fracture Care during COVID-19: Evolution through the Pandemic

INTRODUCTION

The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages.

METHODS

Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted.

RESULTS

A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130).

CONCLUSION

The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic

Objectives

To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort.

Design

Retrospective cohort study.

Setting

Academic medical center.

Patients/Participants

Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020).

Intervention

Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility].

Main Outcome Measurements

Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L).

Results

In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes.

Conclusions

All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic.

Level of Evidence

III.

Factors associated with non-home discharge of patients hospitalized for hip fracture: A nationwide retrospective study using the Japanese diagnostic procedure combination database

In Japan, the length of stay in acute care hospitals has been shortened, home medical care has been promoted following national policy. However, many issues remain in promoting home medical care. The aim of this study was to clarify the profiles of patients with hip fractures, aged ≥ 65 years, who were hospitalized in acute care institutions at the time of discharge and the influence on nonhome discharge. This study used data from patients who satisfied all the following conditions: Patients aged ≥ 65 years who were hospitalized and discharged between April 2018 and March 2019; Patients with hip fractures, and; Patients who were admitted from home. The patients were classified into the home discharge and nonhome discharge groups. Multivariate analysis was conducted by comparing socio-demographic status, patient background factors, patient status at discharge, and hospital function. This study included 31,752 patients (73.7%) and 11,312 patients (26.3%) in the nonhome discharge group and home discharge group, respectively. Overall, the proportions of males and females were 22.2% and 77.8%, respectively. The average (standard deviation) age of the patients was 84.1 years (7.4) and 81.3 years (8.5) in the nonhome discharge and home discharge groups, respectively (P < .01). The following factors affected nonhome discharge: 75 to 84 years (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.68-1.96), ≥85 years (OR = 2.17, 95% CI = 2.01-2.36), electrocardiography or respiratory treatment "(Factor A3) (OR = 1.44, 95% CI = 1.23-1.68), level of assistance with activities of daily living "(Factor B1)" (OR = 4.56, 95% CI = 4.22-4.92), and hospital where the patient-to-nurse ratio is 7:1 (OR = 2.12, 95% CI = 1.91-2.35). The results suggested that support from activities of daily living caregivers and implementing medical treatments such as respiratory care are required to advance home medical care. This study's method enables analysis focusing on aspiration pneumonia and cerebral infarction, which are common among older adults. Furthermore, specific measures for promoting home medical care for patients who are highly dependent on medical and long-term care may be developed.

Deep Learning Assistance Closes the Accuracy Gap in Fracture Detection Across Clinician Types

BACKGROUND

Missed fractures are the most common diagnostic errors in musculoskeletal imaging and can result in treatment delays and preventable morbidity. Deep learning, a subfield of artificial intelligence, can be used to accurately detect fractures by training algorithms to emulate the judgments of expert clinicians. Deep learning systems that detect fractures are often limited to specific anatomic regions and require regulatory approval to be used in practice. Once these hurdles are overcome, deep learning systems have the potential to improve clinician diagnostic accuracy and patient care.

QUESTIONS/PURPOSES

This study aimed to evaluate whether a Food and Drug Administration-cleared deep learning system that identifies fractures in adult musculoskeletal radiographs would improve diagnostic accuracy for fracture detection across different types of clinicians. Specifically, this study asked: (1) What are the trends in musculoskeletal radiograph interpretation by different clinician types in the publicly available Medicare claims data? (2) Does the deep learning system improve clinician accuracy in diagnosing fractures on radiographs and, if so, is there a greater benefit for clinicians with limited training in musculoskeletal imaging?

METHODS

We used the publicly available Medicare Part B Physician/Supplier Procedure Summary data provided by the Centers for Medicare & Medicaid Services to determine the trends in musculoskeletal radiograph interpretation by clinician type. In addition, we conducted a multiple-reader, multiple-case study to assess whether clinician accuracy in diagnosing fractures on radiographs was superior when aided by the deep learning system compared with when unaided. Twenty-four clinicians (radiologists, orthopaedic surgeons, physician assistants, primary care physicians, and emergency medicine physicians) with a median (range) of 16 years (2 to 37) of experience postresidency each assessed 175 unique musculoskeletal radiographic cases under aided and unaided conditions (4200 total case-physician pairs per condition). These cases were comprised of radiographs from 12 different anatomic regions (ankle, clavicle, elbow, femur, forearm, hip, humerus, knee, pelvis, shoulder, tibia and fibula, and wrist) and were randomly selected from 12 hospitals and healthcare centers. The gold standard for fracture diagnosis was the majority opinion of three US board-certified orthopaedic surgeons or radiologists who independently interpreted the case. The clinicians' diagnostic accuracy was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, sensitivity, and specificity. Secondary analyses evaluated the fracture miss rate (1-sensitivity) by clinicians with and without extensive training in musculoskeletal imaging.

RESULTS

Medicare claims data revealed that physician assistants showed the greatest increase in interpretation of musculoskeletal radiographs within the analyzed time period (2012 to 2018), although clinicians with extensive training in imaging (radiologists and orthopaedic surgeons) still interpreted the majority of the musculoskeletal radiographs. Clinicians aided by the deep learning system had higher accuracy diagnosing fractures in radiographs compared with when unaided (unaided AUC: 0.90 [95% CI 0.89 to 0.92]; aided AUC: 0.94 [95% CI 0.93 to 0.95]; difference in least square mean per the Dorfman, Berbaum, Metz model AUC: 0.04 [95% CI 0.01 to 0.07]; p < 0.01). Clinician sensitivity increased when aided compared with when unaided (aided: 90% [95% CI 88% to 92%]; unaided: 82% [95% CI 79% to 84%]), and specificity increased when aided compared with when unaided (aided: 92% [95% CI 91% to 93%]; unaided: 89% [95% CI 88% to 90%]). Clinicians with limited training in musculoskeletal imaging missed a higher percentage of fractures when unaided compared with radiologists (miss rate for clinicians with limited imaging training: 20% [95% CI 17% to 24%]; miss rate for radiologists: 14% [95% CI 9% to 19%]). However, when assisted by the deep learning system, clinicians with limited training in musculoskeletal imaging reduced their fracture miss rate, resulting in a similar miss rate to radiologists (miss rate for clinicians with limited imaging training: 9% [95% CI 7% to 12%]; miss rate for radiologists: 10% [95% CI 6% to 15%]).

