Validation of the Geriatrics at Risk Score (GeRi-Score) on 120-day follow-up, the influence of preoperative geriatric visits, and the time to surgery on the outcome of hip fracture patients: an analysis from the Registry for Geriatric Trauma (ATR-DGU).

A validation of the GeRi-Score on 120-day mortality, the impact of a pre-operative visit by a geriatrician, and timing of surgery on the outcome was conducted. The score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h or a preoperative geriatric visit. PURPOSE: Numerous tools predict mortality among patients with hip fractures, but they include many variables, require time-consuming assessment, and are difficult to calculate. The GeRi-Score provides a quick method of pre-operative assessment. The aim of this study is to validate the score in the 120-day follow-up and determine the impact of a pre-operative visit by a geriatrician and timing of surgery on the patient outcome. METHODS: A retrospective analysis of the AltersTraumaRegister DGU® from 2017 to 2021 was conducted, including all proximal femur fractures. The patients were divided into low-, moderate-, and high-risk groups based on the GeRi-Score. Mortality was analyzed using logistic regression. To determine the influence of the time to surgery and the preoperative visit by a geriatrician, matching was performed using the exact GeRi-Score, preoperative walking ability, type of fracture, and the time to surgery. RESULTS: The study included 38,570 patients, divided into 12,673 low-risk, 18,338 moderate-risk, and 7,559 high-risk patients. The moderate-risk group had three times the mortality risk of the low-risk group (OR 3.19 (95% CI 2.68-3.79; p<0.001)), while the high-risk group had almost eight times the mortality risk than the low-risk group (OR 7.82 (95% CI 6.51-9.93; p<0.001)). No advantage was found for surgery within the first 24 h across all groups. There was a correlation of a preoperative geriatric visit and mortality showing an increase in the moderate and high-risk group on in-house mortality. CONCLUSIONS: The GeRi-Score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h. The analysis did not demonstrate a benefit of the preoperative geriatric visit, but more data are needed.

[Effects of the COVID-19 pandemic on the course of geriatric trauma patients with proximal femoral fractures]. / Auswirkungen der COVID-19-Pandemie auf den Verlauf von alterstraumatologischen Patienten mit proximaler Femurfraktur.

BACKGROUND/OBJECTIVE: In 2020 the COVID-19 pandemic posed a major challenge to the healthcare system. The hypothesis is that the COVID-19 pandemic in 2020 had an impact on the care of older adults with proximal femoral fractures due to resource scarcity, regardless of whether or not the patient was infected. MATERIAL AND METHODS: This study analyzed the data of 87 hospitals which entered 15,289 patients in the Geriatric Trauma Register ("AltersTraumaRegister DGU®", ATR-DGU) in Germany in 2019 and 2020. In this study we analyzed the influence of the COVID-19 pandemic on the inpatient treatment of hip fractures as well as the mid-term follow-up during the first 120 days. For the main analysis, we compared patients documented during the COVID-19 pandemic in 2020 (April-December) with a control group in 2019 (April-December). Additionally, we performed a subgroup analysis of the periods with high COVID-19 incidence rates. RESULTS: Between 2019 and 2020 a total of 11,669 patients (2020: n = 6002 patients vs. 2019: n = 5667 patients) were included in this study. Only minor differences were found between the patients treated during the pandemic; however, when the COVID-19 incidence in Germany was greater than 50/100,000 residents, significantly fewer patients (p < 0.001) were discharged to a geriatric rehabilitation ward (27.2% vs. 36.3%) and an increased mortality rate during inpatient treatment was determined (8.4% vs. 4.6%) (p < 0.001). DISCUSSION: The healthcare system was able to respond to the pandemic and patients' clinical courses were not impaired as long as the incidences were low. Nevertheless, the healthcare system reached its limits in times of higher incidence, which was also directly reflected in the patient outcome, mortality and place of discharge.

Cemented Sacroiliac Screw Fixation versus Conservative Therapy in Fragility Fractures of the Posterior Pelvic Ring: A Matched-Pair Analysis of a Prospective Observational Study.

