Comparison of the Charlson Comorbidity Index with the ASA score for predicting 12-month mortality in acute hip fracture.

BACKGROUNDS: The ASA (American Society of Anaesthesiologists) Score is the current standard for measuring comorbidity in the Australian Hip Fracture registry, however it has never been validated for this purpose. Subsequently, a more appropriate and useful measure should be investigated. This study aimed to compare the ASA and Charlson Comorbidity Index (CCI) scores in predicting 12-month mortality following acute hip fracture. METHODS: A retrospective analysis was performed on an audit database of patients who were admitted to an orthogeriatric unit in a public metropolitan hospital from November 2010 to October 2011. 12-month mortality data was linked through a dual search of Queensland Health and mortality registry data. The Charlson comorbidity index was retrospectively applied. Demographics (age, gender, admission residence) and covariates including ASA, CCI, fracture type, fixation type, cognitive impairment on admission, BMI and time to surgery were analysed with logistic regression. ROC curve analysis was performed to assess varying thresholds for each comorbidity system. RESULTS: A total of 320 patients were available for audit. Unadjusted bivariate analysis demonstrated significant difference between groups regarding increased age (p = 0.004), ASA score (p<0.001), CCI (p = 0.002), age-adjusted CCI (p = 0.002) and admission from a care facility (p<0.001). Logistic regression analysis demonstrated that only ASA (p<0.001) and admission from a care facility (p<0.001, OR=3.36, 95% CI = 1.9 - 6.0) independently predicted 12-month mortality; CCI was not a significant predictor in any models (p = 0.827, age-adjusted CCI: p = 0.864). Using ROC analysis, the ASA (AUC=0.668) outperformed either CCI (AUC=0.607 (CCI), AUC=0.614 (CCI age-adjusted). CONCLUSIONS: The ASA score is independently associated with 12-month mortality; this was not replicated using either version of the CCI. The data does not suggest using the CCI in registry level datasets for the purposes of predicting 12-month mortality.

Effects of anticoagulants on outcome of femoral neck fracture surgery.

PURPOSE: To review records of 330 patients who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy. METHODS: Medical records of 235 women and 95 men aged 48 to 103 years (mean, 81.6; standard deviation [SD], 13.1) who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy were reviewed. 30 patients were on warfarin, 105 on aspirin, 28 on clopidogrel, and 167 were controls. The latter 3 groups were combined as the non-warfarin group and compared with the warfarin group. Hospital mortality, time from admission to surgery, length of hospital stay, return to theatre, and postoperative complications (wound infection, deep vein thrombosis, and pulmonary embolism) were assessed. RESULTS: The warfarin and control groups were significantly younger than the clopidogrel and aspirin groups (80.8 vs. 80.0 vs. 84.2 vs. 83.7 years, respectively, p<0.05). 81% of the patients underwent surgery within 48 hours of admission. The overall mean time from admission to surgery was 1.8 days; it was longer in the warfarin than the aspirin, clopidogrel, and control groups (3.3 vs. 1.8 vs. 1.6 vs. 1.6 days, respectively, p<0.001). The mean length of hospital stay was 17.5 (SD, 9.6; range, 3-54) days. The overall hospital mortality was 3.9%; it was 6.7% in the warfarin group, 3.8% in the aspirin group, 3.6% in the clopidogrel group, and 3.6% in the control group (p=0.80). Four patients returned to theatre for surgery: one in the warfarin group for washout of a haematoma, 2 in the aspirin group for repositioning of a mal-fixation and for debridement of wound infection, and one in the control group for debridement of wound infection. The warfarin group did not differ significantly from non-warfarin group in terms of postoperative complication rate (6.7% vs. 2.7%, p=0.228) and the rate of return to theatre (3.3% vs. 1%, p=0.318). CONCLUSION: It is safe to continue aspirin and clopidogrel prior to surgical treatment for femoral neck fracture. The risk of delaying surgery outweighs the peri-operative bleeding risk.

Hospital mortality after arthroplasty using a cemented stem for displaced femoral neck fractures.

PURPOSE: To review hospital mortality after hemiarthroplasty or total hip arthroplasty (THA) using a cemented stem for displaced femoral neck fractures. METHODS: Medical records of 284 hips in 70 men and 209 women aged 45 to 106 (mean, 81.3) years who underwent hemiarthroplasty (n=232) or THA (n=52) with a cemented stem using third-generation cementing techniques (including use of a plug, lavage, and cement pressurisation) for displaced femoral neck fractures were retrospectively reviewed. According to the American Society of Anesthesiologists (ASA) grading, 6 patients were classified preoperatively as grade 1, 77 as grade 2, 148 as grade 3, 47 as grade 4, and one as grade 5. Patients were operated on within 48 hours. Patients were rehabilitated in the hospital until discharge. The primary outcome measure was hospital mortality, including the cause of death. RESULTS: The mean length of hospital stay was 9.2 (standard deviation, 4.1) days. The hospital mortality was 5.7% (n=16). Of the 16 patients who died, 3 were classified preoperatively as ASA grade 2, 6 as grade 3, and 7 as grade 4. One patient died during the operation. One patient died in the recovery room within 6 hours. Both died from a cardiac arrest and were classified as ASA grade 4. Six patients died within the first 5 days. The causes of death were aspiration pneumonia (n=5), cardiac arrest (n=3), bowel perforation (n=2), multiple organ failure (n=3), type 2 respiratory failure (n=1), heart failure (n=1), and subarachnoid bleeding after a hospital fall (n=1). CONCLUSION: Hemiarthroplasty or THA using a cemented stem resulted in low hospital mortality in our hospital dedicated to the treatment of geriatric hip fractures. Hospital mortality was higher in patients with ASA grade 3 or higher.