Can nutritional and inflammatory indices predict 90-day mortality in fragility hip fracture patients?

INTRODUCTION: Hip fractures in the elderly are related to increased mortality. The identification of patients at risk is essential. Several nutritional and inflammatory parameters were investigated in an effort to find a prognostic indicator for mortality following fragility hip fractures (FHF) surgery. We aim to evaluate their utility and compare between the different factors. METHODS: A retrospective cohort study of patients 65 years and older, who underwent surgery following fragility hip fractures between January 2012 and June 2020, was conducted. Patients who died within 90 days were matched at a 1:1 ratio with surviving controls, based on age, gender, fracture type, and comorbidities. Nutritional and inflammatory indices, including serum albumin, protein energy malnutrition (PEM), albumin-to-globulin ratio (AGR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), and the neutrophile-to-lymphocyte ratio (NLR), were compared between groups. RESULTS: 304 patients were included, 152 in each group. Patients' demographics were similar. Among all indices evaluated, only the PLR significantly differed between the study groups (236.9 ± 193.5 for the study group vs. 186.6 ± 119.3 for the control group (p = 0.007). In patients who survived the initial hospitalization, the PEM was also found to be correlated with 90 days mortality. DISCUSSION: The PLR was found to be correlated with mortality risk following FHF surgery. As it can be easily calculated from accessible blood tests, we recommend its' routine assessment as a screening tool for personalized management of patients at high risk for mortality.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Risk Factors Associated With de Quervain Tenosynovitis in Postpartum Women.

BACKGROUND: De Quervain (DQ) disease is caused by stenosis of the first dorsal compartment containing the abductor pollicis longus and extensor pollicis brevis. This condition affects women 6 times more than men and is also commonly reported in pregnant and lactating women. The natural course of the disease and associated risk factors are not well understood. In this study, we described the gestational risk factors associated with postpartum DQ. METHODS: Sixty-three postpartum women with DQ were included in final study population. Medical records were reviewed for patient characteristics, including age, comorbidities, and body mass index (BMI), and gestational information, including length of pregnancy, gestation number, single or twin birth, and weight at birth. Odds ratio (OR) for developing DQ tenosynovitis were calculated with the control group of 630 postpartum women without DQ who gave birth between 2012 and 2020 in the same district. RESULTS: Length of pregnancy (>40 weeks, OR = 5.81 [3.29-10.28]), first childbirth (OR = 2.23 [1.32-3.77]), and weight (BMI > 25, OR = 2.08 [1.14-3.81]) were all statistically significant risk factors associated with developing DQ. Number of fetuses > 1 (OR = 0.98 [0.29-3.33]) and birth weight more than 3.5 kg (OR = 0.60 [0.30-1.21]) were not associated with higher risk of DQ. CONCLUSIONS: Gestational risk factors associated with developing postpartum DQ include first pregnancy and long pregnancy of more than 40 weeks. Interestingly, child's birthweight and number of fetuses, both factors that might increase load on the first dorsal compartment while holding the child, were not shown to increase the risk of postpartum DQ.

Do cancer patients undergoing surgery for a non-neoplastic related fragility hip fracture have worse outcomes? A retrospective study.

