Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients

Background

Existing reports describe the decline of the mortality rate by conducting surgery for hip fractures within 24 h; however, the theory is still controversial. We have compared the perioperative mortality rate, improvement of mobility, and duration of hospital stay for early surgery (within 24 h) and delayed surgery (beyond 24 h) between two groups.

Methods

We studied 536 cases of proximal femoral fracture in patients >60 years who were treated between September 2003 and December 2006. There were 91 men and 445 women, who had a total of 257 femoral neck fractures and 279 trochanteric fractures. In all, 270 patients were operated on within 24 h after injury and were defined as the early group; 266 patients were treated surgically more than 24 hours after injury and were defined as the delayed group. Based on admission laboratory tests, co-morbidity, dementia, preoperative mobility, and residential environment before injury, we compared the duration of hospital stay, mobility at discharge, and mortality rates between the early group and the delayed group.

Results

There was no significant difference in duration of hospital stay between the two groups. Improvement of mobility was 52% in the early group and 41% in the delayed group, with the difference being significant (P < 0.05). Inpatient mortality rate was 5.6% in the early group and 2.6% in the delayed group, but the difference was not significant. In the early group, men with co-morbidity, dementia, and abnormal laboratory values upon admission showed a significantly higher mortality rate.

Conclusions

Early surgery was useful for improving mobility, but it showed a higher mortality rate in patients with a compromised somatic condition at the time of the injury. For independent patients with a stabilized somatic condition, surgery should be performed within 24 h. For unstable cases, we believe it is better to provide early surgery after stabilizing the patient’s condition to the greatest possible extent.     

老年髋部骨折的手术时机选择与预后分析

目的探讨手术时机选择对老年髋部骨折预后的影响。方法回顾性分析2012年1月至2015年12月期间解放军总医院第七医学中心骨科收治的814例老年髋部骨折患者资料。男272例,女542例;年龄为60~99岁,平均79.9岁;根据美国麻醉师协会(ASA)分级将患者分为全身状态好(ASA分级Ⅰ、Ⅱ级,403例)和全身状态较差(ASA分级Ⅲ、Ⅳ级,411例)两类,每类患者根据是否在入院后48 h内手术再分为2组:早期手术组和晚期手术组。分别比较早期手术组与晚期手术组患者的住院时间、并发症发生率、术后30 d和1年死亡率、术后1年日常生活活动(ADL)评分等。结果在全身状态好的患者中,两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。早期手术组患者术后30 d死亡率[0%(0/94)]、术后1年死亡率[5.3%(5/94)]显著低于晚期手术组患者[4.2%(13/309)、14.2%(44/309)],住院时间[(9.6±5.2)d]显著短于晚期手术组患者[(12.3±5.9)d]、术后1年ADL评分[75(70,85)分]显著高于晚期手术组患者[70(60,80)分],差异均有统计学意义(P<0.05)。两组患者的并发症发生率比较差异无统计学意义(P>0.05)。在全身状态较差的患者中,两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。早期手术组患者住院期间并发症发生率[42.2%(35/83)]显著高于晚期手术组患者[30.5%(100/328)],差异有统计学意义(P<0.05)。而两组患者术后30 d和1年死亡率、住院时间及术后1年ADL评分比较差异均无统计学意义(P>0.05)。结论对于老年髋部骨折,若患者身体状态好,可尽快实施手术;若患者一般状况差,不能一味强调早期手术,需评估身体状态后再选择合适的手术时机。     

老年人髋部骨折的手术治疗策略探讨

目的探讨老年人髋部骨折手术治疗策略、临床应用方法及疗效。方法手术治疗248例老年髋部骨折患者,其中人工髋关节置换治疗114例,内固定治疗134例,按照末次随访患肢髋关节Harris评分及X线片评估疗效。结果 226例获得随访,时间5-76（36.8±14.6）个月。术中无死亡。关节置换者术后有4例脱位,经手法复位皮牵引固定未再脱位;1例术后4年髋臼松动重新置换。内固定治疗者骨折均愈合,无内置物松动、断裂、骨不连发生,并发髋内翻28例,其中螺钉切破股骨头4例,取出内固定行关节置换术后功能恢复。末次随访时226例患肢髋关节Harris评分为72-96（87.7±7.9）分,其中优111例,良84例,可22例,差9例,优良率为86.3%。结论老年髋部骨折患者积极正确的手术治疗可促进早期活动,减少并发症和病死率,提高生活质量。     

服用氯吡格雷的老年髋部骨折患者尽早手术的安全性研究

目的:探讨服用氯吡格雷的老年髋部骨折患者尽早手术的安全性。方法:回顾性分析2016年11月至2017年4月期间北京积水潭医院创伤骨科连续收治的242例老年髋部骨折患者资料。将服用氯吡格雷且停药4 d以内手术患者纳入研究组,共20例,年龄中位数为80（77,81）岁;男6例,女14例。手术方式：股骨颈骨折空心钉固定2例,...     

