Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis

Goals of Care Discussions in Orthopaedic Surgery: Geriatric Hip Fractures

BACKGROUND

Due to the severity of hip fracture complications in the geriatric population, including major morbidity and mortality, it is crucial to establish treatment goals and manage expectations as a patient-centered multidisciplinary team. Goals of care (GOC) are personalized treatment programs designed to align with the individual patient's values and preferences. There is a paucity of literature on the topic of GOC discussions, especially regarding orthopaedic injuries. Therefore, this narrative review aims to provide an account of GOC discussions related to geriatric hip fractures.

METHODS

We reviewed articles published on GOC between 1978 and 2024. The articles were identified by searching PubMed and Google Scholar. We utilized the search terms GOC discussions and hip fracture, with additional descriptors including arthroplasty and geriatric.

RESULTS

There were 11 articles that met the selection criteria and were published between 1978 and 2024. Five articles were published on GOC discussions in orthopaedic surgery, while the remaining 6 articles were published in non-orthopaedic fields. There was one systematic review, 2 narrative reviews, 6 observational studies, and 2 descriptive studies. Supplemental commentary from non-orthopaedic specialties and the fields of law and medical ethics was included to assist in highlighting barriers to GOC discussions and to explore potential strategies to enhance GOC discussions.

CONCLUSIONS

Goals of care discussions provide a framework for treatment decisions based on an individual patient's values and cultural beliefs; however, these conversations may be limited by perceived time constraints, patient health care literacy, and physicians' misconceptions of what is most important to discuss. While no clear consensus was identified regarding strategies for improving GOC discussions in geriatric patients who have hip fractures, the authors recommend standardized training programs, expedited family meetings, multidisciplinary team involvement, assistive technology such as Outcome Prioritization Tool, and the incorporation of GOC discussions into institutional hip fracture pathways.

[Treatment of proximal femoral fractures : Principles, tips and tricks]

Proximal femoral fractures occur at an annual incidence of approximately 200/100,000 inhabitants and mortality rates range up to 30% especially in geriatric patients where complications are not necessarily associated to surgery. In nearly all cases surgical treatment is required. Procedures to preserve the femoral head have to be performed as early as possible (as specified by the Federal Joint Committee, GBA, within 24 h). For joint-preserving approaches in medial femoral neck fractures a time to surgery within 6 h is considered to be advantageous. Perioperative patient care is of high importance regarding the prevention of pneumonia, renal failure, delirium and further complications. Postoperatively full weight bearing enables for early mobilization and prevention of surgery-related complications. Nonunions, avascular necrosis of the femoral head, cut-out and prosthetic dislocation must be avoided by the selection of the appropriate procedure. Minimally displaced femoral neck fractures are primarily treated by osteosynthesis and conservative management is only considered in isolated cases. For displaced femoral neck fractures, factors such as a young biological age with high activity levels, the absence of arthritis and good bone quality with a successful reduction favor for a femoral head-preserving osteosynthesis. Otherwise, (hybrid) total hip replacement (THR) is the preferred method for unstable and displaced fractures, whereby hemiarthroplasty should only be considered for very old and patients with pre-existing diseases. Fractures in the trochanteric region are treated with a proximal femoral nail and subtrochanteric fractures are managed using a long proximal femoral nail. To avoid secondary complications, the choice of optimal treatment should be based on a good understanding of the injury pattern, biomechanical and technical aspects of each procedure.

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

Purpose

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

Patients and methods

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

Results

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

Conclusion

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

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study

PURPOSE

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

METHODS

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

RESULTS

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

CONCLUSION

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients

BACKGROUND AND PURPOSE

Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes.

PATIENTS AND METHODS

21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score.

RESULTS

The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group.

CONCLUSION

Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study

BACKGROUND

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries.

METHODS

We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery.

RESULTS

The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada).

CONCLUSIONS

We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Clinician perspectives on nonoperative management of hip fractures during COVID-19

Aims

To identify factors influencing clinicians' decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Methods

A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)'s Perioperative Special Interest Group and clinicians' personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests.

Results

A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making.

Conclusion

This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people.