CONCLUSION

Clinicians were more accurate at diagnosing fractures when aided by the deep learning system, particularly those clinicians with limited training in musculoskeletal image interpretation. Reducing the number of missed fractures may allow for improved patient care and increased patient mobility.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value"

BACKGROUND

Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF).

METHODS

Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01).

RESULTS

There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001).

CONCLUSION

Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Validation of the Nottingham Hip Fracture Score in Predicting Postoperative Outcomes Following Hip Fracture Surgery

OBJECTIVE

Although several prognostic models have been developed for patients who underwent hip fracture surgery, their preoperative performance was insufficiently validated. We aimed to verify the effectiveness of the Nottingham Hip Fracture Score (NHFS) for predicting postoperative outcomes following hip fracture surgery.

METHODS

This was a single-center and retrospective analysis. A total of 702 elderly patients with hip fractures (age ≥ 65 years old) who received treatment in our hospital from June 2020 to August 2021 were selected as the research participants. They were divided into the survival group and the death group based on their survival 30 days after surgery. The multivariate logistic regression model was used to identify the independent risk factors for the 30-day mortality after surgery. The NHFS and American Society of Anaesthesiologists (ASA) grades were used to construct these models, and a receiver operating characteristic curve was plotted to assess their diagnostic significance. A correlation analysis was performed between NHFS and length of hospitalization and mobility 3 months after surgery.

RESULTS

There were significant differences in the age, albumin level, NHFS, and ASA grade between both groups (p < 0.05). The length of hospitalization in the death group was longer than the survival group (p < 0.05). The perioperative blood transfusion and postoperative ICU transfer rates in the death group were higher than in the survival group (p < 0.05). The death group's incidence of pulmonary infections, urinary tract infections, cardiovascular events, pressure ulcers, stress ulcers with bleeding, and intestinal obstruction was higher than the survival group (p < 0.05). The NHFS and ASA III were independent risk factors for the 30-day mortality after surgery, regardless of age and albumin level (p < 0.05). The area under the curve (AUC) of the NHFS and ASA grade for predicting the 30-day mortality after surgery was 0.791 (95% confidence interval [CI] 0.709-0.873, p < 0.05) and 0.621 (95% CI 0.477-0.764, p > 0.05), respectively. The NHFS positively correlated with hospitalization length and mobility grade 3 months after surgery (p < 0.05).

CONCLUSION

The NHFS demonstrated a better predictive performance than the ASA score for the 30-day mortality after surgery and positively correlated with the hospitalization length and postoperative activity limitation in elderly patients with hip fractures.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures

Objective

The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality.

Materials and Methods

This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality.

Results

We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]).

Conclusion

Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

Low lymphocyte-to-C-reactive protein ratio relates to high 1-year mortality in elderly patients undergoing hemiarthroplasty for displaced femoral neck facture

OBJECTIVE

Lymphocyte-to-C-reactive protein (CRP) ratio (LCR) is a novel biomarker for predicting poor prognosis in many diseases. This study aims to analyze the association between preoperative LCR and 1-year mortality in elderly patients with displaced FNF undergoing hemiarthroplasty.

METHODS

Between May 2017 and May 2019, a retrospective study including 364 elderly patients undergoing hemiarthroplasty for displaced FNF was performed. LCR was defined as the ratio of preoperative lymphocyte count to CRP level. The optimal cutoff value of LCR was determined by receiver operating characteristic curve, and all patients were categorized into low-LCR group and high-LCR group accordingly. The relationship between LCR and 1-year mortality was evaluated by using univariate and multivariate Cox regression analysis. Furthermore, the complications within 30 days after surgery, length of hospital stay, and perioperative red blood cell transfusion were also analyzed stratified by LCR.

RESULTS

A total of 47 patients (12.9%) died within 1-year follow-up after surgery. The optimal cutoff value for LCR was 30,560 (specificity 76.6% and sensitivity 63.4%). Low-LCR (≤ 30,560) group had a higher mortality rate than high-LCR group (23.53% vs. 5.21%, P < 0.001). In multivariate analysis, low LCR, hypoalbuminemia, and Age-Adjusted Charlson Comorbidity Index ≥ 6 were identified as independent predictors for 1-year mortality. Moreover, low level of LCR was associated with high rate of total complications (19.6% vs. 11.4%, P = 0.029), perioperative transfusions (37.9% vs. 27.0%, P = 0.027), and longer hospital stay (7.84 ± 2.40 vs. 7.30 ± 2.32, P = 0.031).

CONCLUSIONS

The low level of preoperative LCR can effectively predict 1-year mortality and 30-day total complications after surgery in elderly patients with displaced FNF undergoing hemiarthroplasty.

Fractures after cephalomedullary nailing of the femur : Systematization of surgical fixation based on the analysis of a single-center retrospective cohort

PURPOSES

Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures.

METHODS

All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination.

RESULTS

The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity.

CONCLUSIONS

Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Improved outcomes and reduced medical costs through multidisciplinary co-management protocol for geriatric proximal femur fractures: a one-year retrospective study

BACKGROUND

To manage the rapidly growing incidence of, and related medical burden resulting from hip fractures in older adults in an aging society, studies involving orthogeriatric co-management treatment models have reported improved outcomes, including reduced medical costs. The treatment gap for osteoporosis was however seldom emphasized in the published treatment protocols. Aiming to improve the existing orthogeriatric protocol, we have established a patient-centered protocol for elderly patient hip fractures, which simultaneously focuses on fracture care and anti-osteoporosis agent prescription in regarding to healthcare quality and medical expense.

METHODS

This was a retrospective study comparing patients who enrolled in the multidisciplinary co-managed protocol for geriatric hip fractures and those who did not. The inclusion criteria for this study were: (a) single-sided hip fractures treated from 1 to 2018 to 30 June 2020, (b) patients who were 60-years or older (c) trauma treated within 3 days from time of injury, and (d) minimal follow-up period of 12 months after surgery.

