Epidemiology and outcome after hip fracture in the under 65s-evidence from the Scottish Hip Fracture Audit

AIM: To report the epidemiology and outcomes after hip fractures in the patients under 65 years of age. PATIENTS AND METHODS: We performed a prospective, multi-centre observational study using the Scottish Hip Fracture Audit Database. Case-mix, process and outcome data was collected by dedicated coordinators on site at the time of admission, at 120 days after the injury and on any re-operations within 12 months. The study cohort consisted of 1896 individuals aged 50-64 years. Patient variables and outcomes were compared to a control group of 15,461 individuals aged 75-89 years of age. The control group consisted of three modal 5-year age groups centred about a median age of 83 years, equal to the database value, excluding the effects of the extreme elderly who may act as confounders. Outcomes measures included 30- and 120-day mortality, length of hospital stay, place of residence and ambulatory status. A multivariate logistic regression model was used to compare outcome between groups while controlling for significant case-mix variables. RESULTS: Patients in the study cohort presented with lower ASA scores and were more likely to be independently mobile and live in their own home at the time of fracture (p<0.001). Pathological fractures were more common in younger patients and accounted for more than 1 in 20 fractures. Mortality at 30 and 120 days was significantly lower (p<0.0001) in the study cohort, however it was increased compared to age and gender adjusted mortality rates for the general population (p<0.001) Younger patients were more likely to recover independent mobility and living. CONCLUSION: Patients aged 50-64 years have significantly better outcome measures after surgery for hip fracture in terms of survival and function. Such differences exist even after controlling for differences in patient case-mix variables.     

Influence of coincident distal radius fracture in patients with hip fracture: single-centre series and meta-analysis

BackgroundHip and wrist fractures are the most common orthopaedic injuries. Combined hip and distal radius fractures are an important clinical and public health problem, since mobilisation and rehabilitation is challenging and likely to be prolonged in this setting. Few studies have explored the influence of an associated wrist fracture in patients with hip fracture. We present the largest series of patients with concomitant hip and wrist fractures. We perform the first meta-analysis of the literature on patients with concurrent hip and wrist fractures.ResultsPatients with the combined fracture were of a similar age compared to those with isolated hip fracture. There were a significantly higher proportion of women in the cohort with both hip and wrist fractures (female:male ratio of 9:1 versus 4:1 p < 0.0001). The combination fracture group had a greater length of hospitalisation (18 vs 13 days p < 0.0001). The survivorship of both groups was not significantly different even after adjustment for age and gender. Meta-analysis of the literature showed female preponderance, increased length of stay but no significant difference in survival in patients with concomitant hip and wrist fractures.ConclusionThe combination fracture occurs much more commonly in women and patients require a greater length of hospitalisation. The patients who sustained simultaneous hip and wrist fractures experienced no statistically significant difference in survivorship when compared to those who suffer isolated hip fractures. This is not withstanding the presence of two fractures. This difference in mortality did not reach statistical significance.

Level of evidence

Level III (retrospective comparative study).     

Re-admission to Level 2 unit after hip-fracture surgery – Risk factors,reasons and outcome

Introduction

Hip fractures are common geriatric fractures with increasing incidence. Treatment of these fractures is still associated with high rates of complications and poor outcome. Data concerning unexpected re-admission to a Level 2 unit after an initial inconspicuous postoperative course are limited. We aimed to identify causes and associated risk factors for admission as well as impact of re-admission on acute care and short-term outcome.

Patients and methods

Patients over 60 years of age with hip fractures were included in this prospective single-centre observational study. Patients with polytrauma or malignancy-associated fractures were excluded. Age, gender, fracture type, pre-fracture residential, physical and cognitive status, recording to the American Society of Anesthesiologists (ASA) score, Barthel Index (BI) and Mini-Mental State Examination (MMSE) were recorded on admission. Date, type of surgery and operation time were evaluated. Postoperatively, the prevalence of and reasons for unexpected re-admission to the Level 2 unit and patients’ outcome were measured. Parameters were hospital mortality, BI at discharge, length of stay in hospital and type of discharge. Univariate and multivariate analyses were performed to identify risk factors for admission to the Level 2 unit and influence on patients’ outcome.