Operative treatment of periprosthetic fractures of the proximal femur with a contralateral, upside-down LISS plate in elderly patients

BACKGROUND

Increasing expectancy of life and levels of activity in the growing geriatric population lead to a rising number of prosthetic implants of the hip and consequently the incidence of periprosthetic fractures of the femur increase. The fracture pattern and the possible instability of the stem are a challenge to the orthopaedic surgeon. Treatment options are complete replacement of the implant or a solitary osteosynthesis. The goal of this study was to analyse the feasibility of the operative intervention using a contralateral reversed anatomic distal femoral LISS® locking plate and the radiological and functional outcome in a geriatric cohort.

METHODS

We included all patients older than 75 years of age with a Vancouver type B fracture, which have been treated by osteosynthesis using a LISS® (contralateral reversed) plate in our institution in an interdisciplinary ortho-geriatric setting between 7/2013 and 12/2021. Perioperative morbidities, clinical and radiological outcome during follow-up were retrospectively analysed.

RESULTS

During the observed time period, 83 patients (mean age: 88 years (range: 76-103), male/female: 26/57) were treated. Most fractures were Vancouver type B2 (n = 45, 54%) followed by B1 (n = 20, 24%) and B3 (n = 18, 22%). The most prevalent postoperative surgical complication was anaemia (n = 73, 88%) followed by infections (n = 12, 14%, urinary infections, pneumonia) and cardiovascular decompensation (n = 8, 10%). Clinical and radiological follow up 6-8 weeks postoperative was possible for 59 patients (70%). The majority of them did not describe pain (n = 50, 85%) and had a good or excellent radiological outcome. Three cases needed revision surgery due to infection and another three due to non-union, loosening of the stem or an additional fracture. 1-year mortality was 30%.

CONCLUSION

We are convinced that the reversed contralateral LISS-plate is an easy-to-use implant with a small complication rate but a very successful and high healing rate in a geriatric, polymorbid cohort.

Disparities in the Epidemiology and Management of Fragility Hip Fractures

PURPOSE OF REVIEW

The purpose of this review is to synthesize the recently published scientific evidence on disparities in epidemiology and management of fragility hip fractures.

RECENT FINDINGS

There have been a number of investigations focusing on the presence of disparities in the epidemiology and management of fragility hip fractures. Race-, sex-, geographic-, socioeconomic-, and comorbidity-based disparities have been the primary focus of these investigations. Comparatively fewer studies have focused on why these disparities may exist and interventions to reduce disparities. There are widespread and profound disparities in the epidemiology and management of fragility hip fractures. More studies are needed to understand why these disparities exist and how they can be addressed.

Differences in age-related characteristics among elderly patients with hip fractures

BACKGROUND

Incidence of hip fracture among aging patients has been increasing annually in Japan; patients aged ≤74 years may be inappropriately classified as elderly. This study aimed to identify differences in the incidence of serious perioperative complications and in-hospital, 90-day, 6-month, and 1-year mortality rates according to three age groups among patients with hip fractures.

METHODS

Patients aged ≥65 years treated for hip fracture by our multidisciplinary treatment system were included in this study. They were divided into the pre-old age (65-74 years), old age (75-89 years), and super-old age (≥90 years) groups. The baseline characteristics and outcomes of the three groups were compared, and variables associated with in-hospital, 30-day, 6-month, and 1-year mortality were analyzed.

RESULTS

In the older population, there was a higher proportion of female participants; those with trochanteric fractures, low bone mineral density, dementia, decreased walking ability and independence in performing activities of daily living; and those not living at home. Moreover, the proportion of patients with hypertension, diabetes mellitus, and circulatory disorders, American Society of Anesthesiologists Physical Status scores, and serum albumin levels significantly differed. Further, there was a significant difference in the incidence of serious complications among males and the 6-month and 1-year mortality rates among females. In addition, female patients in the pre-old age group had a higher mortality rate at any period compared with those in the old age group.