老年髋部骨折患者快速康复方案的临床实施

目的评价老年髋部骨折患者快速康复方案的实施效果。方法将110例老年髋部骨折患者按照随机数字表法分为观察组和对照组各55例。对照组按照老年髋部骨折护理规范实施护理,观察组在常规护理基础上,实施快速康复方案。结果观察组术前等待时间、住院时间显著短于对照组,患者满意度显著高于对照组,且出院后6个月髋关节评分显著高于对照组(P0.05,P0.01)。结论对老年髋部骨折患者实施快速康复方案,能够减少术前等待时间和平均住院日,提高患者满意度,有利于患者髋关节功能恢复,是一种有效的的实践模式。     

老年髋部骨折手术时机选择与术后疗效分析

目的 探讨老年髋部骨折患者手术时机选择对术后疗效的影响.方法 选择2006年7月至2008年6月手术治疗的髋部骨折患者267例,入组后根据手术时机将患者分为早期手术组(入院2 d内手术)和晚期手术组(入院2 d后手术),详细记录患者的并存症、手术细节、术后并发症等.观察两组患者住院期间并发症发生率和死亡率、住院时间、出院时功能恢复情况、术后6和12个月的死亡率以及功能恢复情况.结果 符合入选标准116例,早期手术组45例,晚期手术组71例.两组性别、年龄、并存症等一般情况差异无统计学意义,术中麻醉方式、出血量、固定方式两组亦无统计学意义.早期手术组住院时间、住院期间肺部并发症发生率较晚期手术组明显减少;住院期间、术后6、12个月死亡率和晚期手术组相比差异不统计学意义;出院时、术后6个月日常生活能力评分(the activities of daily living,ADL)较晚期手术组高,差异有统计学意义.术后12个月晚期手术组ADL评分和早期手术相似,差异无统计学意义.结论 在排除自身情况差异后,术后早期(出院时、术后6个月)早期手术患者独立生活能力较晚期手术者恢复好,但从远期来看(术后12个月)二者差异无统计学意义.早期手术者和晚期手术者死亡率的差异无统计学意义.     

老年髋部骨折手术时机选择与术后疗效分析

目的 探讨老年髋部骨折患者手术时机选择对术后疗效的影响.方法 选择2006年7月至2008年6月手术治疗的髋部骨折患者267例,入组后根据手术时机将患者分为早期手术组(入院2 d内手术)和晚期手术组(入院2 d后手术),详细记录患者的并存症、手术细节、术后并发症等.观察两组患者住院期间并发症发生率和死亡率、住院时间、出院时功能恢复情况、术后6和12个月的死亡率以及功能恢复情况.结果 符合入选标准116例,早期手术组45例,晚期手术组71例.两组性别、年龄、并存症等一般情况差异无统计学意义,术中麻醉方式、出血量、固定方式两组亦无统计学意义.早期手术组住院时间、住院期间肺部并发症发生率较晚期手术组明显减少;住院期间、术后6、12个月死亡率和晚期手术组相比差异不统计学意义;出院时、术后6个月日常生活能力评分(the activities of daily living,ADL)较晚期手术组高,差异有统计学意义.术后12个月晚期手术组ADL评分和早期手术相似,差异无统计学意义.结论 在排除自身情况差异后,术后早期(出院时、术后6个月)早期手术患者独立生活能力较晚期手术者恢复好,但从远期来看(术后12个月)二者差异无统计学意义.早期手术者和晚期手术者死亡率的差异无统计学意义.     