Results

Out of 402 included patients, 48 (12%) were re-admitted to the Level 2 unit. The most frequent reasons were non-surgical (n = 38), such as respiratory failure (n = 12), cardiovascular diseases (n = 8) and acute renal failure (n = 5). Ten patients were re-admitted due to a revision surgery of the hip. We identified two independent risk factors for readmission: male gender (odds ratio (OR) = 2.38, confidence interval (95% CI) = 1.10–5.15, p = 0.027) and type of fracture, especially femoral neck fracture (OR = 7.40, 95% CI = 2.39–23.26, p = 0.001). Patients who were re-admitted to the Level 2 unit had a higher mortality (β = 2.09, OR = 8.07, 95% CI = 2.44–26.75, p = 0.001), an increase in hospital stay (β = 7.0, 95% CI 5.2–8.7, p < 0.001) and a lower functional outcome (BI, β = –17, 95% CI = −23 to −10, p < 0.001).

Conclusion

Unexpected admission to the Level 2 unit in the post-surgical period is a frequent phenomenon in geriatric hip-fracture patients. Males and femoral neck fracture patients seem to be especially endangered. Although the majority of reasons for admissions were not immediately life-threatening illnesses, they had a substantial negative impact on patients’ outcome. This emphasises the importance of careful handling of this frail patient population.     

Plasma concentrations of pro- and anti-inflammatory cytokines and outcome prediction in elderly hip fracture patients

Background

Hip fractures, particularly intertrochanteric fractures, frequently occur in the elderly, and they are associated with a high incidence of complications and mortality. The development of markers is essential to allow for adjustments to treatment strategies in patients, as it remains unclear why some patients endure organ failure and others do not under seemingly similar clinical conditions.

Objective

Our objective was to determine the kinetics of tumour necrosis factor (TNF)-a, interleukin (IL)-6 and IL-10 during the hospitalisation of patients and to examine the relationship of these parameters to outcome (mortality and complications) 6 months and 12 months postoperatively.

Methods and subjects

A total of 127 elderly patients, who underwent hip fracture surgery, were prospectively followed up for 12 months, and 60 healthy elderly volunteers were enrolled in the control group to examine the effects of trauma and surgery on the inflammatory response. The epidemiological characteristics, chronic medical conditions and type of operation and anaesthetic were recorded. Cognition was evaluated using the Mini-Mental State Examination, and TNF-a, IL-6 and IL-10 levels were assessed during admission and preoperatively (post-anaesthesia) as well as 1 h, 1 day, 3 days and 5 days postoperatively. During the follow-up period, serious complications and mortality within 1 year were evaluated.

Results

Overall, 96 patients survived, and 31 died within the 6-month postoperative period; 43 patients died, and 84 survived when examining the 12-month postoperative period. There were significant within-subject effects of time on TNF-a, IL-6 and IL-10 (P < 0.001, P < 0.001 and P < 0.001). The above three cytokines were all significantly increased in the hip fracture patients compared with the control group. There were also differences in the kinetic patterns of all three parameters when the patients who died were compared with those who survived during the 6-month and 12-month postoperative periods. Multiple logistic regression analysis showed that TNF-a at 1 day (odds ratio (OR) = 1.020, P = 0.045) and 3 days (OR = 1.034, P = 0.037) postoperatively and IL-6 at 1 day (OR = 1.048, P = 0.000) postoperatively were independent predictors of mortality at 6 months; IL-6 (OR = 1.019, P = 0.025) and IL-10 (OR = 1.018, P = 0.042) at 1 day postoperatively were independent predictors of mortality at 1 year. The analysis of the receiver operating characteristics curve (ROC) showed that only IL-6 or IL-10 had the highest values for the area under the curve for mortality at 6 months and 12 months. Of the 84 patients who survived, 23 patients had 32 complications. The most common complication was pneumonia infection (11/84, 13%). TNF-a, IL-6 and IL-10 kinetics were found to differ in patients with complications compared to those without complications and in patients with infections compared with patients without complications. Multiple logistic regression analysis showed that IL-6 (OR = 1.081, P = 0.000) at 1 day postoperatively was an independent outcome predictor.