RESULTS

From 1 to 2018 to 30 June 2020, 578 patients were included (267 patients in the protocol group vs. 331 patients in the conventional group). The protocol group was associated with significantly reduced lengths of hospital stay (p = 0.041), medical expenditures (p = 0.006), and mortality (p = 0.029) during their acute in-hospital admission period. Early osteoporosis diagnosis and anti-osteoporosis agent prescription were achieved in the protocol group, with a significantly wider coverage for BMD assessment (p < 0.001) and prescriptions for anti-osteoporosis medication (p < 0.001). Yet, there was no significant decline in the one-year refracture rate in the protocol group.

CONCLUSIONS

The implementation of a multidisciplinary co-managed care protocol for geriatric proximal femur fractures successfully improved patient outcomes with significantly reduced lengths of stay, medical expenditures, and mortality during the acute in-hospital admission period. The high prescription rate of anti-osteoporosis medication after hip fractures in the protocol group was not associated with a significantly lower re-fracture rate in the 12-month follow-up. However, the association between early anti-osteoporosis agent prescription and reduced long-term medical expenses in this group of patients has provided a direction for future research.

Preoperative echocardiogram does not increase time to surgery in hip fracture patients with prior percutaneous coronary intervention

BACKGROUND

The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI).

METHODS

Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed.

RESULTS

Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029).

CONCLUSIONS

Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.

Hip fracture in centenarians, what can we expect?

INTRODUCTION

Hip fractures in centenarians are rising due to the increase in life expectancy. The objective of this study is to compare the characteristics of centenarians' hip fracture with a younger control group, and to analyze whether there are differences in terms of in-hospital mortality, complications, and short-medium-term survival between them.

MATERIAL AND METHODS

Retrospective case-control study, with a series of 24 centenarians and 48 octogenarians with a hip fracture. Comorbidities and Charlson index, surgical delay, complications and mortality during admission, and hospital stay were analyzed. At discharge, early mortality, survival after one year, and return to previous functionality were assessed.

RESULTS

No significant differences were found in baseline parameters or comorbidities (P>.05), and the type of was a woman with an extracapsular fracture. Hospital stay was longer in the control group (P=.038), and the most frequent complication was anemia requiring transfusion (23/24 in centenarians, P<.0001). In-hospital mortality and accumulated at one year in the centenarians was 33 and 67%, respectively, compared to 10 and 25% in the octogenarians (P=.017, OR=4.3 [1,224-15,101] and P=.110). Only 2 centenarian patients were able to walk again after the intervention, while in the control group 53.84% returned to the previous functional situation (P=.003).

CONCLUSIONS

Compared to a control group of younger patients, in-hospital mortality and in the first year after a hip fracture is significantly higher in centenarians, and very few recover activity prior to the fracture.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Hip fractures in centenarians: a multicentre review of outcomes

INTRODUCTION

Advances in healthcare have resulted in an increasing UK population, with the proportion of elderly individuals expanding significantly, including centenarians. Hospitals can expect to see growing numbers of so-called 'super-elderly' patients with trauma, a majority of whom will have hip fractures. We performed a multicentre review of hip fracture outcomes in centenarians to assess whether being an outlier in age correlates with poorer prognosis.

METHODS

Centenarians admitted to Basingstoke, Southampton, Dorset, and Salisbury district hospitals with hip fractures between January 2014 and June 2019 were included. Electronic records were searched to obtain demographics, functional status, and admission details.

RESULTS

A total of 60 centenarians were included, with a median age of 101 years (range 100-108 years), 85% of whom were female; 29 were admitted from their own home or sheltered housing and 31 from nursing or residential care; 33 had some outdoor mobility, 26 only mobilised indoors, and 1 had no mobility. Common comorbidities were renal and heart disease and dementia. Of the total, 56 underwent surgery, 51 within 36 hours. In terms of accommodation, 63.4% returned to their pre-injury level of independence. At 30 days, three months, and one year, mortality rates were 27% (n = 16), 40% (n = 24) and 55% (n = 33), respectively.

CONCLUSION

Trauma in the elderly population is an area of growing interest, yet few studies address centenarians with hip fractures. This work demonstrates that mortality rates within one year of injury were high, but almost half survived beyond a year. Two-thirds of patients regained their pre-injury level of independence, suggesting that functional recovery may not be as poor as previously reported.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures

INTRODUCTION

The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89.

METHODS

Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay.

RESULTS

Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group.

DISCUSSION

After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups.

LEVEL OF EVIDENCE

Prognostic level III, retrospective study.

Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?

Introduction

This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery.

Materials and Methods

Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk.

Results

Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification (P = .002). Moderate-risk patients had 33% longer (P = .019) and high-risk patients had 28% longer time to surgery (P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification (P = .015). Low-risk patients had 2.14× higher odds (P = .009), moderate-risk patients had 2.70× higher odds (P = .001), and high-risk patients had 2.18× higher odds of delay to surgery (P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal (P < .001), low (P = .046), and moderate-risk patients (P = .046).

Discussion

Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality.

Conclusion

Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients.

Level of Evidence

Prognostic Level III.

Management of Low-Energy Basicervical Proximal Femoral Fractures by Proximal Femoral Nail Anti-Rotation

Objective

To evaluate clinical and radiological outcomes of proximal femoral nail anti‐rotation (PFNA‐II) devices and demonstrate the effectiveness of PFNA‐II for the treatment of basicervical fractures in elderly patients.

Methods

A retrospective review of all patients treated with PFNA‐II for a proximal femoral fracture between January 2013 and February 2017 at three different institutions (Shanghai General Hospital, Shanghai Punan Hospital and Shanghai Seventh People's Hospital) was conducted. The X‐ray films were strictly reviewed by three trauma surgeons and a professional radiology doctor. Patients over 60 years of age who met the following criteria were included: (i) sustained low‐energy trauma; (ii) a two‐part fracture; (iii) fracture line located at the base of the femoral neck and that was medial to the intertrochanteric line and exited above the lesser trochanter but was more lateral than a classic transcervical fracture. Follow‐up time should be longer than 6 months. A total of 52 patients who met the inclusion criteria were selected. The average age at diagnosis was 75.1 years (range, 63–91 years); 13 patients were men and 39 were women. The same proximal femoral nail anti‐rotation devices and the same surgical procedures were applied to all patients. Postoperative radiographic union time and modified Harris hip scores were used as major indicators for evaluating the effectiveness of surgery.