The aim of this study was to compare the outcome of cemented sacroiliac screw fixation to that of conservative treatment in nondisplaced fragility fractures of the sacrum during a 12-month follow-up. Therefore, matched-pair analysis including 40 patients from a previously performed prospective observational study was conducted. Pain was assessed using the visual analogue scale (VAS), functional capabilities and mobility were assessed using the Barthel index, and health-related quality of life (HRQL) was assessed using the EQ-5D questionnaire at 6 weeks, 6 months, and 12 months after the fracture, respectively. No significant differences between the two groups were seen regarding pain. In the operative group, a significantly improved Barthel index was observed after 6 months. A significantly higher HRQL was identified after 6 weeks in the operative group. Their mobility was comparable between the two groups before the fracture; after 6 weeks, mobility was significantly improved in the operative group. After 12 months, no significant differences were found regarding the functional outcome, HRQL or mobility. The 1-year mortality rate was 25% in the conservative group versus 5% in the operative group (not statistically significant). The present study revealed favorable short-term outcomes concerning the functional outcome, HRQL and mobility after sacroiliac screw fixation. After 12 months, the outcomes were similar to those of the patients managed conservatively.

Liberal intraoperative fluid management leads to increased complication rates in geriatric patients with hip fracture.

PURPOSE: Fractures of the proximal femur in geriatric patients are life-changing and life-threatening events. Previous research has identified fluid volume as an independent factor contributing to trauma patients' complications. Therefore, we aimed to investigate the impact of intraoperative fluid volume on outcomes in geriatric patients undergoing hip fracture surgery. METHODS: We conducted a retrospective single-center study with data from the hospital information systems. Our study included patients aged 70 years or older who had sustained a proximal femur fracture. We excluded patients with pathologic, periprosthetic, or peri-implant fractures and those with missing data. Based on the fluids given, we divided patients into high-volume and low-volume groups. RESULTS: Patients with a higher American Society of Anesthesiologists (ASA) grade and more comorbidities were more likely to receive more than 1500 ml of fluids. We observed significant differences in anesthesiologic management between the two groups, with a higher rate of invasive blood pressure management (IBP) and central venous catheter usage in the high-volume group. High-volume therapy was associated with a higher rate of complications (69.7% vs. 43.6%, p < 0.01), a higher transfusion rate (odds ratio 1.91 [1.26-2.91]), and an increased likelihood of patients being transferred to an intensive care unit (17.1% vs. 6.4%, p = 0.009). These findings were confirmed after adjusting for ASA grade, age, sex, type of fracture, Identification-of-Seniors-At-Risk (ISAR) score, and intraoperative blood loss. CONCLUSIONS: Our study suggests that intraoperative fluid volume is a significant factor that impacts the outcome of hip fracture surgery in geriatric patients. High-volume therapy was associated with increased complications.

Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU).

BACKGROUND: Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU). METHODS: A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models. RESULTS: A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 - 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 - 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group. CONCLUSIONS: SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS.

The Influence of Malnutrition Measured by Hypalbuminemia and Body Mass Index on the Outcome of Geriatric Patients with a Fracture of the Proximal Femur.

Background and Objectives: Fractures of the proximal femur are a life-changing and life-threatening event for older people. Concomitant malnutrition has been described as an independent risk factor for complications and mortality. Therefore, we examined the influence of albumin and body mass index (BMI) as parameters for the nutritional state on the outcome after geriatric hip fracture surgery. Materials and Methods: Data were retrospectively collected from hospital information systems, and complications and all other parameters were obtained from patient charts. We included patients aged 70 years or above with a fracture of the proximal femur. We excluded periprosthetic and peri-implant fractures and patients with a missing BMI or albumin value. Results: Patients with a BMI below 20 kg/m2 were more likely to be female but did not differ from the normal BMI group in terms of baseline parameters. Patients with hypoalbuminemia had a higher ASA grade and Charlson Comorbidity Index, as well as a lower hemoglobin value and prothrombin time compared to those with normal albumin values and low BMI. Hypoalbuminemia was associated with significantly increased rates of complications (57.9% vs. 46.7%, p = 0.04) and mortality (10.3% vs. 4.1%, p = 0.02). Blood loss and transfusion rates were higher in the hypoalbuminemia group. Patients with a BMI below 20 kg/m2 had a higher risk of intraoperative cardiac arrest (2.6% vs. 0.4%, p = 0.05) but did not show higher mortality rates than patients with a BMI above 20 kg/m2. However, the outcome parameter could not be confirmed in the regression analysis. Conclusions: Hypoalbuminemia might be an indicator for more vulnerable patients with a compromised hemoglobin value, prothrombin time, and ASA grade. Therefore, it is also associated with higher mortality and postoperative complications. However, hypoalbuminemia was not an independent predictor for mortality or postoperative complications, but low albumin values were associated with a higher CCI and ASA grade than in patients with a BMI below 20 kg/m2.