Conclusion

In elderly hip fracture patients, cytokine concentrations (TNF-a, IL-6 and IL-10) represented independent outcome predictors for adverse postoperative outcomes (mortality and complications). The inflammatory response played an important role in postoperative organ dysfunction in elderly hip fracture patients, and further study is needed to define whether decreasing the inflammatory response through cytokine antibodies or damage control strategies would decrease mortality and complication following hip fracture.     

Perioperative mortality for patients with a hip fracture

IntroductionStudies on mortality following hip fracture surgery have hitherto focused on the 30 day to 1 year period and beyond. This study focuses on the immediate perioperative period. It examines mortality rates, patient characteristics, operative details and post-operative complications.Patients and methodsA retrospective study of a hip fracture database in a large District General Hospital in the United Kingdom, from 1986 to 2015. A dataset of 9393 patients was identified, including patients undergoing surgery for curative and palliative purposes, over fifteen years of age and with no upper age limit imposed. It compared patients who survived the first 48 h from start of surgery with those who died within this perioperative period.Results9393 patients were treated surgically and included within this study, with a mean age of 80.13 and consisting of 7130 female and 2263 male patients. The all cause mortality within 48 h from start of surgery was 0.8% (72 patients). Increased risk of perioperative mortality was associated with increasing age, ASA grade 3 and above, in-hospital falls, impaired mobility prior to the fall and a reduced mental test score on admission. For the patient with a perioperative death, the most common circumstances identified in this study involved being found dead in bed by attending staff within 48 h of surgery.DiscussionThere has been significant attention paid to the optimization of patient management leading up to hip fracture surgery and its attendant impact on medium and longer term survival. The information from this study may be used to identify patients most at risk of death in the 48 h after surgery. The importance of this dataset is that it provides large numbers, which are needed in order to look for associations, given the low 48 h mortality rate found.ConclusionWe are unable to highlight any correctable or alterable factors associated with mortality. Further studies with detailed collection of data on a national scale may be needed to assess the impact of levels of postoperative care for hip fracture patients and perioperative mortality.     

Functional outcome and survival after hip fracture in elderly: a prospective study of 106 consecutive patients

Abstract Hip fracture is one of the most common, costly, and devastating injuries suffered by elderly. We prospectively analysed the recovery of hip fracture patients in an area of 92 500 inhabitants comprising six municipalities (A-F). Ambulation, functional capacity and survival of 106 consecutive hip fracture patients whose mean age was 79 years (SD=10) were followed for one year. Functional capacity was measured at two weeks, four months and twelve months postoperatively. Locomotor ability was evaluated pre- and postoperatively. Life table method was used in survival analysis. There was a significant decrease in the mean functional capacity of the patients at twelve months compared to the situation prior to the fracture (p=0.001). Prior to the fracture, 59% of the patients were moving without any assistive devices, but one year after fracture only 19% were able to do this. Similarly, not one of the patients was confined to bed before the fracture, but 11% of those who were alive after one year had become bed-ridden (p<0.001). Overall mortality rate was 32%. Age <80 years (OR=7.3; 95% CI, 2.3–23.1), residence in municipalities A and B (OR=4.2; 95% CI, 1.4–12.4 ) and ASA classes 1–3 (OR=5.2; 95% CI, 1.8–15.4) were positive factors for one-year survival. Patients from municipalities A and B (49% of all patients) whose post-acute care was given in the same rehabilitation department of one hospital recovered best. The locomotor ability of the patients decreased significantly in the first postoperative year. It seems that the centralisation of post-acute rehabilitation improves the functional outcome of these patients.     