CONCLUSIONS

Patients with hip fracture who were aged 65-74, 75-89, and ≥90 years differ in terms of baseline characteristics, incidence of complications, and mortality rates. Female patients aged<75 who had fragility hip fractures potentially had worse prognosis. Our findings may be useful in preoperative explanation, postoperative management, and prognostic prediction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The goals of care in acute setting for geriatric patients in case of a hip fracture

PURPOSE

For geriatric hip fracture patients, the decision between surgery and palliative, non-operative management is made through shared decision making (SDM). For this conversation, a physician must be familiar with the patient's goals of care (GOC). These are predominantly unknown for hip fracture patients and challenging to assess in acute setting. The objective was to explore these GOC of geriatric patients in case of a hip fracture.

METHODS

An expert panel gathered possible outcomes after a hip fracture, which were transformed into statements where participants indicated their relative importance on a 100-point scoring scale during interviews. These GOC were ranked using medians and deemed important if the median score was 90 or above. Patients were aged 70 years or older with a hip contusion due to similarities with the hip fracture population. Three cohorts based on frailty criteria and the diagnosis of dementia were made.

RESULTS

Preserving cognitive function, being with family and being with partner scored in all groups among the most important GOC. Both non-frail and frail geriatric patients scored return to pre-fracture mobility and maintaining independence among the most important GOC, where proxies of patients with a diagnosis of dementia scored not experiencing pain as the most important GOC.

CONCLUSION

All groups scored preserving cognitive function, being with family and being with partner among the most important GOC. The most important GOC should be discussed when a patient is presented with a hip fracture. Since patients preferences vary, a patient-centered assessment of the GOC remains essential.

Local Anesthesia Approach for Percutaneous Screw Fixation of an Impacted Subcapital Femoral Neck Fracture: A Technique for High-Risk Patients

Elderly, frail patients and those who have substantial medical co-morbidities who sustain hip fractures present a challenging problem for treatment as they are at very high risk for complications from surgical intervention. The functional outcomes, pain levels, and mortality rates all worsen when non-surgical treatment is used. The safety of administering general or spinal anesthesia may be a concern in certain cases. Other modalities, such as epidural or caudal anesthesia, may be an option; however, the use of local anesthesia may be advantageous for patients with non-displaced and impacted femoral neck fractures undergoing surgical intervention. We present a case report describing the successful treatment of an elderly male who had relative contraindications to spinal anesthesia and high risk for general anesthesia and was successfully treated with percutaneous screw fixation of a femoral neck fracture using local anesthesia with a light, monitored anesthetic.

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

INTRODUCTION

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

METHODS

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

DISCUSSION

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

ETHICS AND DISSEMINATION

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

ETHICS APPROVAL NUMBER

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

TRIAL STATUS

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

Evaluation of the Association between Low-Density Lipoprotein (LDL) and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 339 Patients

BACKGROUND

Many factors affect the prognosis of hip fractures in the elderly. Some studies have suggested a direct or indirect association among serum lipid levels, osteoporosis, and hip fracture risk. LDL levels were found to have a statistically significant nonlinear U-shaped relationship with hip fracture risk. However, the relationship between serum LDL levels and the prognosis of patients with hip fractures remains unclear. Therefore, in this study, we assessed the influence of serum LDL levels on patient mortality over a long-term follow-up period.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019, and their demographic and clinical characteristics were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between LDL levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

Overall, 339 patients with a mean follow-up period of 34.17 months were included in this study. Ninety-nine patients (29.20%) died due to all-cause mortality. Linear multivariate Cox regression models showed that LDL levels were associated with mortality (HR = 0.69, 95%CI: 0.53, 0.91, p = 0.0085) after adjusting for confounding factors. However, the linear association was unstable, and nonlinearity was identified. An LDL concentration of 2.31 mmol/L was defined as the inflection point for prediction. A LDL level < 2.31 mmol/L was associated with mortality (HR = 0.42, 95%CI: 0.25, 0.69, p = 0.0006), whereas LDL > 2.31 mmol/L was not a risk factor for mortality (HR = 1.06, 95%CI: 0.70, 1.63, p = 0.7722).

CONCLUSIONS

The preoperative LDL level was nonlinearly associated with mortality in elderly patients with hip fractures, and the LDL level was a risk indicator of mortality. Furthermore, 2.31 mmol/L could be considered a predictor cut-off for risk.