The Predictive Value of the "Identification of Seniors at Risk" Score on Mortality, Length of Stay, Mobility and the Destination of Discharge of Geriatric Hip Fracture Patients.

Purpose: The German Society for Geriatrics recommends the "ISAR" questionnaire as a screening tool for patients ≥70 for geriatric screening in emergency rooms. Although the ISAR-score is collected routinely in the "AltersTraumaRegister DGU®" (ATR-DGU), to date less is known about the predictive value of the "ISAR"-score in geriatric trauma patients. Patients and Methods: Currently, 84 clinics participate in the ATR-DGU. This evaluation is limited to the subgroup of proximal femur fractures from 2016-2018. Patients ≥70 years, who underwent surgery for a hip fracture are included in the ATR-DGU. In this evaluation, the influence of the "ISAR"-score on mortality, length of stay, mobility and the destination of discharge was examined. Results: Overall 10,098 patients were included in the present study. The median age was 85 years (interquartile range (IQ) 80-89 years). According to the ISAR-score 80.6% (n=8142) of the patients were classified as geriatric patients (cut off "ISAR"-score ≥2 points). These group of patients had a length of stay of 16 days (IQ10.1-22.1) compared to the non-geriatric patient cohort showing a length of stay of 15 days (IQ10.1-20.1). Patients showing an ISAR-score ≥2 had an increased risk of being discharged to a nursing home (OR 8.25), not being able to walk (OR 12.52) and higher risk of mortality (OR 3.45). Conclusion: The "ISAR"-score shows predictive power for the length of stay, mobility, hospital mortality and discharge after hospital in the collective of geriatric trauma patients. It therefore seems suitable as a screening tool for geriatric trauma patients in the emergency department and should be considered in this context.

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®.

Background and Objectives: The increased use of direct oral anticoagulants (DOACs) results in an increased prevalence of DOAC treatment in hip fractures patients. However, the impact of DOAC treatment on perioperative management of hip fracture patients is limited. In this study, we describe the prevalence of DOAC treatment in a population of hip fracture patients and compare these patients with patients taking vitamin K antagonists (VKA) and patients not taking anticoagulants. Materials and Methods: This study is a retrospective analysis from the Registry for Geriatric Trauma (ATR-DGU). The data were collected prospectively from patients with proximal femur fractures treated between January 2016 and December 2018. Among other factors, anticoagulation was surveyed. The primary outcome parameter was time-to-surgery. Further parameters were: type of anesthesia, surgical complications, soft tissue complications, length of stay and mortality. Results: In total, 11% (n = 1595) of patients took DOACs at the time of fracture, whereas 9.2% (n = 1325) were on VKA therapy. During the study period, there was a shift from VKA to DOACs. The time-to-surgery of patients on DOACs and of patients on VKA was longer compared to patients who did not take any anticoagulation. No significant differences with regard to complications, type of anesthesia and mortality were found between patients on DOACs compared to VKA treatment. Conclusion: An increased time-to-surgery in patients taking DOACs and taking VKA compared to non-anticoagulated patients was found. This underlines the need for standardized multi-disciplinary orthopedic, hematologic and ortho-geriatric algorithms for the management of hip fracture patients under DOAC treatment. In addition, no significant differences regarding complications and mortality were found between DOAC and VKA users. This demonstrates that even in the absence of widely available antidotes, the safe management of geriatric patients under DOACs with proximal femur fractures is possible.

COVID-19 and Proximal Femur Fracture in Older Adults-A Lethal Combination? An Analysis of the Registry for Geriatric Trauma (ATR-DGU).