Epidemiology and social costs of hip fracture

Hip fracture is an important and debilitating condition in older people, particularly in women. The epidemiological data varies between countries, but it is globally estimated that hip fractures will affect around 18% of women and 6% of men. Although the age-standardised incidence is gradually falling in many countries, this is far outweighed by the ageing of the population. Thus, the global number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. The direct costs associated with this condition are enormous since it requires a long period of hospitalisation and subsequent rehabilitation. Furthermore, hip fracture is associated with the development of other negative consequences, such as disability, depression, and cardiovascular diseases, with additional costs for society.In this review, we show the most recent epidemiological data regarding hip fracture, indicating the well-known risk factors and conditions that seem relevant for determining this condition. A specific part is dedicated to the social costs due to hip fracture. Although the costs of hip fracture are probably comparable to other common diseases with a high hospitalisation rate (e.g. cardiovascular disease), the other social costs (due to onset of new co-morbidities, sarcopenia, poor quality of life, disability and mortality) are probably greater.     

An estimate of the worldwide prevalence,mortality and disability associated with hip fracture

The aim of this study was to quantify the global burden of osteoporosis as judged by hip fracture and the burden in different socio-economic regions of the world. The population mortality in 1990 and the incidence of hip fracture in different regions were identified, where possible in 1990. Excess mortality from hip fracture used data for Sweden, and disability weights were assigned to survivors from hip fracture. In 1990 there were an estimated 1.31 million new hip fractures, and the prevalence of hip fractures with disability was 4.48 million. There were 740,000 deaths estimated to be associated with hip fracture. There were 1.75 million disability adjusted life-years lost, representing 0.1% of the global burden of disease world-wide and 1.4% of the burden amongst women from the established market economies. We conclude that hip fracture is a significant cause of morbidity and mortality worldwide.     

Utilization of inpatient care before and after hip fracture: a population-based study

Summary  Evaluation of hospitalizations in a 70+ population showed that hip fractures (HF) were associated with a significant increase in the utilization of inpatient care for a lengthy period. Hospital days attributable to several diagnostic classes still exceeded both prefracture and population levels in the second year after HF. Introduction  The goal was to assess effects of HF on the inpatient care utilization. Methods  The study covered HF patients and the 70+general population (26,000) living in Central Finland. Hospitalization data categorized by the ICD-10 main classes were obtained from the nationwide discharge register. Results  In 2002–2003, 498 residents (mean age 82 SD 7, 74.9% women) of the study area sustained HF. Among them, the number of hospital days was 23, 107, and 52 per person-year in the prefracture, first and second postfracture year, respectively. In the 70+ general population, the number was constantly 11 per year. The age- and gender-adjusted rate ratio of hospital days between the two groups was 1.30 (95% CI 1.27 to 1.32), 6.91 (95% CI 6.85 to 7.00), and 3.61 (95% CI 3.55 to 3.67) for the prefracture, first and second postfracture year, respectively. Hospital days due to injuries were more prevalent in the HF group throughout the period. Moreover, excess of days was seen in six other diagnostic classes in the first and in four classes in the second postfracture year. Conclusions  Hospital days in HF patients still exceeded both the prefracture and population levels in the second year after HF. Days attributable to several other causes than HF itself became also more prevalent indicating that HF can steeply decrease patients’ coping capacity and launch a cascade of impairments in the function of different organ systems.     