Results

The average follow‐up period was 22.5 months (18.5, 23.9, and 21.2 months, respectively) and radiographic unions were observed at an average of 19.6 weeks (range, 12–28 weeks). The patients were evaluated immediately after surgery, as well as 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Of the 49 patients, 38 had good reduction qualities (75.5%), 9 acceptable (18.3%), and 3 poor (6.1%). Radiographic union was confirmed in all fractures at an average of 19.6 weeks (range, 12–28 weeks). The mean Harris hip score was 84.9 (range, 65–99): excellent in 9 patients (18.36%), good in 30 (61.22%), medium in 8 (16.32%), and poor in 2 (4.08%). Slight persistent pain occurred in 3 patients, but these patients could still walk with the help of a cane. Two patients had symptoms of excessive telescoping. Eight patients experienced postoperative medical complications, mainly pneumonia and urinary tract infection.

Conclusion

Based on the clinical and radiological outcomes, the PFNA‐II devices provide strong rotational stability and excellent clinical prognosis, and are an appropriate treatment option for basicervical proximal femoral fracture in elderly patients.

Development and validation of the Brabant Hip Fracture Score for 30-day and 1-year mortality

BACKGROUND

Hip fractures in the elderly are associated with advanced comorbidities and high mortality rates. Mortality prediction models can support clinicians in tailoring treatment for medical decision making in frail elderly patients. The aim of this study was to develop and internally validate the Brabant Hip Fracture Score, for 30-day (BHFS-30) and 1-year mortality (BHFS-365) after hip fracture.

MATERIAL AND METHODS

A cohort study was conducted in 2 hospitals on operatively treated patients of 65 years and older with a hip fracture. Manual backward multivariable logistic regression was used to select independent predictors of 30-day and 1-year mortality. Internal validation was performed using bootstrapping techniques. Model performance was assessed with: (1) discrimination via the area under the receiver operating characteristic curve (AUC); (2) explained variance via Nagelkerke's R²; (3) calibration via Hosmer-Lemeshow (H&L) test and calibration plots.

RESULTS

Independent predictors of 30-day mortality were: age, gender, living in an institution, Hb, respiratory disease, diabetes and malignancy. In addition, cognitive frailty and renal insufficiency, were selected in the BHFS-365. Both models showed acceptable discrimination after internal validation (AUC = 0.71 and 0.75). The Hosmer-Lemeshow test indicated no lack of fit (p > 0.05).

DISCUSSION

We demonstrated that the internally validated and easy to use BHFS in surgically treated elderly patients after a hip fracture showed acceptable discrimination and adequate calibration. In clinical practice a cutoff of BHFS-30 ⩾ 24 could identify frail elderly patients at high risk for early mortality and could support clinicians, patients and families in tailoring treatment for medical decision making.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Survival and functionality in the elderly over 85 years of age with hip fracture

BACKGROUND

There is a tendency for the aging population to fracture their hips. Our aim was to compare survival and functionality at one year, among elderly and very elderly patients with hip fracture.

MATERIAL AND METHODS

A prospective cohort of patients included in the Institutional Registry of Elderly Patients with Hip Fracture between 2014 and 2017. We classified patients as elderly patients (EP) <65 and <85 years and very elderly patients (VEP) ≥85 years.

RESULTS

We included 952 patients, 43% were EP and 57% were VEP. The proportion of women was 84% and 86% (P=.33) and with 2 or more points in the Charlson comorbidities index (28 and 31%, P= .36), respectively. The VEP were more dependent according to the Barthel score (34% and 62%, P<.01) and frailer according to the Edmonton score (30% and 61%, P<.01). One-year survival was 91% (95% CI 86-93) in the EP and 76% (95% CI 70-89) in the VEP. In-hospital complications were more frequent in the VEP 12% (7% in the EP, P<.01). Age is an independent risk factor for one-year survival (HR 2.11; 95% CI 1.36-3.29, P<.001).

CONCLUSIONS

Age is a risk factor for the VEP group survival despite fragility and comorbidities. Because of their vulnerability, an appropriate care plan should be considered for VEP.

Surgical treatment of hip fracture in centenarians: Complications and independent risk factors of death

BACKGROUND

The increase in life expectancy has led to the appearance of a subgroup of hip fracture (HF) patients with special characteristics known as centenarians. The aim of the present study is to analyse the demographic characteristics, complications and mortality rate of this subgroup in order to identify the specific risk factors for mortality in these patients.

METHODS

Retrospective analysis of 69 patients (58 women and 11 men) aged 100 years or older admitted to a tertiary hospital for HF between 1999 and 2018.

RESULTS

The average age was 101.3 years (100-108, median 101). More than half (62.3%) of all patients presented with extracapsular fractures. The most common complications observed were delirium (52.3%) and urinary retention (27.7%). Haematoma (9.2%) was the most common surgical complication. Only 3 patients (7.3%) changed their place of residence after admission. In-hospital, 30-day and 1-year mortality rates were 13.8%, 21.5% and 54.2%, respectively. A high Charlson Comorbidity Index and baseline Functional Ambulation Classification (FAC) <3 were associated with a higher in-hospital mortality rate (OR = 1.95 95% CI [1.03-3.69] and OR = 5.7 95% CI [1.2-26.8]), respectively. The presence of more than 3 comorbidities and baseline FAC <3 were associated with a higher risk of 30-day mortality (OR = 6, 95% CI [1.4-24.7] and OR = 4, 95% CI [1.13-14.2]), respectively. Dementia has been associated with a higher risk of 30-day and 1-year mortality (OR = 4.6, 95% CI [1.2-16.7]) and OR = 5.11, 95% CI [1.6-21]) respectively.

CONCLUSION

FAC score, number of comorbidities, dementia and the Charlson Comorbidity Index have been shown to be risk factors of mortality in centenarians with HF.

'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary?

Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.