OBJECTIVES: COVID-19 can be a life-threatening illness, especially for older patients. The COVID-19 outbreak created a dramatic organizational challenge in treating infected patients requiring surgical treatment, like those suffering a proximal femur fracture, in a pandemic setting. We investigate the impact of a COVID-19 infection in patients with a proximal femur fracture not only on mortality but also on quality of life (QoL), length of stay, and discharge target. DESIGN: Retrospective cohort analysis from July 1, 2020, to December 31, 2020. The Registry for Geriatric Trauma collected the data prospectively. Patient groups with and without COVID-19 infection were compared using linear and logistic regression models. SETTING AND PARTICIPANTS: Retrospective multicenter registry study including patients aged ≥70 years with proximal femur fracture requiring surgery from 107 certified Centers for Geriatric Trauma in Germany, Austria, and Switzerland. MEASURES: The occurrence and impact of COVID-19 infection in patients suffering a proximal femur fracture were measured regarding in-house mortality, length of stay, and discharge location. Moreover, QoL was measured by the validated EQ-5D-3L questionnaire. RESULTS: A total of 3733 patients were included in our study. Of them, 123 patients tested COVID-19 positive at admission. A COVID-19 infection resulted in a 5.95-fold higher mortality risk (odds ratio 5.95, P < .001], a length of stay prolonged by 4.21 days [regression coefficient (ß) 4.21, P < .001], a reduced QoL (ß -0.13, P = .001), and a change in discharge target, more likely to their home instead of another inpatient facility like a rehabilitation clinic (P = .013). CONCLUSIONS AND IMPLICATIONS: The impact of a COVID-19 infection in patients suffering a proximal femur fracture is tremendous. The infected patients presented a dramatic rise in mortality rate, were significantly less likely to be discharged to a rehabilitation facility, had a longer in-hospital stay, and a reduced QoL.

Impact of concomitant injuries in geriatric patients with proximal femur fracture : an analysis of the Registry for Geriatric Trauma.

AIMS: The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures. METHODS: A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries. RESULTS: A total of 22,602 patients met the inclusion criteria. The overall prevalence of a concomitant injury was 8.2% with a predominance of female patients (8.7% vs 6.9%; p < 0.001). Most common were fractures of the ipsilateral upper limb. Concomitant injuries resulted in prolonged time-to-surgery (by 3.4 hours (95 confidence interval (CI) 2.14 to 4.69)) and extended length of stay in hospital by 2.2 days (95% CI 1.74 to 2.61). Mortality during the admission was significantly higher in the concomitant injury group (7.4% vs 5.3%; p < 0.001). Additionally, walking ability and quality of life were reduced in these patients at discharge. More patients were discharged to a nursing home instead of their own home compared to patients without additional injuries (25.8% vs 30.3%; p < 0.001). CONCLUSION: With a prevalence of 8.2%, the appearance of a concomitant injury is common in elderly patients with hip fracture. These patients are at a greater risk for death during the admission, longer hospital stays, and delayed surgery. This knowledge is clinically important for all who are involved in the treatment of proximal femur fractures. Cite this article: Bone Joint J 2021;103-B(9):1526-1533.

Which factors influence treatment decision in fragility fractures of the pelvis? - results of a prospective study.

BACKGROUND: The aim of the present study was to describe specific characteristics of patients suffering from pelvic fragility fractures and evaluate factors that might influence treatment decisions which may optimize treatment pathways and patient mobility in the future. METHODS: A prospective study with patients suffering from fractures of the pelvis and aged 60 years or above was performed between 2012 and 2016. Data acquisition took place at admission, every day during hospitalization and at discharge. RESULTS: One hundred thirty-four patients (mean age of 79.93 (± 7.67) years), predominantly female (84%), were included. Eighty-six patients were treated non-operatively. Forty-eight patients underwent a surgical procedure. The main fracture types were B2 fractures (52.24%) and FFP IIb fractures (39.55%). At the time of discharge, pain level (NRS) could be significantly reduced (p <  0.001). Patients who underwent a surgical procedure had a significantly higher pain level on day three and four compared to the non-operative group (p = 0.032 and p = 0.023, respectively). Significant differences were found in the mobility level: patients treated operatively on day four or later were not able to stand or walk on day three as compared to non-operatively treated patients. Regarding B2 fractures, a significantly higher mobility level difference between time of admission and discharge was found in patients treated with a surgical procedure compared to patients treated non-operatively (p = 0.035). CONCLUSIONS: Fracture type, mobility level and pain level influence the decision to proceed with surgical treatment. Especially patients suffering from B2 fractures benefitted in terms of mobility level at discharge when treated operatively. LEVEL OF EVIDENCE: II.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications.

Backgroundand Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialisand Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017-2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81-89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction-3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures-Results from the Registry for Geriatric Trauma of the German Trauma Society.

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

Four-month outcome after proximal femur fractures and influence of early geriatric rehabilitation: data from the German Centres of Geriatric Trauma DGU.