Conversion arthroplasty after failed extracapsular hip fracture fixation is associated with high complication rates

Background/Aim: There is no standard treatment of choice that addresses all extracapsular fractures, which account for approximately half of the elderly hip fractures. Arthroplasty is mostly favored secondary to unsuccessful fixation or unstable primary fractures. However, conversion arthroplasty complication rates are high in the literature. This study compares arthroplasty performed after unsuccessful fixation and primary arthroplasty for unstable extracapsular hip fractures. Methods: In this retrospective study, we compared the first-year results of the groups that underwent conversion arthroplasty (cHA) and the primary arthroplasties (pHA) for extracapsular hip fractures. In the cHA group, patients were indicated for operation if there was a failure of fixation after extracapsular hip fractures (n=44). In the pHA group, patients were for unstable extracapsular hip fractures (n=44). In the cHA group, failure of fixation causes were cut-out of lag screws (54.5%), cut-through of lag screws (9.1%), non-union of fractures (27.3%), and osteonecrosis of femoral heads (9.1%). While total hip replacement was applied to all patients in the cHA group, total hip replacement was applied to ten patients in the pHA group and hemiarthroplasty to 34 patients. In comparing groups, duration of operation, amount of bleeding, intraoperative complications, post-operative complications, mobilization capacities, functional status, and mortality rates were used. Results: There were 44 patients in both groups. The surgical time (134.3 [34.5)] vs. 66 [16], [P<0.001]), the amount of bleeding (1000 ml [400] vs. 300ml [200], [P<0.001]), the need for red blood cell transfusion in the operations (80% vs. 32%, [P<0.001]), and the frequency of intraoperative femur fracture (30% vs. 0%, [P<0.001]) were larger or longer in the cHA group compared to pHA group (P<0.001). While 14 complications requiring surgical intervention were observed in 12 of 44 patients in the CHA group in the post-operative 1st year, four complications were observed in four of 44 patients in the pHA group. There was no difference in mortality rates (3 vs. 3, [P =1]), mobilization capacities (5.9 [2.1] vs. 5.7 [2.0], [P=0.597]), and functional status (12.5 [3.3] vs. 13.0 [2.7], [P=0.434]) between the groups. Conclusion: Arthroplasty performed as conversion surgery after unsuccessful fixation has a higher risk of intraoperative and post-operative complications than primary arthroplasty performed after extracapsular hip fractures. We believe the cases prone to implant failure, non-union, or restricted mobilization because of the patient and fracture-type reasons should be treated with primary arthroplasty.

What are Risk Factors of Postoperative Pneumonia in Geriatric Individuals after Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Postoperative pneumonia (POP) is a common postoperative complication. Negative consequences associated with POP included prolonged hospital length of stay, more frequent intensive care unit (ICU) stays, and a higher rate of sepsis, readmission, and mortality. This meta-analysis aimed to assess the incidence and risk factors associated with POP after hip fracture surgery in elderly patients. PubMed, Web of Science, and Cochrane Library were searched (up to March 31, 2022). All studies on the risk factors for POP after hip fracture surgery in elderly patients, published in English, were reviewed. The qualities of the included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled, and a meta-analysis was performed. Ten studies, including 12,084 geriatric patients undergoing hip fracture surgery, were included. Of these 12,084 patients, POP occurred in 809 patients. The results indicated that age (mean difference [MD] = 4.95, 95% confidence interval [CI]: 3.22-6.69), male (odds ratio [OR] = 1.41, 95% CI: 1.02-1.93), the American Society of Anaesthesiologists classification ≥3 (OR = 3.48, 95% CI: 1.87-6.47), dependent functional status (OR = 5.23, 95% CI: 2.18-12.54, P = 0.0002), smoking (OR = 1.33, 95% CI: 1.07-1.65), chronic obstructive pulmonary disease (OR = 3.76, 95% CI: 2.07-6.81), diabetes mellitus (OR = 1.19, 95% CI: 1.01-1.40), coronary heart disease (OR = 1.74, 95% CI: 1.23-2.46), arrhythmia (OR = 1.47, 95% CI: 1.01-2.14), cerebrovascular disease (OR = 1.88, 95% CI: 1.56-2.27), dementia (OR = 2.36, 95% CI: 1.04-5.36), chronic renal failure (OR = 1.85, 95% CI: 1.29-2.67), hip arthroplasty (OR = 1.30, 95% CI: 1.08-1.56), delayed surgery (OR = 6.40, 95% CI: 3.00-13.68), preoperative creatinine (MD = 5.32, 95% CI: 0.55-10.08), and preoperative serum albumin (MD = -3.01, 95% CI: -4.21 - -1.80) were risk factors for POP. Related prophylactic measures should be provided in geriatric patients with the above-mentioned risk factors to prevent POP after hip fracture surgery.