INTRODUCTION: An increasing number of patients sustaining a fragility hip fracture (FHF) have either an active diagnosis or a history of cancer. However, little is known about the outcomes of non-malignant related FHF in this group of patients. We aimed to evaluate the mortality and complications rates during hospitalization, as well as at 1-year follow-up within this population. METHODS: A retrospective cohort study of patients 65 years of age and above, who underwent surgery for the treatment of proximal femoral fractures between January 2012 and June 2016 was conducted. Patients diagnosed with malignancies, both solid (Carcinomas) and a hematological neoplasias (Lymphomas, Multiple Myeloma) were included, along with consecutive controls without a diagnosis of cancer in the 5 years prior to the study period. Demographic, clinical and radiographic parameters were recorded and analyzed. RESULTS: Seven hundred and fifty-two patients with FHF were included, of whom 51 had a malignancy diagnosis within the 5-year period preceding the fracture (18% metastatic disease). The mean time from malignancy diagnosis to FHF was 4.3 ± 4.8 years. Time to surgery did not differ between groups, and the vast majority of patients from both groups (over 87%) were operated within the desirable 48 h from admission. Patients with malignancy had a higher probability of being admitted to an internal medicine department both pre and post-surgically (p < 0.001), and were more susceptible to pre-operative anemia (p = 0.034). In-hospital mortality did not differ between groups, yet 1-year mortality was higher for the malignancy group (41.2% vs 19.5%, p < 0.001). At 1-year post-operatively, orthopedic complications were similar between groups. CONCLUSION: Patients with a history of malignancy in the 5-years prior to a non-neoplastic FHF, showed similar mortality and complications rates during admission but increased 1 year mortality rate when compared to patients without cancer undergoing surgical treatment of a non-neoplastic proximal femoral fracture.

Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons?

BACKGROUND: As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon. METHODS: A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents. RESULTS: In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons. CONCLUSION: A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.

Thickness of the Subcutaneous Fat as a Risk Factor for Surgical Site Infection Following Fragility Hip Fracture Surgery.

INTRODUCTION: Surgical site infection (SSI) following fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. SIGNIFICANCE: Prediction of patients at risk for SSI is fundamental. We aimed to determine whether subcutaneous radiographic fat measurement (SRM) is associated with increased SSI risk. METHODS: A retrospective case-control comparison of SRMs at 3 locations around the hip. Patients diagnosed with SSI in the first post-operative year were matched with age, gender, surgical year, Charlsons' co-morbidity index score, and surgical type controls, not diagnosed with SSI, at a 1:2 ratio. Measurements included the distance between (1) the sourcil to skin surface (SS), (2) the tip of the greater trochanter to skin surface (TGTS), and (3) the most prominent lateral aspect of the greater trochanter to skin surface. RESULTS: 1430 patients were operated during the study period, of whom 45 patients presented with a diagnosis of SSI and compared to 90 controls. Infections occurred 27.4 ( ± 24.8) days following surgery. SRM significantly differed between groups, and all were higher in the study group; SS, 86.8 ± 25.5 cm vs 74.2 ± 15.3 cm; TGTS, 59.8 ± 26.3 cm vs 47.0 ± 15.8 cm; and LGTS, 45.4 ± 25.1 cm vs 33.2 ± 15.1 cm (P = .003, .004, and .004, respectively). Intraclass correlation coefficients (intra-rater) were high for all measurements (.999 for all). Intraclass correlation coefficients (inter-rater) for SS, TGTS and LGTS were high, .749 (.663.815), .792 (.719.847) and .817 (.751.866), respectively. CONCLUSIONS: SRMs were found to be a valid and reproducible tool for predicting high risk of SSI in geriatric patients sustaining FHFs. LEVEL OF EVIDENCE: III.

Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture.

INTRODUCTION: Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery. MATERIALS AND METHODS: A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year. RESULTS: Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson's co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar. CONCLUSIONS: Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.

[CAN HIP FRACTURE PATTERN OR TYPE OF SURGERY PREDICT ONE-YEAR MORTALITY OR MOBILITY?]

BACKGROUND: Several demographic and medical factors have an established effect on mortality and function after hip fractures, however varying fracture characteristics and surgical factors have been less thoroughly investigated. The study assessed the impact of specific fracture patterns on mortality and mobility one year post hip fracture. Other surgical factors including the type of intervention, major complications and sequential fractures were assessed as well. METHODS: An institutional hip fracture registry was reviewed. Mobility status scores were calculated one year post-operatively. RESULTS: Thirty days mortality was 4.6% and one year mortality was 19.9%. There was no significant effect of fracture type on mortality. However, patients receiving hemiarthroplasty had a significantly higher mortality (28.1%) than other patients receiving internal fixation (18.6%) or total hip arthroplasty (4%). An increased mobility status after intra-capsular fractures over extracapsular fractures was demonstrated. Patients receiving total hip arthroplasty had significantly better mobility at one year than patients with fracture fixation or hemiarthroplasty. Major complications and sequential fractures had no significant effect on outcome. CONCLUSIONS: Critical factors that influence decision making for orthopedic surgeons are revealed to have a lesser effect on the patient's ultimate outcome.

