Team Approach: Multidisciplinary Treatment of Hip Fractures in Elderly Patients

A retrospective chart analysis with 5-year follow-up of early care for geriatric hip fracture patients: why we should continue talking about hip fractures

BACKGROUND

Timing of surgery remains a topic of debate for hip fracture treatment in the geriatric patient population. The quality indicator "early surgery" was implemented in 2014 at the Department of Trauma Surgery of the University Hospitals Leuven to enhance timely operative treatment. In this follow-up study, we aim to evaluate the performance of this quality indicator, the clinical outcomes, and room for improvement.

METHODS

The charts of 1190 patients surgically treated for an acute hip fracture were reviewed between June 2017 and May 2022 at the University Hospitals Leuven. Primary endpoints were adherence to early surgery, defined as surgery within the next calendar day, and the evaluation of the reasons for deviating from this protocol. Secondary endpoints were length of stay (LOS); intensive care unit (ICU) admission and length of ICU stay; mortality after 30 days, 60 days, 90 days, and 6 months; and 90-day readmission rate. Pearson's Chi-square test and Mann-Whitney U test were used for data analysis.

RESULTS

One thousand eighty-four (91.1%) patients received early surgery versus 106 (8.9%) patients who received delayed surgery. The main reasons for surgical delay were the use of anticoagulants (33%), a general health condition not allowing safe surgery and/or existing comorbidities requiring workup prior to surgery (26.4%), and logistical reasons (17.9%). Patient delay and transfer from other hospitals were responsible for respectively 8.5% and 6.6% of delayed surgery. Early surgery resulted in a significantly shorter LOS and ICU stay (12 [8-25] vs. 18 [10-36] and 3 [2-6] vs. 7 [3-13] days, early vs. delayed surgery, respectively). No significant reduction was observed in ICU admission, mortality, and readmission rate.

CONCLUSION

We have been able to maintain the early surgery hip fracture protocol in approximately 90% of the patients. Comorbidities and anticoagulant use were responsible for delayed surgery in the majority of the patients. Correct implementation of the existing protocol on anticoagulant use could lead to a one-third decrease in the number of delayed surgeries. Subsequently, since the LOS and ICU stay in the delayed surgery group were significantly longer, a further increase of early surgery will lower the current economic burden.

Patients Aged 80 or More With Distal Radius Fractures Have a Lower One-Year Mortality Rate Than Age- and Gender-Matched Controls: A Register-Based Study

Introduction

With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.

Material and Methods

Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.

Results

The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients' ability to live independently in their own home had the highest impact on survival.

Discussion

The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.

Conclusions

The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level.

Postfracture survival in a population-based study of adults aged ≥66 yr: a call to action at hospital discharge

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50 yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66 yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6 yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85 yr, 51.9%-63.9%; ≥86 yr, 34.5%), followed by vertebral fractures in males (66-85 yr, 53.2%-69.4%; ≥86 yr, 35.5%), and hip fractures in females (66-85 yr, 69.8%-79.0%; ≥86 yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86 yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.

Identification of concomitant injuries associated with specific spine level fractures in polytrauma patients

INTRODUCTION

Spine fractures are associated with high energy mechanisms and can lead to substantial morbidity and mortality in the trauma setting. Rapid identification and treatment of these fractures and their associated injuries are paramount in preventing adverse outcomes. The purpose of this study is to identify concomitant skeletal and non-skeletal injuries related to cervical, thoracic, and lumbar fractures.

METHODS

A retrospective review of institutional American College of Surgeons (ACS) registry was conducted on 3,399 consecutive trauma patients identifying those with spine fractures from 1/2016-12/2019. Two-hundred ninety patients were included(8.5%) and separated into three groups based on fracture location: eighty-eight cervical(C)-spine, 129thoracic(T)-spine, and 143lumbar(L)-spine. Logistic regression analyses were performed to identify associated injuries, presenting injury severity score(ISS) and Glasgow coma scale(GCS), mechanism of injury, demographic data, substance use, and paralysis for each group. Cox hazard regression was utilized to identify factors associated with inpatient mortality.

RESULTS

C-spine fractures were associated with head trauma(OR2.18,p = 0.003),intracranial bleeding (OR2.64,p = 0.001),facial(OR2.25,p = 0.02) and skull fractures(OR3.92,p = 0.001),and cervical cord injuries(OR4.78,p = 0.012). T-spine fractures were associated with rib fractures(OR2.31,p = 0.003). L-spine fractures were associated with rib(OR1.77, p = 0.04), pelvic(OR5.11,p<0.001), tibia/fibula (OR2.31,p = 0.05), and foot/ankle fractures(OR3.32,p = 0.04), thoracic(OR2.43,p = 0.008) and retroperitoneal cavity visceral injuries(OR27.3,p = 0.001). Falls≤6meters were also significantly associated with C-spine fractures(OR1.70,p = 0.04) while falls>6meters were associated with L-spine fractures(OR4.30,p = 0.001). Inpatient mortality risk increased in patients with C-spine fractures(HR4.41,p = 0.002), higher ISS(HR1.05, p<0.001), and lower GCS(HR0.85,p<0.001). Last, patients≥65-years-old were more likely to experience C-spine fractures(OR1.88,p = 0.03).

CONCLUSION

Patients who experience fractures of the cervical, thoracic, or lumbar spine are at risk for additional fractures, visceral injury, and/or death. Awareness of the associations between spinal fractures and other injuries can increase diagnostic efficacy, improve patient care, and provide valuable prognostic information. These associations highlight the importance of effective and timely communication and multidisciplinary collaboration.

Preoperative simplified geriatric assessment in planned hip and knee arthroplasty

INTRODUCTION

Hip and knee arthroplasties are the most common planned orthopedic surgical procedures in older persons. It would be useful to identify frailties before surgery to improve the outcome of older patients.

PURPOSE

The objective of this work was to identify the criteria of a simplified comprehensive geriatric assessment (mini-CGA) that were associated with unplanned hospital readmission and postoperative complications within 3 months after the planned hip and/or knee arthroplasty in patients ≥ 65 years.

METHODS

This prospective study was carried out in the orthopedic department of Marseille University Hospital from January to May 2019. A mini-CGA was performed preoperatively.

RESULTS

One hundred four patients were included in the study. The rate of early readmission within 3 months after surgery was 12.5% and the rate of postoperative complications was 40.4%. In multivariate analysis, dependence in the activities of daily living (ADL ≤ 5) was the only factor associated with unplanned readmission (aOR = 9.9, 95% CI 1.9-50.8), and living alone was the only factor associated with postoperative complications (aOR = 3.2, 95% CI 1.2-8.8).

CONCLUSIONS

We found that the ADL score was associated with the risk of unplanned readmission in older patients undergoing planned arthroplasty, and that living alone was associated with postoperative complications. A preoperative mini-CGA appears essential to limit postoperative morbidity.