Mobility and mortality outcomes among older individuals with hip fractures at a teaching hospital in Malaysia

The challenges of hip fracture care in Malaysia is scarcely discussed. This study evaluated the outcomes of older patients with hip fracture admitted to a teaching hospital in Malaysia. We found that one in five individuals was no longer alive at one year after surgery. Three out of five patients did not recover to their pre-fracture mobility status 6 months following hip fracture surgery.

PURPOSE

With the rising number of older people in Malaysia, it is envisaged that the number of fragility hip fractures would also increase. The objective of this study was to determine patient characteristics and long-term outcomes of hip fracture in older individuals at a teaching hospital in Malaysia.

METHODS

This was a prospective observational study which included consecutive patients aged  ≥ 65 years old admitted to the orthopedic ward with acute hip fractures between March 2016 and August 2018. Patient socio-demographic details, comorbidities, pre-fracture mobility status, fracture type, operation and anesthesia procedure, and length of stay were recorded. Post-fracture mobility status was identified at 6 months. Cox proportional hazard analysis was used to assess the risk of death in all patients.

RESULTS

310 patients (70% women) with the mean age of 79.89 years (SD 7.24) were recruited during the study period. Of these, 284 patients (91.6%) underwent surgical intervention with a median time to surgery of 5 days (IQR 3-8) days. 60.4% of patients who underwent hip fracture surgery did not recover to their pre-fracture mobility status. One year mortality rate was 20.1% post hip fracture surgery. The independent predictor of mortality included advanced age (hazard ratio, HR = 1.05, 95% CI = 1.01-1.08; p = 0.01), dependency on activities of daily living (HR = 2.08, 95% CI = 1.26-3.45; p = 0.01), and longer length of hospitalization (HR = 1.02, 95% CI = 1.01-1.04; p < 0.01).

CONCLUSION

One in 5 individuals who underwent hip fracture surgery at a teaching hospital in Kuala Lumpur was no longer alive at one year. A systematic approach to hip fracture management is crucial to improve outcomes and restore pre-fracture function of this vulnerable group of patients.

Creative bracing: A descriptive overview of an alternative technique for non-operative fracture management of frail older adults

As the world population ages, a higher proportion of older and frailer patients will sustain fragility fractures. Considering their depleted physiologic reserve and potentially different goals of care at their stage in life, these patients; especially those enrolled in hospice care, with profound dementia, or at end-of-life care; may not benefit from traditional surgical methods of fracture care. Non-operative treatment using standard immobilization or casting techniques in older and frailer patients can still render them susceptible to complications and adverse events. Here we describe our alternative non-operative treatment method of creative bracing to address the needs of this specific population. Creative bracing can be done with simple supplies available in almost all healthcare settings. Through patient-specific pre-treatment assessment, a creative brace tailored to the patient's risk factors and goals of care can be designed to provide sufficient fracture immobilization and comfort. Creative bracing is a low-cost, low-technical demand modality for non-operative treatment of some fragility fractures. Its benefit can be appreciated to greatest effect in the frailest patients for whom standard, surgical treatment does not represent best care.

Impact of sarcopenia on intertrochanteric femoral fracture in the elderly

Objective

The aim of this study was to investigate the effect of skeletal sarcopenia on the prognosis of intertrochanteric fracture in the elderly.

