Patients With Un-Displaced Or Displaced Intra Capsular Proximal Femur Fractures Do Not Represent A Different Patient Group And Have Similar Short And Long Term Mortality

BackgroundProximal femur fractures in geriatric patients are associated with substantial mortality. Management of intracapsular proximal femur fractures has been based on age, displacement, cognition, and pre-injury mobility. However, over the last decade, there has been a tendency to offer arthroplasty rather than internal fixation for these patients irrespective of displacement, to allow early mobilisation and negate the higher rate of reoperation due to failed internal fixation. There are no previous investigations analysing whether the severity of fracture displacement is related to different patient characteristics.AimThis study examines whether patients sustaining undisplaced or displaced intracapsular proximal femur fractures represent different patient groups with different pre-injury characteristics and post-operative mortality, irrespective of treatment modality.MethodsA retrospective series of 329 consecutive patients over the age of 55 years who sustained intracapsular proximal femur fractures, who underwent surgical management at a district general hospital over a period of 2 years (2012-2013) were identified using the national hip fracture database. Demographics, American Society of Anaesthesiologist (ASA) grade, pre-injury outdoor mobility status, cognitive status, and admission serum investigations, fracture displacement, type of surgery, and mortality rates at short term (2 years) & long-term (7-9 years) were reviewed.ResultsThere were 109 male and 220 female patients with a minimum follow-up of 7 years. The mean age at surgery was 81.6 years (range 55-103 years). There were 63 (19.1%) undisplaced fractures (Garden 1 &2) and, 265 (80.5%) displaced fractures (Garden 3 & 4).The median survival in this cohort was 2.95 years (95% CI 2.3-3.6). Mortality rates were 77.4% (n=257) at long-term (7-9 years) follow-up. Admission patient characteristics showed no statistically significant difference between displaced and undisplaced fracture groups. This included ASA, pre-operative cognition, and mobility status. Fracture displacement was not an independent predictor of mortality at short or long term.ConclusionIn patients sustaining intracapsular proximal femur fractures, the degree of displacement is not a caveat for a different patient group. Fracture displacement is not predicted by the pre-injury level of function and does not predict short or long-term mortality.     

Mortality and its risk factors in nonagenarians after hip fractures

BackgroundThe purpose of this study was to assess mortality with a minimum of 2-year follow-up, related risk factors for mortality, and functional outcomes after surgical interventions in nonagenarian patients with hip fractures at the latest follow up.MethodsBetween June 2003 and November 2015, 260 nonagenarians (271 hips) with femoral neck and intertrochanteric fractures were included in this retrospective study. Cumulative mortality using the Kaplan-Meier method and risk factors for mortality using Cox proportional-hazards regression model were estimated. As functional outcome, ambulatory ability was assessed before injury and at the latest follow-up.ResultsSix-teen patients (16 hips) were lost to follow-up. The mean age at the time of surgery was 92.2 years (range 90–108 years). Mortality rates were 23.4% (57 of 244 patients) at 1 year and 40.6% (99 of 244 patients) at 2 years. Both genders had elevated standardized mortality ratio at 2-year post-fracture compared to that a 1-year post fracture. Multivariate analysis showed that American Society of Anesthesiologists (OR, 1.371; 95% CI, 1.021–1.843; P = 0.036) and time interval from trauma to operation (OR, 1.043; 95% CI, 1.002–1.086; P = 0.039) were significantly associated with risk of mortality. Of 58 patients alive, 13 patients (22.4%) had the same ambulatory ability before and after injury.ConclusionsThis study demonstrates that mortality is higher in nonagenarians with hip fracture. Risk factors for mortality in nonagenarians with hip fracture are American Society of Anesthesiologists and time interval from trauma to operation. And, nonagenarians with hip fractures have lower rate of maintaining pre-injury ambulatory ability.     