Early surgery after hip para-articular femoral fracture. Results of a prospective study of surgical timing in 161 elderly patients

In a prospective analysis the question should be answered, wether the mortality rate of femur fractures close to the hip joint can be diminished by operating as early as possible. 161 patients elder than 65 years could be included in the study. 86% of the 161 patients were operated upon 24 hours after trauma. The infection rate amounted to 3.4% after endoprothesis and to 1.2% after osteosynthesis. The hospital mortality was 7.4%. More than 85% of the patients could be discharged into the usual domestic surroundings. The rate of systemic complications (25.3%) was similar to the rate reported by the Chamber of Physicians with 26.1%. The hospital length of stay could not be diminished by this concept. By operating as early as possible the patients' request for mobility is fulfilled without running unjustifiable risks regarding mortality and postoperative complications. The mortality rate corresponds to the literature.     

家庭访视指导对髋关节置换术后老年患者院外康复的作用

目的 探讨家庭访视对人工髋关节置换术后老年患者院外康复的影响.方法 将46例行髋关节置换的老年患者随机分为观察组和对照组各23例.时照组住院期间接受常规护理,观察组在此基础上增加3个月的家庭访视指导(每2周访视1次).结果 两组术后3个月Harris髋关节评分、康复知识掌握情况比较,差异有统计学意义(均P＜0.01).结论 家庭访视指导可促进患者肢体功能恢复,提高其生活质量.     

Paramedian technique of spinal anesthesia in elderly patients for hip fracture surgery

The objective of this study was to observe the success rate, difficulties and complications during the technique of spinal anesthesia through para median approach in elderly frail patients with spinal abnormalities, for femur fracture surgery. Case series study was performed at Pakistan Naval Shifa Hospital, Karachi, Pakistan from August 2002 to July 2003, after approval from Scientific Research Council of the Hospital and consent of the patients. Forty elderly patients with spinal abnormalities, ASA II, age 88+/- 8 years, weight 68.5+/-3.5 kg, declared high-risk for anesthesia, scheduled for femur fracture surgery under spinal anesthesia, were selected for study after failure of lumbar puncture (LP) through midline approach at L3-4 or L4-5 level. First routine LP was performed, if failed, then second LP through para median approach was attempted. The success rate of the para median approach was 100%. In 4 patients (10%) there was bloody tap and LP was done after selecting another space or re-adjusting the needle in the same space. Forty percent patients felt paraesthesia during the advancement of spinal needle into the sub-arachnoid space. In conclusion, in the elderly frail patients with spinal deformity, declared high-risk for general anesthesia and where lumbar puncture through midline approach fails due to spinal abnormalities, para median route is an alternate safe approach with success rate of 100%.     

综合护理干预预防老年髋部骨折患者术后谵妄

目的探讨综合护理干预对老年髋部骨折术后谵妄的预防效果。方法将186例髋部骨折手术老年患者分为对照组94例、观察组92例。对照组行常规护理;观察组实施针对性综合护理干预措施,包括心理干预、疼痛管理、氧疗、视听觉及谵妄前兆的观察、睡眠管理,渐进式功能锻炼。结果观察组谵妄发生率及住院时间显著低于/短于对照组,患者满意率显著高于对照组(P0.05,P0.01)。结论对老年髋部骨折手术患者实施针对性综合护理干预能有效降低术后谵妄发生率,缩短住院时间,从而提高患者满意度。     

老年髋部骨折患者术后2年内再发对侧髋部骨折的危险因素研究

目的:探讨老年髋部骨折患者术后2年内再发对侧髋部骨折的相关危险因素。方法:回顾性分析2015年5月至2018年4月期间北京积水潭医院创伤骨科采用手术治疗的1 962例老年髋部骨折患者资料。男573例,女1 389例;首次骨折时的年龄中位数为81（75,86）岁。根据术后2年内是否发生对侧髋部骨折分为两组：对侧髋部骨折组...     