Mortality following hip fracture: trends and geographical variations over the last 40 years

Hip fractures are an ever increasing cause of morbidity and mortality. Treatment of this condition requires an all-encompassing approach from prevention to post-operative care. It is important in such a situation to gather data on the incidence and trends of hip fractures to aid in the future treatment planning of this important condition. A review of all articles published on the outcome after hip fracture over a four decade period (1959-1998) was undertaken to determine any changes that had occurred in the demographics of patients and mortality over this time period. The mean age of patients sustaining hip fractures was found to be steadily increasing over the study period at a rate of 1 year of age for every 5-year time period. The mean age in the 1960s was 73 years to a mean of 79 years in the 1990s. No notable differences were seen in the proportion of male patients over the years but a definite downward trend was noticed with regard to intracapsular fractures. The mortality at 6 and 12 months after injury remained essentially unchanged over the four decades reviewed. Mortality after a hip fracture remains significant, being 11-23% at 6 months and 22-29% at 1 year from injury. Geographical variations exist in the mortality after hip fracture. More detailed international comparisons are required to determine if these differences in outcome are accounted for by the variations in the demographics of patients or due to diversities in treatment methods.     

Hip fracture audit: Creating a ‘critical mass of expertise and enthusiasm for hip fracture care’?

The care of frail older people admitted with hip fracture has improved greatly over the last half-century, largely as a result of combined medical care and surgical care and the rise – over the last four decades – of large-scale hip fracture audit.A series of European initiatives evolved. The first national hip fracture audit was the Swedish Rikshöft in the late 1980s, and the largest so far is the UK National Hip Fracture Database (NHFD), launched in 2007. An external evaluation of the NHFD demonstrated statistically significant increases in survival at up to 1 year associated with improved early care: with rising geriatrician involvement and falling delays to surgery, and from which lessons have been learned.Comparable national audits have emerged since in northern Europe and in Australia and New Zealand, and most recently in Spain and Japan. Like the NHFD, these use the synergy of agreed clinical standards and regular – ideally continuous – audit feedback that can prompt and monitor clinical and service developments, often demonstrating both rising quality and improved cost effectiveness.In addition, important benchmarking studies of hip fracture care have been reported from India and China, both of which face huge challenges in providing care of fragility fractures in populations characterised by first-generation mass ageing. The ‘halo effect’ of the impact of growing expertise in hip fracture care on the care of other fragility fractures is noteworthy and now relevant globally.Although many national audits have now published encouraging reports of progress, the details of context and process determinants of the initiation and development of effective hip fracture audit have received relatively little attention.To address this, an extended discussion section – based on the author’s experience of participation in several substantial audits, variously supporting and observing many others, and from his numerous discussions with audit colleagues over the years – may be of value in offering practical advice on some obvious and less obvious practical issues that arise in the setting up of large-scale hip fracture audits in a variety of healthcare contexts.     

Minimal impact of a care pathway for geriatric hip fracture patients

BackgroundAdherence to guidelines for patients with proximal femur fracture is suboptimal.ObjectiveTo evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.DesignThe European Quality of Care Pathways study is a cluster randomized controlled trial.Setting26 hospitals in Belgium, Italy and Portugal.SubjectsOlder adults with a proximal femur fracture (n = 514 patients) were included.MethodsHospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.ResultsIn the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.DiscussionImplementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.Trial registrationClinicalTrials.gov: NCT00962910.     

Association of ABO blood group with fracture pattern and mortality in hip fracture patients

Introduction

The mechanism of falling has been proposed as the exclusive explanation for hip fracture pattern. Evidence exists that other genetic factors also influence proximal femoral fracture configuration. The ABO blood group serotype has been associated with other pathologies but any role in hip fracture has yet to be definitively characterised.

Methods

Our National Hip Fracture Database was interrogated over a four-year period. All patients had their blood group retrieved, and this was compared with hip fracture pattern and mortality rates. Confounding factors were accounted for using logistic regression and the Cox proportional hazards model.

Results

A total of 2,987 consecutive patients presented to our institution. Those with blood group A were significantly more likely to sustain intracapsular fractures than ‘non-A’ individuals (p=0.009). The blood group distribution of patients with intracapsular fractures was identical to that of the national population of England. However, blood group A was less common in patients with intertrochanteric fractures than in the general population (p=0.0002). Even after correction for age and sex, blood group A was associated with a decrease in the odds of suffering an intertrochanteric fracture to 80% (p=0.002). Blood group A had inferior survivorship correcting for age, sex and hip fracture pattern (hazard ratio: 1.14, p=0.035). This may be due to associated increased prevalence of co-morbid disease in this cohort.