This study analyzed the outcome of orthogeriatric patients with hip fracture 4 months after surgery. The overall mortality rate was 12.2%. Sixty-five percent presented a degradation in walking ability, and 16% had to move to a nursing home. Early geriatric rehabilitation reduces the mortality rate and increases the rate of anti-osteoporotic treatment. PURPOSE: Hip fractures are increasingly common with severe consequences. Therefore, the German Trauma Society (DGU) implemented an orthogeriatric co-management and developed the concept for certified Centre for Geriatric Trauma DGU. The patients' treatment data and the optional 120 days of follow-up were collected in the Registry for Geriatric Trauma DGU (ATR-DGU). This study analyzed these 4-month treatment results. METHODS: A retrospective analysis of the ATR-DGU was conducted. Outcome parameters were the rate of readmission, rate of re-surgery, anti-osteoporotic therapy, housing, mortality, walking ability, and quality of life (QoL) 120 days post-surgery. The influence of the early geriatric rehabilitation (EGR) was evaluated using a regression analysis. RESULTS: The follow-up data from 9780 patients were included. After 120 days, the mortality rate was 12.2%, the readmission rate 4%, and the re-surgery rate 3%. The anti-osteoporotic treatment increased from 20% at admission to 32%; 65% of the patients had a degradation in walking ability, and 16% of the patients who lived in their domestic environment pre-surgery had to move to a nursing home. QoL was distinctly reduced. The EGR showed a positive influence of anti-osteoporotic treatment (p<0.001) and mortality (p=0.011) but led to a slight reduction in QoL (p=0.026). CONCLUSION: The 4-month treatment results of the ATR-DGU are comparable to international studies. The EGR led to a significant rise in anti-osteoporotic treatment and a reduction in mortality with a slight reduction in QoL.

Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®.

BACKGROUND: Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units. METHODS: We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU®. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate. FINDINGS: A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80-89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA ≥ 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35-5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48-4.3), ISAR ≥ 2 (OR 1.88, 95% CI 1.33-2.76), and male gender (OR 1.71, 95% CI 1.39-2.09). INTERPRETATION: Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.

Medical and economic consequences of perioperative complications in older hip fracture patients.

Patients suffering from complications during inpatient treatment after hip fracture surgery are associated with a worse mid-term outcome. While surgically treatable complications only delay the healing process, internal complications seem to worsen the outcome in the long run. All complications come with significant increased costs during the hospital stay. PURPOSE: Due to the demographic changes, the importance of hip fractures is still increasing nowadays. Not only surgical but also medical complications represent a major challenge in the treatment of those patients. Nevertheless, only few is known about the functional, medical, and economic consequences of complications. METHODS: A total of 402 hip fracture patients ≥ 60 years were observed prospectively at a German university hospital. Complications were assessed during the inpatient stay and classified by Clavien and Dindo. Afterwards their influence on acute care costs was examined as well as their influence on the mortality, health-related quality of life (HRQL) (EQ5D), functional capacities (Barthel index), and mobility (Tinetti score) in the follow-up periods of 6 and 12 months. RESULTS: Complications that required surgical revision/treatment (type III) were associated with an increased 6 months' mortality, while type II and IV complications did not influence mortality after 6 and 12 months. Six months after surgery, HRQL, Barthel score, and Tinetti score were reduced in patients suffering from all different types of complications. After 12 months however, HRQL, Barthel score, and Tinetti score following type II and IV complications remained reduced, while the scores improved in patients suffering from type III complication. All types of complications led to significantly increased acute care costs. CONCLUSIONS: The results of the present study emphasize the crucial role of perioperative complications in older patients with hip fractures. Therefore, special attention has to be given to the prevention of those complications, e.g., with orthogeriatric treatment models, which have been shown to be effective in the reduction of complications.

Type of underlying fracture after the surgical treatment of geriatric trauma patients has no effect on mortality during intensive care treatment.

AIM: Due to demographic change, the number of geriatric patients is still rising. Although hip fractures are the subject of current research, little is known about the remaining geriatric trauma entities. The aim of this study was to collect data of the age-related traumatological intensive care unit (ICU) population, its underlying diagnosis, and the influence on mortality and length of stay in the ICU. METHODS: Geriatric trauma patients (aged ≥65 years) treated postoperatively in our surgical ICU were included in this retrospective observational study covering the period 2013-2017. In addition to the underlying fracture entities, patient characteristics, such as age, sex, Charlson Comorbidity Index, length of stay and mortality, were collected to identify possible independent predictive factors for mortality in the ICU using multivariate analysis. RESULTS: During the observation period, 805 (60.5%) patients met the inclusion criteria. 47.6% of the patients suffered from a proximal femoral fracture. The total mortality rate during the stay in the ICU was 7.5%. Significant predictive factors for mortality in the ICU were Charlson Comorbidity Index (P < 0.001) and length of stay (P < 0.001). The different fracture types themselves were not a significant risk factor for mortality (P = 0.862). CONCLUSION: Patients with proximal femoral fractures account for approximately half of the patients in intensive care. The mortality rate of these patients is no higher than that in geriatric trauma patients with other fractures. The progression is essentially influenced by the patient's comorbidities. Nowadays, the focus shifts from trauma care to the therapy of concomitant diseases. Nevertheless, this cohort, when adequately treated, shows a comparatively low mortality rate. Geriatr Gerontol Int 2020; 20: 1120-1125.