PURPOSE

In previous literature, elderly with a hip fracture are frequently defined as ≥ 70 years. However, given the ageing population and the rapidly increasing number of 'nonagenarians' (aged ≥ 90 years), the question rises whether this definition is still actual. The aim of this study is to determine whether nonagenarians show differences compared to patients aged 70-79 years and patients aged 80-89 years in terms of patient characteristics, complications and mortality rate.

METHODS

From April 2008 until December 2016, hip fracture patients aged ≥ 70 years treated according to our orthogeriatric treatment model were included. Patients were divided into three different groups based on age at admission: 70-79 years, 80-89 years and ≥ 90 years. Patient characteristics, risk of early mortality, complications and outcomes were analysed. Risk factors for 30-day mortality in nonagenarians were determined.

RESULTS

A total of 1587 patients were included: 465 patients aged 70-80 years, 867 patients aged 80-90 years and 255 patients aged ≥ 90 years. Nonagenarians were more often female and had a lower haemoglobin level at admission. Prefracture, they were more often living in a nursing home, were more dependent in activities of daily living and mobility and had a higher risk of early mortality calculated with the Almelo Hip Fracture Score (AHFS). Post-operative, nonagenarians suffer significantly more often from delirium and anaemia. The 30-day mortality and 1-year mortality were significantly higher. Differences increased gradually with age.

CONCLUSION

Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.

Frailty is Associated with an Increased Risk of Major Adverse Outcomes in Elderly Patients Following Surgical Treatment of Hip Fracture

We intended to explore the effect of level of frailty on, and relationship with, 1-, 3-, and 6-month postoperative emergency department visits, readmissions, and mortality. This is a prospective multicenter observational cohort study design. Patients aged 50 years or older treated for hip fracture (n = 245) were taken from Orthopedic wards in one medical center (n = 131) and one district hospital (n = 114) in Changhua County, Taiwan. Frailty was defined as measured by the validated Clinical Frailty Scale and categorized as robust, pre-frail, and frail. We used Kaplan-Meier analysis to estimate survival rates and Cox regression to estimate the risk of frailty associated with adverse outcomes. To examine the longitudinal associations between frailty and adverse outcome, the cross-lagged models were explored. Of the 245 patients, 55 (22.4%) were classified as frail, 113 (46.1%) as pre-frail, and 77 (31.4%) as robust. More cumulative events occurred for frail than for robust patients for each adverse outcome. Frailty has long-term effect on each adverse outcome after discharge, rather than the effect simultaneously. Targeting pre-frailty and frailty is essential for prevent adverse outcomes and improving the overall health of older adults after discharge for hip fracture.

Age Does Not Affect Metoprolol's Effect on Perioperative Outcomes (From the POISE Database)

BACKGROUND:

Perioperative β-blockade reduces the incidence of myocardial infarction but increases that of death, stroke, and hypotension. The elderly may experience few benefits but more harms associated with β-blockade due to a normal effect of aging, that of a reduced resting heart rate. The tested hypothesis was that the effect of perioperative β-blockade is more significant with increasing age.

METHODS:

To determine whether the effect of perioperative β-blockade on the primary composite event, clinically significant hypotension, myocardial infarction, stroke, and death varies with age, we interrogated data from the perioperative ischemia evaluation (POISE) study. The POISE study randomly assigned 8351 patients, aged ≥45 years, in 23 countries, undergoing major noncardiac surgery to either 200 mg metoprolol CR daily or placebo for 30 days. Odds ratios or hazard ratios for time to events, when available, for each of the adverse effects were measured according to decile of age, and interaction term between age and treatment was calculated. No adjustment was made for multiple outcomes.

RESULTS:

Age was associated with higher incidences of the major outcomes of clinically significant hypotension, myocardial infarction, and death. Age was associated with a minimal reduction in resting heart rate from 84.2 (standard error, 0.63; ages 45–54 years) to 80.9 (standard error, 0.70; ages >85 years; P < .0001). We found no evidence of any interaction between age and study group regarding any of the major outcomes, although the limited sample size does not exclude any but large interactions.

CONCLUSIONS:

The effect of perioperative β-blockade on the major outcomes studied did not vary with age. Resting heart rate decreases slightly with age. Our data do not support a recommendation for the use of perioperative β-blockade in any age subgroup to achieve benefits but avoid harms. Therefore, current recommendations against the use of β-blockers in high-risk patients undergoing noncardiac surgery apply across all age groups.

Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients

OBJECTIVE

To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.

DESIGN

Retrospective observational cohort study.

SETTING

Urban, American College of Surgeons-Verified, Level-1, Trauma Center.

PATIENTS/PARTICIPANTS

Three hundred seventy-seven consecutive patients with isolated hip fractures.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications.

RESULTS

Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = -0.12) and albumin (P < 0.001; r = -0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15-7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality.

CONCLUSIONS

When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor.

LEVEL OF EVIDENCE

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

[Surgical revision for complications after gamma3-nailing osteosynthesis of proximal humeral fractures : Follow-up series of 1500 patients]

BACKGROUND

The γ‑nailing system is a widespread intramedullary therapeutic option that has been used for intertrochanteric and subtrochanteric fractures since the late 1980s; however, some reports from the 1990s describing femoral shaft fractures questioned the indications for this system in simple fracture types. Due to increasing numbers of patients treated with this system, the complication rate is continuously falling as confirmed by many recent studies.

OBJECTIVE

Between 2008 and 2013 a total of 1500 operations using the γ‑nailing system were performed at this traumatology department. The standard 200 mm nail was used in 1290 cases and the extended system available from 340 to 440 mm in 210 cases. The aim of this study was to record the excellent results using the standard γ‑nailing system and to confirm the indications of the long intramedullary nailing system (Gamma3®) also for use in complex intertrochanteric and subtrochanteric fractures.

MATERIAL AND METHODS

All 1500 patients were retrospectively analyzed. Information on epidemiological data, intraoperative and postoperative complications and patient outcome was retrieved from the digital patient medical history. All available radiographs were assessed by a single traumatologist.

RESULTS

The results showed a low complication rate of 5% for surgical complications, mainly caused by cutting out in 34.66%, followed by hematomas in 21.33% and fractures of the nail in 16%. A comparison of the standard and long nailing systems could be carried out, showing a complication rate of 3.64% for the standard system compared to 13.33% for the long γ‑nail system.