Evaluation of a 30-day-mortality risk calculator for patients undergoing surgical fixation of fragility hip fractures

IntroductionHip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system.Materials & Methods625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk calculator were also evaluated.ResultsThe observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated troponin were significantly associated with 30-day mortality.DiscussionThe HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia.Level of EvidenceIV     

Mortality profile after 2 years of hip fractures in elderly patients treated with early surgery

BackgroundIn geriatric age group, hip fractures tend to become a major public health hazard. Due to this high occurrence, there is a need to develop standardized, effective, and multidisciplinary management for treatment. These elderly patients have excessive mortality that can extend ahead of the time of recovery. Early surgery after hip fractures has lead to a notable reduction in mortality rates. Still, it is considerably high as compared to other fractures.Methods266 patients of >65 years who were operated within 72 h hours in a tertiary level health care centre for hip fractures were included. They were evaluated with X-rays and grade of Singh’s index was noted. Mortality rates and the factors associated with it such as age, sex, co morbidities (using Charlson’s co morbidity Index/CCI) were evaluated after 2 year follow up.ResultsThe overall 2-year mortality reported in our study population was 11.2%. It was broadly lower as compared to most of the other studies. It was 6.3% in females as compared to 18.1% in males. While it was reported to be only 6% in 65–74 years of age, it was 25% in patients who were 85 years and above. 76.6% of the patients had Singh’s index of ≤ grade 3 showing osteoporosis. The patients with Low Charlson’s score showed only 4.2% mortality while those with high Charlson’s score showed 25.5% mortality.ConclusionIt was concluded that Mortality among elderly patients after early surgery after osteoporotic hip fractures is quite significant. The factors for improvement in long term survival post-hip fracture may include changing treatment patterns, increasing life expectancy and early surgery. Increase in age, female sex, and high CCI Scores were major risk factors of mortality after hip fractures in a 2-year follow-up period.     

Reversal of direct oral anticoagulants in adult hip fracture patients. A systematic review and meta-analysis

BackgroundIncreasing numbers of patients are taking Direct Oral Anticoagulants at the time of hip fracture. Evidence is limited on how and if the effects of DOAC's should be reversed before surgical fixation. Wide variations in practice exist. We conducted a systematic review to investigate outcomes for three reversal strategies. These were: “watch and wait” (also referred to as “time-reversal”), plasma product reversal and reversal with specific antidotes.MethodsA systematic search was conducted using multiple databases. Results were obtained for studies directly comparing different DOAC reversal strategies in hip fracture patients and for studies comparing DOAC-taking hip fracture patients (including patients “reversed” using any method and “non-reversed” patients) against matched controls taking either a vitamin-K antagonist or not receiving anticoagulation therapy. This allowed construction of a network meta-analysis to indirectly compare outcomes between “reversed” and “non-reversed” DOAC patients. With respect to “watch and wait”/“time-reversal”, a cut-off time to surgery of 36 hours was used to distinguish between “time-reversed” and “non time-reversed” DOAC patients. The primary outcome was early/inpatient mortality, reported as Odds Ratios (OR).ResultsNo studies investigating plasma products or reversal agents specifically in hip fracture patients were obtained. Fourteen studies were suitable for analysis of “watch and wait”/“time- reversal”. Two studies directly compared “time-reversed” and “non time-reversed” DOAC-taking hip fracture patients (58 “time-reversed”, 62 “non time-reversed”). From 12 other studies we used indirect comparisons between “time-reversed” and “non time-reversed” DOAC patients (total, 357 “time-reversed”, 282 “non time-reversed”). We found no statistically significant differences in mortality outcomes between “time-reversal” and “non time-reversal” (OR 1.48 [95%CI: 0.29-7.53]). We also did not find a statistically significant difference between “time reversal” and “non time-reversal” in terms of blood transfusion requirements (OR 1.16 [95% CI 0.42-3.23]). However, several authors described that surgical delay is associated with worse outcomes related to prolonged hospitalisation, and that operating within 36 hours is safe.ConclusionsWe suggested against “watch and wait” to reverse the DOAC effect in hip fractures. Further work is required to assess the optimal timing for surgery as well as the use of plasma products or specific antidotes in DOAC-taking hip fracture patients.     