Conclusions

Blood group is an independent predictor of hip fracture pattern, with group A patients more likely to sustain an intracapsular fracture and non-A individuals more likely to sustain an intertrochanteric fracture. The determinants of fracture pattern are likely to be related to complex interactions at a molecular level based on genetic susceptibility. The mechanism of fall may not be the only aetiological determinant of proximal femoral fracture configuration.     

Consequences of a hip fracture: A prospective study over 1 year

From a population of 230 000 residents, 1429 consecutive hip fracture patients were studied with regard to their social and physical functions both before sustaining the fracture and 1 year later. Changes in the patients' accommodation, need of help and walking aids were described. Using logistic regression we found important factors regarding the ability to return home, mortality within 1 year and length of hospital stay. The cost of a hip fracture over the time a patient is in hospital is, including the cost of an internal fixation, about US $6000. The total cost over 1 year is about US $26 000 per patient, including the operation.     

Baseline and pre-operative 1-year mortality risk factors in a cohort of 509 hip fracture patients consecutively admitted to a co-managed orthogeriatric unit (FONDA Cohort)

IntroductionThe aim of this study was to determine the patient characteristics that predict 1-year mortality after a hip fracture (HF).MethodsAll patients admitted consecutively with fragility HF during 1 year in a co-managed orthogeriatric unit of a university hospital (FONDA cohort) were assesed. Baseline and admission demographic, clinical, functional, analytical and body-composition variables were collected in the first 72 h after admission. A protocol designed to minimize the consequences of the HF was applied. One year after the fracture patients or their carers were contacted by telephone to ascertain their vital status.ResultsA total of 509 patients with a mean age of 85.6 years were included. One-year mortality was 23.2%. The final multivariate model included 8 independent mortality risk factors: age >85 years, baseline functional impairment in basic activities of daily living, low body mass index, cognitive impairment, heart disease, low hand-grip strength, anaemia at admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The association of several of these factors greatly increased mortality risk, with an OR (95% confidence interval [CI]) of 5.372 (3.227–8.806) in patients with 4 to 5 factors, and an OR (95% CI) of 11.097 (6.432–19.144) in those with 6 or more factors.ConclusionsIn addition to previously known factors (such as age, impairment in basic activities of daily living, cognitive impairment, malnutrition and anaemia at admission), other factors, such as muscle strength and hyperparathyroidism associated with vitamin D deficiency, are associated with greater 1-year mortality after a HF.     

Excess mortality following hip fracture: the role of underlying health status

Summary We evaluated the long-term excess mortality associated with hip fracture, using prospectively collected data on pre-fracture health and function from a nationally representative sample of U.S. elders. Although mortality was elevated for the first six months following hip fracture, we found no evidence of long-term excess mortality. Introduction The long-term excess mortality associated with hip fracture remains controversial. Methods To assess the association between hip fracture and mortality, we used prospectively collected data on pre-fracture health and function from a representative sample of U.S. elders in the Medicare Current Beneficiary Survey (MCBS) to perform survival analyses with time-varying covariates. Results Among 25,178 MCBS participants followed for a median duration of 3.8 years, 730 sustained a hip fracture during follow-up. Both early (within 6 months) and subsequent mortality showed significant elevations in models adjusted only for age, sex and race. With additional adjustment for pre-fracture health status, functional impairments, comorbid conditions and socioeconomic status, however, increased mortality was limited to the first six months after fracture (hazard ratio [HR]: 6.28, 95% CI: 4.82, 8.19). No increased mortality was evident during subsequent follow-up (HR: 1.04, 95% CI: 0.88, 1.23). Hip-fracture-attributable population mortality ranged from 0.5% at age 65 among men to 6% at age 85 among women. Conclusions Hip fracture was associated with substantially increased mortality, but much of the short-term risk and all of the long-term risk was explained by the greater frailty of those experiencing hip fracture.     