Methods

We collected information on 144 patients with femoral intertrochanteric fracture (FIF). The influence of sarcopenia on the chance of death was determined using binary Probit regression analysis. For additional analysis, the Chow test was utilized to select the best distinguishing node in the instrumental activities of daily living (IADL) score. We looked for characteristics that were linked to a higher probability of death and a poor IADL outcome within 1 year. The data collected above were analyzed using logistic regression analysis. The internal calibration degree and model validity were assessed by GiViTI calibration.

Results

Sarcopenia, EuroQol-5D 1 month score, age, gender, and hypertension were identified as risk factors for death in older patients with FIF within a year by logistic regression analysis. Sarcopenia, psychotropics, BMI, and length of hospital stay were all found to be risk factors for poor IADL outcomes (P < 0.1). The calibration curves indicated that the anticipated and actual probabilities of these two models were very close. The study's reliability coefficient was 0.671, showing a satisfactory level of reliability.

Conclusion

In elderly patients with FIF, sarcopenia, EuroQol-5D score, age, gender, and hypertension were risk factors for death; sarcopenia, hospital stay length, BMI were risk factors for poor quality of life.

A Comparative Study of Hip Arthroplasty and Closed Reduction Proximal Femur Nail in the Treatment of Elderly Patients with Hip Fractures

Objective

To compare the clinical effect of hip arthroplasty and closed reduction intramedullary nailing of proximal femur in the treatment of elderly hip fracture patients.

Methods

There are 90 elderly hip fracture patients being recruited in the present study. Fifty patients in Group A received closed reduction intramedullary nailing of proximal femur, and 40 patients in Group B received hip arthroplasty. All patients were followed up for 12 months after surgery, clinical outcomes included surgical indicators, visual analog scale (VAS) score, Harris score, quality of life, mental status, and complications.

Results

The surgery time, bleeding volume, infusion volume of patients in Group A are all significantly lower than those in Group B (p < 0.05), while the weight-bearing activity time and first workout time of Group A are all significantly higher than those in Group B (p < 0.05). The VAS score in patients of Group A at 1 week postoperative is significantly lower than that in patients of Group B (p < 0.05). The Harris score in patients of Group A at 3, 6, and 12 months postoperative are all significantly higher than those in patients of Group B (p < 0.05), and the excellent and good rate of hip function recovery at 12 months postoperative in patient of Group A is significantly lower than that in patients of Group B (80% vs. 95%, p < 0.05). Furthermore, The score of SF-36 standardized physical component, SF-36 standardized mental component and Barthel in patients of Group A at 6 months postoperative are significantly lower than those in patients of Group B (p < 0.05), and the score of mini-mental state examination is significantly higher (p < 0.05), while there are not significantly different at 12 months postoperative (p > 0.05). The incidence of postoperative complications in Group A was significantly lower than that in Group B (10% vs. 27.5%, p < 0.05).

Conclusion

Elderly hip fracture patients treated with closed reduction intramedullary nailing of proximal femur has less surgical trauma and lower complication rates, but slower postoperative recovery compared with hip arthroplasty.

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

Importance

Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population.

Objective

To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy.

Design, Setting, and Participants

This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2).

Exposures

Shared decision-making (SDM) followed by nonoperative or operative fracture management.

Main Outcomes and Measures

The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire).

Results

Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8.

Conclusions and Relevance

Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

Determinants of Higher Mortality at Six Months in Patients with Hip Fracture: A Retrospective Study

(1) Background: Hip fracture is a pathology with high mortality, but the lack of a universal adaptation of the factors associated with death makes it difficult to predict risk and implement prevention in this group. This study aimed to identify the factors that determine a higher mortality at six months following hip fracture. (2) Methods: A retrospective longitudinal study, whose study population consisted of patients over 65 years of age. The main variable was mortality at 6 months of fracture. Relevant data related to sociodemographic and clinical variables for subsequent bivariate (χ²) and multivariate analysis were obtained. (3) Results: In all, 665 people participated in the study, 128 of whom died within 6 months of the fracture. The multivariate adjusted analysis demonstrated significant relationships between the main variable and aspects such as institutionalization at discharge (Odds Ratio (OR) = 2.501), a worse overall functional capacity (OR = 2.453) and cognitive capacity (OR = 3.040) at admission, and complications such as heart failure (OR = 5.767) or respiratory infection (OR = 5.308), in addition to the taking of certain drugs and the presence of a greater number of comorbidities. (4) Conclusions: There are certain factors related to higher mortality at six months in patients with hip fracture who are aged 65 years or older.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Risk factors and new diagnostic index for deep venous thrombosis of lower extremities in elderly patients with traumatic femoral neck fracture

Purpose

To determine the incidence and risk factors of deep vein thrombosis (DVT) of lower extremities at admission in elderly Chinese patients with femoral neck fracture, and to establish and evaluate a new DVT predictor based on these risk factors.