The influence of pre-operative antiplatelet and anticoagulant agents on the outcomes in elderly patients undergoing early surgery for hip fracture

BackgroundEarly surgery improves the prognosis of elderly patients with hip fractures. However, many patients take antiplatelet and anticoagulant therapies for comorbidities. This study compared perioperative outcomes and 1-year mortality rates with early surgery in elderly patients with hip fractures taking or not taking these agents preoperatively.MethodsAmong 418 patients undergoing surgery for hip fractures at our institution from 2014 to 2016, 266 patients over 65 years who had surgery within 48 hours of admission were enrolled. We excluded patients with high-energy injuries, multiple or pathological fractures, and patients undergoing osteosynthesis for femoral neck fractures. The study population was divided into those who underwent hemiarthroplasty for neck fractures and those who underwent osteosynthesis for trochanteric fractures. We also divided the population into patients receiving chronic anticoagulation therapy (medicated group: 19 hemiarthroplasty, 70 osteosynthesis) and patients not receiving anticoagulation therapy (non-medicated group: 47 hemiarthroplasty, 130 osteosynthesis). Comorbidities, intraoperative blood loss, estimated blood loss from admission to the first and seventh day after surgery, transfusions, length of stay, complications, and 1-year mortality rates were evaluated.ResultsDiabetes mellitus and cerebrovascular disorders were significantly more common in the medicated group for both surgery types. In the osteosynthesis group, estimated blood loss on the first day was 710 ml in the medicated group and 572 ml in the non-medicated group (P = 0.015). In the hemiarthroplasty group, corresponding values were 668 and 480 ml, respectively (P = 0.016). Estimated blood loss on the seventh day, complications, length of stay and 1-year mortality rate were not increased significantly.ConclusionsThe medicated group had an increase in estimated blood loss on the first day. However, there was no significant increase in transfusions, complications and 1-year mortality rates. Early surgery for elderly patients with hip fractures is recommended, even for those taking antiplatelet and anticoagulant agents.     

Mortality in patients sustaining a periprosthetic fracture following a previous extracapsular hip fracture fixation

BackgroundMortality rates following hip fractures are decreasing. As these outcomes improve, it increases the potential for further falls and the potential to sustain a periprosthetic fracture. The aim of this study was to analyse the 1 year mortality of periprosthetic fractures around an implant used to treat an extracapsular hip fracture. Secondary outcomes included 30 day mortality, complications and risk factors associated with mortality.MethodsA retrospective case note and radiographic review of all patients who presented to a single institution with a periprosthetic femoral fracture around an implant previously used to treat an extracapsular hip fracture between 1st January and 2008 and 31st May 2015.Results29 patients with a mean age of 75.8. 6 males and 23 females. 20 (69.0%) patients had capacity to consent for surgery. Pre-operatively 34.5% mobilised independently without any walking aids. 79.3% lived at home. 62.1% had a Charlson co-morbidity score of 0 or 1, 27.6% a score of 2 or 3, 6.9% a score of 4 and 5, and 3.4% a score of more than 5.3.4% was ASA grade 1, 13.8% ASA2, 65.5% ASA 3 and 17.2% were ASA 4. The previous implant a dynamic hip screw in 75.9% dynamic hip screws and an intramedullary nail in 24.1%. There were 4 (13.8%) in-patient deaths. The 30 day mortality 17.2% (5 patients) was and the 1 year mortality was 44.8% (13 patients). There were 0 complications that required return to surgery during admission. 1 patient with a revision intramedullary nail had dynamisation performed due to delayed union 7 months following surgery. 1 patient required removal of metalwork 2 years following surgery for infection. When comparing risk factors for mortality, there were no significant risk factors found in this study for 30 day and 1 year mortality.ConclusionsThis paper suggests that periprosthetic fractures sustained after the surgical treatment of extra capsular neck of femur fractures have higher mortality rates than hip fractures. These patients should be given the same priority as these patients in there management.     

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma

MethodsWe queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS) > 15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS ≧ 4) head injuries.ResultsThere were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar.In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p < 0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8 ± 1.8 units/patient in the DOAC group vs. 6.7 ± 6.4 units per patient in the warfarin group; p = 0.001).ConclusionIn conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.     

Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis

BackgroundThe impact of concurrent upper limb and fragility hip fractures has not been well defined. A greater understanding of this can guide decision making in the early peri-operative period and subsequent rehabilitation of such patients.AimsTo identify if patients with concurrent upper limb and fragility hip fractures have different outcomes and demographics than those with an isolated hip fracture.MethodsA search of MEDLINE and EMBASE was performed to identify cohort and case-control studies, comparing concurrent hip and upper limb fractures with isolated hip fractures. Meta-analysis was conducted using RevMan 5.4. Subgroup analyses were performed for concurrent distal radius and concurrent proximal humerus fractures.Results13 studies were included reporting on 196,916 patients with an isolated hip fracture and 13,373 with concurrent hip and upper limb fractures. Patients with concurrent upper limb fractures had a significantly longer length of hospital stay (mean difference: 3.97 days, 95% CI: 1.36, 6.57, P=0.003) as compared to those with isolated hip fractures. Patients with concurrent upper limb fractures were significantly more likely to be female (OR: 0.57, 95% CI: 0.46, 0.70, P<0.00001), reside at home pre-injury (OR: 0.6, 95% CI: 0.37, 0.96, P=0.03) and have no cognitive impairment (OR: 0.54, 95% CI: 0.35, 0.84, P=0.006). Patients with concurrent distal radius fractures had significantly lower 90-day mortality (OR: 0.70, 95% CI: 0.49, 0.99, P=0.04) and 1-year mortality (OR: 0.68, 95% CI: 0.51, 0.90, P=0.008).ConclusionsConcurrent fragility hip and upper limb fractures are associated with increased length of hospital stay. We recommend early, aggressive, individualised rehabilitation to help improve outcomes and early hospital discharge in this highly vulnerable patient group.     

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study

PurposeThe COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3–4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture.MethodsA multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for “fragility hip fractures” were included in the study. Patients’ 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27.ResultsA total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865–3.978).ConclusionHip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of “long-COVID” and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.     

Are factor Xa inhibitors effective thromboprophylaxis following hip fracture surgery?: A large national database study

IntroductionThe purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.MethodsPatients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.ResultsDVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p = 0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.DiscussionXaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.ConclusionsThis study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.     

Nonagenarian hip fractures: Morbidity and mortality at a single institution

ObjectivesThe incidence of hip fractures continues to rise dramatically, but few studies have examined these injuries in the population of individuals over 90 years of age, which is one of the fastest growing populations. We present the largest such study specifically examining hip fractures in the super-elderly.MethodsA review of 216 hip fracture patients over 90 years of age were examined for immediate postoperative complications and in-house, 30-day, and 1-year mortality.ResultsOverall 1-year mortality was 38.1%. Statistically-significant risk factors for 1-year mortality included oncologic fracture, dementia, and CHF. Fracture classification and hospital length of stay were associated with perioperative complications including anemia and pneumonia.ConclusionThe nonagenarian hip fracture is associated with a higher 1-year mortality than prior reported rates of mortality for elderly hip fractures. Factors previously reported to influence the risk of 1-year mortality in hip fractures are not observed in the super-elderly.     

Hip fractures in centenarians: a multicentre review of outcomes

IntroductionAdvances in healthcare have resulted in an increasing UK population, with the proportion of elderly individuals expanding significantly, including centenarians. Hospitals can expect to see growing numbers of so-called ‘super-elderly’ patients with trauma, a majority of whom will have hip fractures. We performed a multicentre review of hip fracture outcomes in centenarians to assess whether being an outlier in age correlates with poorer prognosis.MethodsCentenarians admitted to Basingstoke, Southampton, Dorset, and Salisbury district hospitals with hip fractures between January 2014 and June 2019 were included. Electronic records were searched to obtain demographics, functional status, and admission details.ResultsA total of 60 centenarians were included, with a median age of 101 years (range 100–108 years), 85% of whom were female; 29 were admitted from their own home or sheltered housing and 31 from nursing or residential care; 33 had some outdoor mobility, 26 only mobilised indoors, and 1 had no mobility. Common comorbidities were renal and heart disease and dementia. Of the total, 56 underwent surgery, 51 within 36 hours. In terms of accommodation, 63.4% returned to their pre-injury level of independence. At 30 days, three months, and one year, mortality rates were 27% (n = 16), 40% (n = 24) and 55% (n = 33), respectively.ConclusionTrauma in the elderly population is an area of growing interest, yet few studies address centenarians with hip fractures. This work demonstrates that mortality rates within one year of injury were high, but almost half survived beyond a year. Two-thirds of patients regained their pre-injury level of independence, suggesting that functional recovery may not be as poor as previously reported.     

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients

IntroductionThere has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures.Patients and methodsHip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture.Results81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture.Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture.Discussion and conclusionSimultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.     