CONCLUSION

The γ‑nailing system is a safe treatment option for trochanteric femoral fractures and failure of the implant is associated with high biomechanical forces in unstable fractures. A low complication rate is linked to a thorough surgical technique under consideration of a correct positioning of the implant.

Biomechanical Comparison of Three Different Intramedullary Nails for Fixation of Unstable Basicervical Intertrochanteric Fractures of the Proximal Femur: Experimental Studies

Objectives

This biomechanical study was conducted to compare fixation stability of the proximal fragments and their mechanical characteristics in proximal femur models of unstable basicervical IT fractures fixed by cephalomedullary nailing using 3 different types of the femoral head fixation.

Methods

A total of 36 composite femurs corresponding to osteoporotic human bone were used. These specimens were fixed with Gamma 3 (hip screw type; group 1) in 12, Gamma 3 U-blade (screw-blade hybrid type; group 2) in 12, and proximal femoral nail antirotation-II (helical blade type; group 3) in 12, respectively, and an unstable basicervical IT fracture was created by an engraving machine. After preloading and cyclic loading, the migration of the proximal fragment according to 3 axes was assessed by the stereophotogrammetric method and the migration of screw or blade tip within the femoral head was measured radiographically. Next, the vertical load was continued at a speed of 10 mm/min until the construct failure occurred. Finite element analysis was additionally performed to measure the stress and compressive strain just above the tip of screw or blade within the femoral head.

Results

The rotational change of the proximal fragment according to the axis of screw or blade was much greater in group 1 than in groups 2 and 3 (p=0.016 and p=0.007, respectively). Varus collapse was greater in group 3 than in group 2 (p=0.045). Cranial and axial migration of screw or blade within the femoral head were significantly greater in group 3 than in both group 1 (p=0.001 and p=0.002, respectively) and group 2 (p=0.002 and p=0.016, respectively). On finite element analysis, group 3 showed the highest peak von-Mises stress value (13.3 MPa) and compressive strain (3.2%) just above the tip of the blade within the femoral head. Meanwhile, groups 1 and 2 showed similar results on two values.

Conclusions

Screw-blade hybrid type and blade type would be more effective in minimizing rotation instability of the proximal fragment in unstable basicervical IT fractures. However, varus collapse of the proximal fragment and cranial and axial migration within the femoral head were greater with blade type than screw-blade hybrid type.

Hip fractures in the oldest old. Comparative study of centenarians and nonagenarians and mortality risk factors

INTRODUCTION

Centenarians and nonagenarians constitute a rapidly growing age group in Western countries and they are expected to be admitted to hospital with hip fractures. The aim of this study was to compare outcomes of centenarian and nonagenarian patients following a hip fracture and to identify risk factors related to in-hospital and post-discharge mortality in both groups.

PATIENTS AND METHODS

A prospective evaluation of centenarian patients and nonagenarian controls admitted to a tertiary university hospital in Barcelona with hip fractures over a period of 5 years and 9 months. Baseline characteristics and outcomes in both patient groups were compared. Variables associated with in-hospital, 30-day, 3-month and 1-year mortality were also analyzed.

RESULTS

Thirty-three centenarians and 82 nonagenarians were included. The most relevant statistically significant differences found were: Barthel index at admission (61.90 vs. 75.22), number of drugs before admission (4.21vs 5.55), in-hospital complication rates (97 vs. 78%), readmissions at 3 months and 1 year (0 vs 11.7% and 3.4 vs. 19.5% respectively) and mortality at 3 months and 1 year (41.4 vs. 20.8% and 62.1 vs. 29.9%, respectively). Mean number of complications, rapid atrial fibrillation, mean age, and urinary tract infection were risk factors associated with mortality.

CONCLUSIONS

Centenarian patients had similar in-hospital outcomes to nonagenarians, but experienced more complications and twice the 3-month and 1-year mortality rate. The mean number of complications was the risk factor most consistently related to in-hospital and post-discharge mortality. These findings emphasize the need to improve care in very old patients to prevent complications.

Factors influencing survival following hip fracture among octogenarians and nonagenarians in the United States

INTRODUCTION

Hip fractures account for a significant disease burden in the Unites States. With an aging population, this disease burden is expected to increase in the upcoming decades.

MATERIALS AND METHODS

This represents a retrospective cohort study to assess mortality following hip fracture in the octogenarian and nonagenarian populations. Odds ratios for postoperative mortality were constructed using normalized patients from United States Social Security death tables. Kaplan Meier analysis and binary logistic regression were used to assess the impact of surgical delay and medical comorbidity (measured by the Carlson Comorbidity Index (CCI)) on postoperative mortality.

RESULTS

189 octogenarians and 95 nonagenarians were included. One-year mortality was nearly three times higher for both the octogenarians (OR: 3.1) and nonagenarians (OR: 3.14), and returned to that of the normal population 4 years post-op for octogenarians and 5 years post-op for nonagenarians. Higher preoperative medical comorbidity (CCI) was associated with higher post-op mortality for both octogenarians (log rank = 0.026) and nonagenarians (log rank = 0.034). A 48-h surgical delay resulted in significantly increased postoperative mortality among healthy patients (CCI of 0 or 1, OR: 18.1), but was protective for patients with significant medical comorbidity (CCI ≥ 3). Age, preoperative CCI, and 48-h surgical delay were all independent predictors of 1-year post-op mortality.

CONCLUSIONS

Following hip fracture, there is a 3-fold increase in mortality for octogenarians and nonagenarians at 1 year post-op. A 48-h surgical delay significantly increased mortality for healthier patients but was protective against mortality for sicker patients.

Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

Introduction:

The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications.

Methods:

A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital.

Results:

We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection.

Conclusion:

Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

Short-Term Outcomes Following Hip Fractures in Patients at Least 100 Years Old

BACKGROUND

The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are ≥100 years old and sustain a hip fracture fare worse in the hospital than those who are younger.

METHODS

Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were ≥65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and ≥100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates.

RESULTS

A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were ≥100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality.

CONCLUSIONS

Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization.