Mortality and Function after Hip Fractures in Different Ethnic Populations in Israel.

BACKGROUND: Mortality and decrease in function after hip fracture are significantly related to patient factors including age, gender, co-morbidities, and mental status. Several studies demonstrated ethnic disparities in incidence, mortality, and functional outcome after hip fractures in the United States. OBJECTIVES: To assess the relationship between ethnicity and hip fracture incidence and outcomes of mortality, functional change, and perioperative complications in the Israeli population. METHODS: We reviewed our institutional hip fracture registry for all patients from 2014-2015. Patients with incomplete data, < 60 years of age, or pathologic and periprosthetic fractures were excluded. Our study comprised 693 patients. Ethnicity was based on country of birth. Specifically, for those born in Israel, the nationality of either Jewish or Arab was further dichotomized. Perioperative complications, mortality, and mobility status at 1 year follow-up were recorded. The ethnicities of 27,130 patients admitted to the medicine and surgical wards during the same time interval served as a control group for the hip fracture cohort. RESULTS: Immigrants from Europe and America had the highest incidence of hip fractures. Fracture types varied in incidence in groups with 70% of extracapsular hip fractures occurring in Arabs and immigrants from Eastern countries, compared to 60% in immigrants from Western countries and the former Soviet Union. Mortality, perioperative complications, and mobility at 1 year were similar in all ethnic groups. CONCLUSIONS: Our study demonstrated significant differences in incidence and fracture characteristic among ethnicities, but no difference in patient outcome. These findings differed from the available North American studies.

A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization?

INTRODUCTION: Hip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards. PATIENTS AND METHODS: A retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts. RESULTS: 102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9±5.1 vs. 10.8±6.7days, p=0.022) and presented a lower in-hospital complication rates (0.6±0.96 vs. 1±1.9, p=0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p=0.004, 3.9% vs. 14.5%, p=0.010 and 2.9% vs. 12.2%, p=0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups. CONCLUSIONS: Our study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times.

Cardiac involvement in HIV-positive patients.

INTRODUCTION: The history of HIV/AIDS in Romania is different compared to the rest of the world. Here, the vast majority of HIV-positive patients have been infected since infancy and have been receiving HAART treatment for at least ten years. This situation is a unique environment to check for long-term cardiac involvement in HIV-positive patients with a long evolution of the infection. METHODS: A group of 40 HIV-positive patients were randomly selected to undergo an echocardiogram to check for cardiac involvement. Data collection took place at the National Institute for Infectious Diseases "Prof.Dr. Matei Bals" in Bucharest, Romania, from September 2011 to February 2012. Patients were examined and compared based on cardiovascular risk factors and disease risk factors described in field literature, including: age, gender, blood pressure, lipid profile, glucose, HbA1c, lifestyle habits, time from infection, duration of treatment and drug class use. RESULTS: The median age of patients was 23, with a mean time from infection of 20.85 years and a duration of treatment of 15.9 years. Out of the 40 patients included in the study, 15 (37.5%) had cardiac involvement such as hyperkinetic syndrome, hypertrophy, atheroma, pulmonary hypertension or overlapping syndromes. The main risk factors were: male gender (OR 3.187, 90%CI 1.038-9.779), high cholesterol (>200 mg/dL) or smoking (OR 2.538, 90%CI 0.789-8.163), with a high risk for cardiac involvement in patients that were smokers and also had high levels of cholesterol (OR 5.75, 90%CI 1.263-26.169). CONCLUSION: An important aspect of this study is that both major risk factors identified are modifiable to an extent, and while cholesterol levels can be controlled with lipid-lowering medication, smoking can be stopped with or without replacement therapy. We need to stress on the importance of smoke-reducing policies and, particularly, encouraging young patients to not start smoking.