影响老年髋部骨折患者术后1年死亡率的因素分析

[目的]回顾性分析影响老年髋部骨折患者术后1年死亡率的危险因素。[方法]2010年1月²012年1月,130例年龄>70岁的髋部骨折患者,全部采用人工全髋关节置换术或人工股骨头置换术治疗。分析的因素包括患者的性别、年龄、受伤至入院时间、受伤至手术时间、合并症数目、ASA分级、入院血清白蛋白含量、入院淋巴细胞计数、入院血红蛋白含量以及输血量。手术后随访1年,或者随访至患者死亡。有效随访92例,男28例,女64例。生存率的单因素分析采用Fisher精确检验,多因素分析采用多因素Cox比例风险模型。[结果]92例患者,随访1年内死亡8例,存活84例,院内死亡2例。单因素分析患者术后1年死亡的危险因素包括受伤至入院时间>5 d,ASA分级Ⅲ、Ⅳ级,入院血清白蛋白含量<3.5 g/dl,入院血红蛋白含量<120 g/L以及输血量>1 000 ml;86岁以上患者的死亡率(20.0%)高于702012年1月,130例年龄>70岁的髋部骨折患者,全部采用人工全髋关节置换术或人工股骨头置换术治疗。分析的因素包括患者的性别、年龄、受伤至入院时间、受伤至手术时间、合并症数目、ASA分级、入院血清白蛋白含量、入院淋巴细胞计数、入院血红蛋白含量以及输血量。手术后随访1年,或者随访至患者死亡。有效随访92例,男28例,女64例。生存率的单因素分析采用Fisher精确检验,多因素分析采用多因素Cox比例风险模型。[结果]92例患者,随访1年内死亡8例,存活84例,院内死亡2例。单因素分析患者术后1年死亡的危险因素包括受伤至入院时间>5 d,ASA分级Ⅲ、Ⅳ级,入院血清白蛋白含量<3.5 g/dl,入院血红蛋白含量<120 g/L以及输血量>1 000 ml;86岁以上患者的死亡率(20.0%)高于70⁸5岁患者(5.6%),受伤至手术时间>7 d的患者死亡率(15.8%)高于<7 d的患者(3.0%),但无统计学意义(分别为P=0.065和P=0.061)。多因素分析显示,ASA分级Ⅲ、Ⅳ级和入院血清白蛋白减低是老年髋部骨折患者死亡的独立危险因素。[结论]ASA分级Ⅲ、Ⅳ级和入院血清白蛋白减低是老年髋部骨折患者术后1年死亡的独立危险因素。     

Risk factors for contra-lateral hip fracture in elderly patients with previous hip fracture

Introduction

Contra-lateral hip fractures in elderly patients with a previous hip fracture increase the incidence of complications and socioeconomic burden. The purpose of this study was to identify the risk factors that contribute to the occurrence of contra-lateral hip fracture in elderly patients.

Materials and methods

Among 1093 patients treated for a hip fracture, 47 patients sustained a contra-lateral hip fracture. These patients were compared with 141 patients with a unilateral hip fracture (controls).

Results

The incidence of contra-lateral hip fracture was 4.3% among the 1093 patients treated for a hip fracture at our institute. A contra-lateral hip fracture occurred within 2 years of initial fracture in 66%, and subsequently, the annual incidence rate decreased. A similar fracture pattern was noted in 70% of patients who sustained an intertrochanteric fracture. In terms of preoperative factors, respiratory disease (OR 2.57, P = 0.032) and visual impairment (OR 2.51, P = 0.012) were higher in patients with a contra-lateral hip fracture than in controls, and for postoperative factors, the proportions of patients with postoperative delirium (OR 2.91, P = 0.022), late onset of rehabilitation (OR 1.05, P = 0.023), and poor ambulatory status at 3 months (OR 1.34, P = 0.002) were also significantly higher in patients than in controls.

Conclusions

Postoperative delirium and underlying visual impairment and respiratory disease could be risk factors of contra-lateral fracture in elderly patients. Early and active rehabilitation after surgery is important to prevent the occurrence of contra-lateral hip fracture in the elderly.     

Quality of life after hip fracture surgery in the elderly

As the world population ages, the prevalence of osteoporosis and the incidence of hip fractures will increase dramatically, being responsible for an increase of the health expenditure. On the other hand, there is the inescapable fact of scarcity creating the necessity of making difficult choices with regard to the allocation of human resources. So the question remains: should we carry on investing an important part of our health expenditure for the treatment of hip fractures in elderly people? To answer this statement, we compared 384 hip fracture patients of 70 years and older treated in our department between 1978 and 1983 with 1102 patients treated between 1998 and 2003. Both groups had a prospective follow-up of at least one year. There were no statistically significant differences: mortality rate 24% vs. 23%; good functional outcome 82% vs. 73%; and home going rate 60% vs. 66%. The factors influencing these results were studied. So we can conclude: The number of hip fractures treated nowadays has increased compared with twenty years ago; There is no significant improvement in mortality, nor in quality of life; Age is not a contraindication for hip fracture surgery.     