What are the influencing factors in self-rated health status after hip fracture? A prospective study on 402 patients.

Health status (HS) and influencing factors in HS were evaluated six and 12 months after hip fracture. One-third of the patients did not reach their pre-fracture HS within 1 year. HS before fracture and fall risk could, inter alia, be identified as influencing factors. PURPOSE: From a patient's perspective, regaining pre-fracture health status (HS) is one of the most important factors concerning the outcome after hip fracture. The aim of this study was to evaluate the HS and particularly to identify influencing factors in HS 6 and 12 months after hip fracture. METHODS: A total of 402 patients with hip fractures aged 60 years and older were included. HS was evaluated using the EQ-5D questionnaire pre-fracture and at 6 and 12 months after surgery. Multivariate regression analysis was performed to identify influencing factors in HS at 6 and 12 months. Afterwards, the results in the EQ-5D index were dichotomized into worse and equal/better results than before fracture, and a multivariate logistic regression analysis was performed for the dichotomized variables at 6 and 12 months. RESULTS: The EQ-5D index decreased from 0.71 before the fracture to 0.60 at 6 months (p < 0.001) and increased slightly to 0.63 at 12 months (p = 0.328). A high pre-fracture EQ-5D index was associated with not reaching the pre-fracture EQ-5D index, and a high Tinetti score at hospital discharge was associated with reaching the pre-fracture EQ-5D index at 6 and 12 months. A high ASA score was an influencing factor behind a lower EQ-5D index than before the fracture at 6 months. CONCLUSIONS: Hip fractures constitute a deep and long-lasting drop in the patients' HS. Early and intensive physiotherapy and individualized rehabilitation programmes regarding a patient's living situation before the fracture seem to be essential to improve HS.

Development of the Barthel Index 5 years after hip fracture: Results of a prospective study.

AIM: The importance of proximal femoral fractures is increasing due to demographic change. Despite appropriate care, these are associated with poor results. We are still lagging behind, and require information on the long-term functional outcome of these patients and the predictive factors involved. METHODS: Between 2009 and 2011, 402 patients aged >60 years with hip fractures were included in this prospective observational study. Patients were assessed with the Barthel Index before fracture, at discharge, and 6 months, 1 year and 5 years after surgery. In addition, a variety of parameters (sex, age, fracture type, American Society of Anesthesiologists classification, Mini-Mental State Examination, housing situation, occurrence of complications during inpatient stay and type of care) were collected to identify the possible independent predictive factors using multivariate analysis. RESULTS: The lowest Barthel Index was found at discharge (66 ± 24) for patients from an acute hospital. The Barthel Index improved within the first 6 months (86 ± 21) and decreased afterwards. The factors associated with a significantly higher point loss of the Barthel Index in the multivariate analysis were age (P-value 0.020), pre-fracture Barthel Index, (P ≤ 0.001), Mini-Mental State Examination (P ≤ 0.001) and type II complications (P = 0.001). The other values showed no significant influence on the Barthel Index. CONCLUSIONS: The present results showed that patients after a hip fracture have a great rehabilitation potential within the first 6 months after the event. More attention should be paid to type II complications and the occurrence of cognitive impairment. Both seem to be a surrogate parameter for the frailty of the patients. Geriatr Gerontol Int 2019; 19: 809-814.

Risk factors for secondary displacement in conservatively treated isolated greater tuberosity fractures: An analysis of 82 cases.

INTRODUCTION: The optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed. HYPOTHESIS: Certain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures. PATIENTS AND METHODS: All patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity. RESULTS: 82 patients (42 male, 40 female) were eligible for further analyses. Median follow-up was 8.0±39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7±15.5, group 2: 68.3±14.3; p<0.001) and had significantly more shoulder dislocations (p=0.024), whereas gender (p=0.299), side of fracture (p=0.189) and fragment/head ratio (p=0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement. DISCUSSION: The present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement. LEVEL OF PROOF: III, Retrospective comparative study.