Methods

Patients who were hospitalized from January 2018 to December 2020 at three independent centers were reviewed. According to the results of lower extremities vascular ultrasound at admission, they were divided into DVT group and non-DVT group. Single and multivariate logistic regression analysis were applied to identify independent risk factors for DVT occurrence, and then a prediction formula for DVT based on the risk factors was developed. The new predictive index of DVT was calculated by the formula. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic value of different factors and the new predictive index.

Results

There were 203 elder patients were included in the final analysis after application of the exclusion criteria. Thirty seven patients (18.2%) were diagnosed as DVT by ultrasound, including 33 patients (89.2%) of peripheral type, 1 patient (2.7%) of central type and 3 patients (8.1%) of mixed type.Multivariate logistic regression analysis showed that four factors including injured side, hemoglobin, fibrinogen, d-dimer were the independent risk factors for the incidence of DVT. On this basis, a new formula for DVT predictive factor was constructed: New predictive index = 0.895 * injured side (right = 1, left = 0) + 0.899 * hemoglobin (<109.5 g/L = 1, > 109.5 g/L = 0) + 1.19 * fibrinogen (>4.24 g/L = 1, < 4.24 g/L = 0) + 1.221* d-dimer (>2.4 mg/L = 1, < 2.4 mg/L = 0). The AUC value of this new developed index was 0.735.

Conclusions

This work showed that the incidence of DVT in elderly patients with femoral neck fracture in China was high at admission. New DVT predictive value can be used as an effective diagnosis strategy for evaluation of thrombosis at admission.

Association between Neutrophil Levels on Admission and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 2,589 Patients

OBJECTIVE

To evaluate the association between neutrophil levels and all-cause mortality in geriatric hip fractures.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019. Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between neutrophil levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

A total of 2,589 patients were included in this study. The mean follow-up period was 38.95 months. During the study period, 875 (33.80%) patients died due to various causes. Linear multivariate Cox regression models showed that neutrophil levels were associated with mortality after adjusting for confounding factors, when neutrophil concentration increased by 1∗10⁹/L, the mortality risk increased by 3% (HR = 1.03, 95% CI: 1.00-1.06, and P=0210). Neutrophil concentration was used as a categorical variable; we only found statistically significant differences when neutrophil levels were high (HR = 1.27, 95% CI:1.05-1.52, and P=0.0122). In addition, the results are stable in P for trend and propensity score matching sensitivity analysis.

CONCLUSIONS

Neutrophil levels are associated with mortality in geriatric hip fractures and could be considered a predictor of death risk in the long-term. This study is registered with the Chinese Clinical Trial Registry (ChiCTR) as number ChiCTR2200057323.

Influence of comorbidity on postoperative course and mortality in patients with hip fracture

Introduction/Objective. Epidemiological research shows that we have a dramatic increase in the number of people with hip fractures, especially those over 65 years of age. The main objectives of this study are to assess the association between preoperative comorbidity and the risk of postoperative complications and mortality and postoperative worsening of comorbid conditions and their relationship to mortality within one year of hip fracture surgery. Methods. In the period from January 2018. until January 2020. in a retrospective study, at the Department of Orthopedic Surgery in Kosovska Mitrovica, we operated 64 patients with hip fractures. We monitored the number of comorbidities and their significance on the preoperative risk and the course of concomitant diseases in the postoperative period and one - year mortality from surgery, in patients with hip fractures. Results. We collected data on patients from the moment of admission to discharge from the hospital accompanied by medical histories, and after discharge after follow-up examinations, six months and one year from discharge. Of the total number of subjects, 23 (35.9%) had one or two comorbidities, most often of cardiac and neurological nature, in 25 patients (39.1%) we had three concomitant diseases, and in 11 (17.2%) four and more comorbidities. The mean age of the patients was 72.51 years (69-92 years). Conclusion. Approximately 45-60% of men and women who suffer a hip fracture have three or more comorbid states. In older people with hip fractures, the presence of three or more comorbidities is the strongest preoperative risk factor.

Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning

Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.

X-Ray Film under Artificial Intelligence Algorithm in the Evaluation for Nursing Effect of Gamma Nail Internal Fixation in Elderly Patients with Intertrochanteric Fracture of Femur

The aim of this work was to explore the effects of Gamma nail internal fixation for intertrochanteric fracture of femur by X-ray film classification and recognition method based on artificial intelligence algorithm. The study subjects were 100 elderly patients with intertrochanteric fracture of femur admitted to hospital. The cases were diagnosed as elderly (over 60 years old) femoral intertrochanteric fractures by X-ray or CT. They were divided into two groups, with 50 persons in each group: one group used the X-ray film evaluation image guidance based on the artificial intelligence algorithm (research group), and the other group did not use algorithmic guidance (control group). The results showed that the segmentation effect of the proposed algorithm was similar to the gold standard segmentation result, indicating that the algorithm was effective and feasible in the segmentation of fractures and bones. The global level set algorithm was set as the control. The ultimate measurement accuracy (UMA) value of the algorithm group was (1.77 ± 0.22), and the UMA value of the global level set algorithm group was (3.42 ± 0.36), indicating that the image processed by the algorithm group had obvious numerical effect, high accuracy, and good retention of details. The operation time, intraoperative blood loss, incision length, hospital stay, weight-bearing time, and fracture healing time of the two groups were all better than those of the control group. One month after surgery, the Harris score of the algorithm group was 67, and that of the control group was 51, with a 16-point difference between the two groups (p < 0.05). The patient had less pain and fast recovery speed, indicating that it was a good way to treat elderly intertrochanteric fractures with the nursing effect of X-ray Gamma nail internal fixation based on an artificial intelligence algorithm. The artificial intelligence algorithm not only can be applied to the Gamma nail internal fixation of elderly patients with intertrochanteric fractures but also can be applied to the X-ray image processing of other fractures and other surgical methods to provide effective treatment for fracture patients.

Prevalence, Characteristics, and Associated Risk Factors of the Elderly with Hip Fractures: A Cross-Sectional Analysis of NHANES 2005-2010

Objective

This cross-sectional study was aimed to update the assessment of prevalence, characteristics, and risk factors of the elderly with hip fractures in a non-institutionalized American population.

Methods

This current study included a total of 31,034 participants from the existing National Health and Nutritional Examination Survey (NHANES) database from 2005 to 2010, and 4,265 participants aged 65 years and older were ultimately identified. Their condition of hip fractures was determined by method of questionnaires according to the orthopedic surgeons' diagnosis, and related epidemiological and demographic data were further collected. The univariate analysis was used to screen the risk factors of hip fractures in the elderly, and the logistic regression model was established to conduct the multivariate analysis.

Results

Of the total 4,265 participants with clear information of hip fractures in elderly, 127 individuals with hip fractures were identified according to results of questionnaires, exhibiting a prevalence of 28.49 per 1,000 (95% confidence interval [CI]=21.38-35.60) for males and 31.03 per 1,000 (95% CI=23.72-38.35) for females. The mean age of the elderly with hip fractures was 77.12±5.88 years and tumble (48.0%) was the primary factor. In univariate analysis, age, race, smoking, drinking alcohol, and combined with osteoporosis were regarded as risk factors. Multivariate analysis showed that age (80 years and older), living alone, smoking, combined with diabetes and osteoporosis were the independent risk factors.

Conclusion

Our nationwide data indicate the prevalence of hip fractures in the elderly is generally on the rise, and the female occupies a higher proportion. Age (especially aged 80 years and older), race (mainly Non-Hispanic white), smoking, drinking alcohol, living alone, combined with diabetes and osteoporosis may be closely linked to the occurrence of hip fractures in the elderly, although these variables still need to be verified in further prospective investigations.