LEVEL OF EVIDENCE

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

Mortality, readmission, and reoperation after hip fracture in nonagenarians

Background

Osteoporotic hip fractures are associated with high mortality and morbidity in people of advanced age; however, few studies have investigated the complication rates in nonagenarians. In this study, we applied a competing risk analysis to estimate the mortality, readmission, and reoperation rates after surgery for hip fracture among nonagenarians.

Methods

A total of 11,184 nonagenarians (aged ≥ 90) who received surgery for hip fracture during the period 1 January 1997 and 31 December 2010 were selected from Taiwan’s National Health Insurance (NHI) database. Nonagenarians were followed up until the end of 2012, death, or the date they left the NHI program. Cumulative mortality was estimated using the Kaplan-Meier analysis and risk factors for mortality were investigated using a Cox proportional hazards model. Competing risk analysis was used to estimate cumulative incidence rates and to assess the risk factors for reoperation and readmission.

Results

The mortality rates were 29.5% at 1 year, 45.0% at 2 years and 78.1% at 5 years. The cumulative incidence rates of reoperation were 7.3% at 1 year, 9.2% at 2 years and 11.6% at 5 years whereas those of readmission were 18.9% at 1 month and 24.1% at 3 months. Significant risk factors for death included age, male gender, trochanteric fracture, and higher Charlson comorbidity index (CCI) whereas those for reoperation were age, cervical fracture and higher CCI. Furthermore, age, male gender, and higher CCI were risk factors for readmission.

Conclusions

The overall 2-years mortality rate among nonagenarians in Taiwan was around 45%, the 2-years reoperation rate was around 9% and the 90-days medical complication rate was around 24%. High complication rates are associated with increased risk for death. Postoperative care to prevent medical complications is likely the most effective strategy to reduce mortality rates among nonagenarians with hip fracture.

Screening and Treating Prostate Cancer in the Older Patient: Decision Making Across the Clinical Spectrum

Treatment of the growing geriatric patient population is increasingly being recognized as a necessary priority of the oncology community. As the most common cancer among men in developed countries, prostate cancer afflicts a sizable portion of elderly men. Caring for this population requires knowledge of aspects of disease presentation, screening strategies, treatment approaches, and survivorship care considerations unique to the geriatric population. In this article, we review characteristics of prostate cancer screening and treatment decision making for localized disease in elderly men, including a discussion of the biology of disease in the elderly population. We also review best practices for providing treatment for localized and recurrent disease in an elderly population, including engaging in a basic geriatric assessment to determine fitness for treatment, eliciting information about patient preferences and support systems, and balancing treatment decisions in the context of these factors using the resources of a multidisciplinary care team. We then consider complications of prostate cancer survivorship related to systemic treatment in the elderly population of men with this disease. Finally, we emphasize the importance of engaging patients in treatment decision making across the spectrum of disease to personalize treatment plans and provide optimal care.

A critical review of the long-term disability outcomes following hip fracture

BACKGROUND

Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. This review aims to quantify the impact of hip fracture on older people's abilities and quality of life over the long term.

METHODS

Studies were identified through PubMed and Scopus searches and contact with experts. Cohort studies of hip fracture patients reporting outcomes 3 months post-fracture or longer were included for review. Outcomes of mobility, participation in domestic and community activities, health, accommodation or quality of life were categorised according to the World Health Organization's International Classification of Functioning and synthesised narratively. Risk of bias was assessed according to four items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

RESULTS

Thirty-eight studies from 42 publications were included for review. Most followed a clearly defined sample from the time of fracture. Hip fracture survivors experienced significantly worse mobility, independence in function, health, quality of life and higher rates of institutionalisation than age matched controls. The bulk of recovery of walking ability and activities for daily living occurred within 6 months after fracture. Between 40 and 60 % of study participants recovered their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40-70 % regained their level of independence for basic activities of daily living. For people independent in self-care pre-fracture, 20-60 % required assistance for various tasks 1 and 2 years after fracture. Fewer people living in residential care recovered their level of function than those living in the community. In Western nations, 10-20 % of hip fracture patients are institutionalised following fracture. Few studies reported impact on participation in domestic, community, social and civic life.

CONCLUSIONS

Hip fracture has a substantial impact on older peoples' medium- to longer-term abilities, function, quality of life and accommodation. These studies indicate the range of current outcomes rather than potential improvements with different interventional approaches. Future studies should measure impact on life participation and determine the proportion of people that regain their pre-fracture level of functioning to investigate strategies for improving these important outcomes.

Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients

BACKGROUND

Only a little is known about whether type of surgical intervention has an effect on mortality of these patients. Our primary objective was to assess whether different type of surgical procedures has an effect on mortality among elderly patients with hip fracture. A secondary objective was to examine factors that are related to mortality in our patient population. Our hypothesis is that type of surgical procedure, especially external fixation, should have an influence on mortality outcomes.

METHODS

We included 785 patients age 65 years or older, with hip fractures. Operative treatment consisted of external fixation, internal fixation, total hip arthroplasty and hip hemiarthroplasty. Age, gender, type of fracture, type of surgery performed, American Society of Anesthesiology (ASA) grade, clinical comorbidities, anesthesia type, blood transfusion requirement, time to surgery, intensive care unit requirement, operation length and length of hospital stay and number of comorbidities were documented.

RESULTS

During the study period, 785 patients (262 male, 523 female) were included to study, Overall mortality rate was 37.2 % (292/785). Their age ranged between 65 and 100 years (mean 81). Surgery type Kaplan-Meier cumulative mortality curves suggested no significant difference between four different types of surgery groups (p = 0.064). Transfusion requirement was significantly lower in external fixation group comparing to other groups (p = 0.014). Cox regression analysis showed the number of comorbidities 2 and ≥ 3 (p = 0.0027, p = 0.015), transfusion requirement (p = 0.0001), ASA 4 (p = 0.016) to be significant predictors of mortality.

CONCLUSIONS

Transfusion requirement, ASA grade 4 and having more than two comorbidities are risk factors for mortality in geriatric hip fractures. Type of surgical intervention and fracture type had similar mortality rates in our patient population.

Associations of vitamin D deficiency with postoperative gait and mortality among patients with fractures of the proximal femur

Objective

To assess whether serum vitamin D concentration is associated with gait status and mortality among patients with fractures of the proximal femur, six months after suffering the fracture.