Impact of length of red blood cells transfusion on postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study

PurposeThe purpose of the present study was to test whether older red blood cells (RBCs) transfusion results in an increased risk of postoperative delirium (POD) and various in-hospital postoperative complications in elderly patients undergoing hip fracture surgery.Materials and methodsPatients (≥65 years) who underwent hip fracture surgery were enrolled, 179 patients were divided into two groups according to the storage time of the RBCs. The shorter storage time of RBCs transfusion group comprised patients who received RBCs ≤14 days old and the longer storage time of RBCs transfusion group comprised patients who received RBCs >14 days old. The blood samples were collected before anaesthesia induction, 4 and 24 h after RBCs transfusion for the determination of proinflammatory mediators, malondialdehyde, and superoxide dismutase activity.ResultsThere was no difference in the baseline characteristics, the incidence of POD, and the in-hospital postoperative complications between the shorter storage time of RBCs transfusion group and the longer storage time of RBCs transfusion groups (P > 0.05). Compared with the shorter storage time of RBCs transfusion group, the longer storage time of RBCs transfusion caused significantly longer duration of POD (P < 0.05). There were significantly increased plasma levels of IL-8 and malondialdehyde at 24 h and IL-1β at 4 h after RBCs transfusion in the POD group compared with the non-POD group (P < 0.05).ConclusionTransfusion of the longer storage RBCs is not associated with a higher incidence of POD or in-hospital postoperative complications, but with longer duration of POD in elderly patients undergoing hip fracture surgery.     

Primary hyperparathyroidism in elderly patients with hip fracture

Primary hyperparathyroidism (PHPT) is associated with low bone mineral density (BMD), but its association with fractures is controversial. Our aim was to evaluate the prevalence of PHPT in hip fracture patients. We studied 444 of 450 consecutive elderly patients (404 women and 40 men) admitted to a rehabilitation hospital after hip fracture. All the fractures were either spontaneous or sustained as a result of minimal trauma. The diagnosis of PHPT was established when both serum calcium adjusted for serum albumin exceeded the normal range and PTH was either elevated or high normal. Also, 444 sex-matched subjects, aged 65 years and older, who were referred for their first osteodensitometry, were studied as controls. Among the hip fracture patients, 21/444 (i.e., 4.7%) fulfilled the diagnostic criteria of PHPT. Logistic multiple regression showed no meaningful associations between PHPT and sex, age, weight, height, fracture type (cervical or trochanteric), and femoral BMD in the hip fracture patients. Among the 444 controls, 5 patients (i.e., 1.13%) fulfilled the diagnostic criteria of PHPT. When evaluated by Pearsons chi-square, the difference in PHPT prevalence between the hip fracture patients and the controls was significant (P < 0.01). Data show that the prevalence of PHPT in a sample of elderly patients after hip fracture was increased when compared to that found in a sample of control subjects, suggesting that PHPT enhances hip fracture risk.     

Policy encouraging earlier hip fracture surgery can decrease the long-term mortality of elderly patients

Background

In April 2004 the Israeli Ministry of Health decided to condition DRG payment for hip surgery by time between hospitalisation and operation, giving a fine for every day's delay beyond 48 h. An evaluation study performed 2 years after the reform has shown the positive influence of the reform on patient's survival in the hospital. This study evaluates the impact of the reform on the longer-term mortality of patients.

Methods

A retrospective study based on data from nine hospitals of the national trauma registry available for the years 2001–2007, with surveillance on 2-year survival through data of Ministry of the Interior. The study population includes patients aged 65 and above with an isolated hip fracture following trauma. Mortality curves and Cox regression were utilised to compare the influence of different parameters on long-term mortality.

Results

Earlier surgery had a significant positive impact on survival through the whole length of the study period. In the period after the introduction of the new reimbursement system for hip fracture surgeries, a significant decrease in the longer-term mortality was observed up to 6 months of follow-up, even when adjusted by patients’ age, gender and the receiving hospital. After 6 months there was no further decrease in relative risk, though the survival advantage remained with patients hospitalised after the reform.

Conclusions

The reform appears successful in decreasing the longer-term patient mortality after hip fracture through influencing surgical practice.     

Predictors of severe pain in the immediate postoperative period in elderly patients following hip fracture surgery

Introduction

The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery.

Patients and methods

Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists’ preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥7 one hour after surgery indicated severe pain.

Results

Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (>12 yr in school) (P < 0.05). Higher cognitive function was associated with higher postoperative pain (P < 0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P < 0.05, P < 0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery.

Conclusion

Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.