Metabolic syndrome and hip fracture: Epidemiology and perioperative outcomes

IntroductionHip fractures and metabolic syndrome (MetS) are becoming major global healthcare burdens as populations age. This study sought to determine the impact of MetS in hip fracture patients on perioperative outcomes following operative fixation or arthroplasty.MethodsData from the 2004–2014 Nationwide Inpatient Sample was used to select 3,348,207 discharges with hip fracture. MetS patients were identified by having at least 3 of 4 component comorbidities: hypertension, dyslipidemia, obesity, and diabetes. Logistic regression was used to estimate odds ratios for the association between MetS and perioperative outcomes adjusted for age, gender, race, payer status, and comorbidities.ResultsOverall, 32% of hip fracture patients were treated with open reduction internal fixation (ORIF), 28% hemiarthroplasty (HA), 18% closed reduction with internal fixation (CRPP), and 3% primary total hip arthroplasty (THA). The remaining 19% of cases were either treated via unspecified procedure of hip repair (9%), managed non-operatively (2%), underwent multiple procedures during the hospital stay (6%), or the surgical procedure data was missing (2%) and were excluded from procedural analyses. The prevalence of MetS was 7.9% and increased among minorities, patients treated at urban hospitals, with comorbidities (heart failure, kidney disease, peripheral vascular disease), and with Medicare coverage. MetS was associated with increased odds of any adverse event (p < 0.0001), specifically: acute renal failure, myocardial infarction, acute posthemorrhagic anemia. MetS was also associated with increased LOS (p < 0.0001) and increased total charges (p < 0.0001). However, MetS was associated with reduced odds of postoperative pneumonia, deep vein thrombosis and pulmonary embolism, surgical site infection, septicemia, and in-hospital mortality (p < 0.0001). The above associations were maintained for MetS patients stratified according to their treatment groups: HA, CRPP, and ORIF.ConclusionsMetS is associated with increased odds of complications in hip fracture patients but decreased odds of in-hospital mortality. This may be related to patients’ nutritional status and catabolic states in the perioperative period.     

Decreased glomerular filtration rate estimated by 2009 CKD-EPI equation predicts mortality in older hip fracture population

ObjectiveWe examined estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology equation (eGFR_CDK-EPI), removal of urinary catheter during hospitalization and polypharmacy as predictors of mortality in older hip fracture patients.MethodsPopulation-based prospective data were collected on 1425 consecutive hip fracture patients aged ≥65 years. Outcome was mortality at one year. Independent variables were age, sex, body mass index, fracture type, American Society of Anesthesiology score, delay to surgery, urinary catheter removal during acute hospitalization, eGFR_CDK-EPI, number of daily medications, diagnosis of memory disorder, prefracture mobility and living arrangements.ResultsOf the 1425 patients, 567 (40%) had renal dysfunction on admission, 526 (37%) had their urinary catheters removed during hospitalization and 1177 (83%) were taking ≥4 medications regularly before the fracture. In the multivariate analyses with the Cox proportional hazards model adjusted simultaneously for all the independent variables, eGFR_CDK-EPI 30–44 ml/min/1.73 m² (HR 1.91, 95% CI 1.44–2.52) and <30 ml/min/1.73 m² (HR 1.95, 95% CI 1.36–2.78), non-removal of the urinary catheter (HR 1.45, 95% CI 1.12–1.88) and large number of daily medications (4–10 HR 1.81, 95% CI 1.78–2.79, >10 HR 2.21, 95% CI 1.38–3.54) were associated with mortality.ConclusionsIn older hip fracture patients, moderate to severe level renal dysfunction measured by eGFR_CDK-EPI, non-removal of urinary catheter before discharge and polypharmacy increase mortality after hip fracture. Careful assessment of renal function and medications and following the care protocols on urinary catheter removal are essential in the care of geriatric hip fracture patients.     

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

IntroductionWe conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD.MethodsThis study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality.ResultsThe 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD.ConclusionsIn elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.