Methods

Consecutive patients aged ≥65 years with fractures of the proximal femur, who were admitted to the orthopedics and traumatology ward of our service between January and December 2011, were prospectively evaluated. Clinical, radiological, epidemiological and laboratory analyses were performed, including vitamin D. The patients underwent surgery and were followed up as outpatients, with return visits 15, 30, 60 and 180 days after discharge, at which the outcomes of gait and mortality were evaluated.

Results

Eighty-eight patients were evaluated. Two of them were excluded because they presented oncological fractures. Thus, 86 patients of mean age 80.2 ± 7.3 years were studied. In relation to serum vitamin D, the mean was 27.8 ± 14.5 ng/mL, and 33.7% of the patients presented deficiency of this vitamin. In relation to gait, univariate and multivariate logistic regression showed that vitamin D deficiency was not associated with gait recovery, even after adjustment for gender, age and type of fracture (OR: 1.463; 95% CI: 0.524–4.088; p = 0.469). Regarding mortality, Cox regression analysis showed that vitamin D deficiency was not related to its occurrence within six months, even in multivariate analysis (HR: 0.627; 95% CI: 0.180–2.191; p = 0.465).

Conclusion

Serum vitamin D concentration was not related to gait status and/or mortality among patients with fractures of the proximal femur, six months after suffering the fracture.

Relationship between American Society of Anesthesiologists (ASA) grade and 1-year mortality in nonagenarians undergoing hip fracture surgery

This study retrospectively reviewed 327 nonagenarians who underwent hip fracture surgery at six hospitals. Functional status, postoperative complications, and 1-year mortality were evaluated, and relationships between these factors and American Society of Anesthesiologists (ASA) grade were analyzed. ASA grade was significantly associated with postoperative complications and 1-year mortality.

INTRODUCTION

Few previous studies have reported outcomes after hip fracture in nonagenarians, and these studies did not report significant associations between ASA grade and mortality. However, most of these studies included only a small number of patients from a single hospital. This study aimed to evaluate the relationships between ASA grade and functional status, postoperative complications, and mortality rate in nonagenarians undergoing hip fracture surgery.

METHODS

This study included 327 nonagenarians who underwent hip fracture surgery between January 2000 and December 2012. Patients with open fractures, subtrochanteric fractures, polytrauma, and pathological fractures were excluded. The medical records and X-rays were retrospectively reviewed. The relationships between ASA grade and functional status, postoperative complications, and 1-year mortality were analyzed.

RESULTS

There were significant associations between the ASA grade and the rates of postoperative complications and 1-year mortality (both p < 0.05). All pairwise comparisons showed significant differences in postoperative complication rates between ASA grades (all p < 0.05). All pairwise comparisons, except for grades I vs. II and grades II vs. III, also showed significant differences in mortality rates between ASA grades (all p < 0.05). There were significant associations between the preoperative ability to manage activities of daily living and the rates of postoperative complications and 1-year mortality (both p < 0.05).

CONCLUSIONS

ASA grade was significantly associated with the rates of postoperative complications and 1-year mortality in nonagenarians undergoing hip fracture surgery. The preoperative functional status was also significantly associated with these outcomes.

Functional recovery of elderly patients with surgically-treated intertrochanteric fractures: preliminary results of a randomised trial comparing the dynamic hip screw and proximal femoral nail techniques

INTRODUCTION

Intertrochanteric fractures of the femur are prevalent in the elderly, and leave patients with functional restrictions after surgical treatment. The aim of this study was to compare the functional recovery at 1-year follow-up of elderly patients with intertrochanteric fractures treated surgically with the dynamic hip screw (DHS) or proximal femoral nail (PFN) fixation techniques.

MATERIAL AND METHODS

This prospective, randomised, blinded trial included patients aged over 65 years with intertrochanteric fractures classified as AO group 31.A1 or 31.A2. The patients were allocated into one of two treatment groups: one treated with DHS and the other with PFN. Data on functional recovery were obtained using the Functional Recovery Score developed by Zuckerman for elderly patients with hip fracture. Variables were described as means and standard deviations, and the non-parametric Kolmogorov-Smirnov test was used to verify the normality of data distribution. Non-normally distributed variables were compared using the non-parametric Friedman and Mann-Whitney U tests. Data processing and analysis were carried out in SPSS 10.0. Results were deemed significant at the 5% level (p ≤ 0.05).

RESULTS

There were no significant between-group differences in age (p=0.152), sex (p=0.363), or American Society of Anaesthesiologists (ASA) score (p=0.579). Functional recovery scores in the DHS group at 3 and 6 months after surgery were significantly reduced from preoperative baseline scores (p=0.007) compared with in the PFN group. However, there were no statistically significant differences between the two groups in functional recovery scores at baseline (p=0.346) or at 3 months (p=0.880), 6 months (p=0.699), and 12 months (p=0.468) after surgery. There was no between-group difference in mortality (p=0.140).

CONCLUSION

At 1-year follow-up, functional recovery scores were similar in elderly patients treated with the DHS and PFN techniques. However, DHS-treated patients exhibited significant loss of function in the first 6 months after surgery, which did not occur in the PFN-treated group.

Outcome of surgery for unstable intertrochanteric fractures in octogenarians

This study aims to determine pre-morbid parameters as possible predictors of outcome of hip fracture in octogenarians with unstable intertrochanteric fracture treated operatively. Presence of co-morbidities, pre-injury level of ambulation, type of surgery, and period of delay in surgery were considered, and their effect on the post-operative outcome was evaluated using the Harris Hip Score. The computed probability of survival of octogenarians who had surgery was approximately 11 months. In patients with two or more co-morbidities, there is a significant effect on Harris Hip Score in terms of pain and deformity. Delay in surgery of more than two weeks significantly decreased the distance travelled at one year. The overall recovery is correlated to preinjury level of ambulation and delay in surgery. Patients with intertochanteric fracture in this age group, who have less co-morbidities and with more independent ambulation, are good candidates for timely operative treatment.

Functional outcome and mortality in nonagenarians following hip fracture surgery

INTRODUCTION

The world's population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture.

METHODS AND SUBJECTS

56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year.

RESULTS

Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery.

CONCLUSION

Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.