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BackgroundWarfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.MethodsThis was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the “wait and watch” method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.ResultsThere were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.ConclusionsPartial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.     

Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

IntroductionThe British Orthopaedic Association published 2019 guidelines ‘The Older or Frail Orthopaedic Trauma Patient’. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population.Materials and Methods: We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality.ResultsWe identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14).ConclusionPatients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.     

Clinical characteristics and short to mid term functional outcomes of surgically treated occult hip fractures in the elderly

BackgroundOccult hip fractures in the elderly are challenging to diagnose and often result in surgical delays which may worsen outcomes. However, the minimally displaced nature of these fractures may conversely lead to better outcomes. The aim of this study was to determine if surgically treated occult hip fractures have better short to mid term functional outcomes when compared to non-occult fractures. The secondary aim was to determine if there are any differences in clinical characteristics of patients who present with occult hip fractures.MethodsThis was a retrospective cohort study of all elderly patients aged 65 years and above who presented with hip fractures in a single institution from January 2012 to December 2013. Elderly patients who presented with hip fractures were enrolled into an Ortho-geriatric carepath and were eligible for recruitment. The exclusion criteria included patients with pathological fractures and multiple injuries. Demographic and pre-injury variables were collected. The functional outcome measurement was the Modified Barthel’s Index (MBI). Patients were divided into non-occult hip fractures (Group 1) and occult hip fractures (Group 2).ResultsA total of 1017 patients were admitted during this period into the hip fracture carepath, of which 49 (4.8%) were diagnosed to have occult hip fractures. There was no significant difference between the demographics, Charlson co-morbidity index, abbreviated mental test scores or pre-morbid patient dependence between the groups. There was a significant delay to surgery for occult hip fractures when compared to non-occult fractures. (p = 0.03) Subgroup analysis showed that pre-morbidly, patients with occult inter-trochanteric fractures were significantly more independent than patients with non-occult inter-trochanteric fractures. (p = 0.03) There was no significant difference between the length of stay, surgical complications and 1-year mortality between the 2 groups. Occult inter-trochanteric fractures had better MBI scores at all time points when compared to non-occult inter-trochanteric fractures.ConclusionsDespite the significant delay to surgical intervention for patients with occult hip fractures, the short to mid term functional outcomes for this group of patients are comparable to surgically treated non-occult hip fractures. There are no distinctive clinical characteristics of elderly patients who are more likely to suffer occult hip fractures.     

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.     

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture

ObjectiveThis study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures.MethodsA total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60–108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients’ pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality.ResultsA total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality.ConclusionWe demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population.Level of EvidenceLevel IV, Prognostic Study     

Increased hip fracture and mortality in chronic kidney disease individuals: The importance of competing risks

BackgroundMany studies have shown a correlation between chronic kidney disease (CKD) and fracture. However, increased mortality in CKD patients is a competing risk scenario not accounted for in previous studies. Our aim was to investigate the true impact of CKD on hip fracture after accounting for a competing risk with death.MethodsWe conducted a population-based cohort study to determine the impact of CKD on hip fractures in individuals aged ≥ 50 years old registered in the SIDIAP^Q database (representative of 1.9 million people in Catalonia, Spain). Cox regression was used to estimate hazard ratio (HR) for death and hip fracture according to CKD status. A competing risk (Fine and Gray) model was fitted to estimate sub-HR for hip fracture in CKD or CKD-free patients accounting for differential mortality.ResultsA total of 873,073 (32,934 (3.8%) CKD) patients were observed for 3 years. During follow-up, 4,823 (14.6%) CKD and 36,328 (4.3%) CKD-free participants died (HR, 1.83 [95% CI, 1.78–1.89]), whilst 522 (1.59%) and 6,292 (0.75%) sustained hip fractures, respectively. Adjusted Cox models showed a significantly increased risk of hip fractures for the CKD group (HR, 1.16 [1.06–1.27]), but this association was attenuated in competing risk models accounting for mortality (SHR, 1.14 [1.03–1.27]).ConclusionsBoth death and hip fracture rates are increased (by 83% and 16%, respectively) in CKD patients. However, the association between CKD and hip fractures is attenuated when an excess of mortality is taken into account. A competing risk with death must be considered in future analyses of association between CKD and any health outcomes.