Validation of the Charlson Comorbidity Index for the prediction of 30-day and 1-year mortality among patients who underwent hip fracture surgery.

INTRODUCTION: The aim of our study was to validate the original Charlson Comorbidity Index (1987) (CCI) and adjusted CCI (2011) as a prediction model for 30-day and 1-year mortality after hip fracture surgery. The secondary aim of this study was to verify each variable of the CCI as a factor associated with 30-day and 1-year mortality. METHODS: A prospective database of two-level II trauma teaching hospitals in the Netherlands was used. The original CCI from 1987 and the adjusted CCI were calculated based on medical history. To validate the original CCI and the adjusted CCI, the CCI was plotted against the observed 30-day and 1-year mortality, and the area under the curve (AUC) was calculated. RESULTS: A total of 3523 patients were included in this cohort study. The mean of the original CCI in this cohort was 5.1 (SD ± 2.0) and 4.6 (SD ± 1.9) for the adjusted CCI. The AUCs of the prediction models were 0.674 and 0.696 for 30-day mortality for the original and adjusted CCIs, respectively. The AUCs for 1-year mortality were 0.705 and 0.717 for the original and adjusted CCIs, respectively. CONCLUSIONS: A higher original and adjusted CCI is associated with a higher mortality rate. The AUC was relatively low for 30-day and 1-year mortality for both the original and adjusted CCIs compared to other prediction models for hip fracture patients in our cohort. The CCI is not recommended for the prediction of 30-day and 1-year mortality in hip fracture patients.

Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study.

Purpose: The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery. Patients and methods: A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis. Results: 8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001). Conclusion: A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

Risk factors for prosthetic joint infections after hemiarthroplasty of the hip following a femoral neck fracture.

PURPOSE: The primary aim of this study was to identify risk factors and validate earlier reported risk factors for Prosthetic Joint Infection (PJI) after hemiarthroplasty. The secondary aim was to assess peri­operative clinical outcomes, adverse events and mortality rates in PJI patients after hemiarthroplasty. METHODS: A prospective hip fracture database was used to obtain data for this observational cohort study. Patients who underwent hemiarthroplasty between 2011 and 2021 were included. A PJI was diagnosed by the Musculoskeletal Infection Society criteria. Univariable and multivariable analyses were performed to identify factors highly associated with a PJI. RESULTS: In total, 2044 patients were analysed of which 72 patients (3.5 %) developed PJI. The multivariable analysis showed that Body Mass Index (BMI) >30 (OR2.84, P = 0.020), operating time of <45 min (OR=2.80, P = 0.002), occurrence of haematoma (OR=6.24, P<0.001), decreasing level of hemoglobin (OR=1.62, P = 0.001) and re-operation for luxation (OR=9.25, P<0.001) were significant independent prognostic risk factors for development of PJI after hemiarthroplasty. Diabetes Mellitus (OR=0.34, P = 0.018) and >20 hemiarthroplasties performed by the surgeon in the previous year (OR=0.33, P = 0.019) were prognostic protective factors. In patients with PJI, 40 % (n = 29) died within one year after surgery, compared with 27 % (n = 538) in patients without PJI (OR=1.80, P = 0.017). CONCLUSION: Independent significant prognostic factors highly associated with PJI after hemiarthroplasty were BMI >30, operating time of <45, decreasing level of hemoglobin, occurrence of haematoma and re-operation for luxation. Diabetes Mellitus and >20 hemiarthroplasties performed by the surgeon in the previous year were prognostic protective factors for the development of PJI. PJI was associated with significantly higher 1-year all-cause mortality.

Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes.

Purpose: The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery. Patients and Methods: A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria. Results: The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)). Conclusion: Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.

Influence of time to surgery on clinical outcomes in elderly hip fracture patients : an assessment of surgical postponement due to non-medical reasons.

AIMS: Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. METHODS: This observational cohort study enrolled consecutively admitted patients with a proximal femoral fracture, for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. A total of 1,803 patients were included, of whom 1,428 had surgery < 24 hours and 375 had surgery ≥ 24 hours after admission. RESULTS: Prolonged total length of stay was found when surgery was performed ≥ 24 hours (median 6 days (interquartile range (IQR) 4 to 9) vs 7 days (IQR 5 to 10); p = 0.001) after admission. No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of 12 hours each, pressure sores and urinary tract infections were diagnosed more frequently when time to surgery increased. CONCLUSION: Longer time to surgery due to non-medical reasons was associated with a higher incidence of postoperative pressure sores and urinary tract infections when time to surgery was more than 48 hours after admission. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay.Cite this article: Bone Joint J 2022;104-B(12):1369-1378.

Clinical outcomes of tranexamic acid in acute hip hemiarthroplasties in frail geriatric patients.

BACKGROUND: Tranexamic acid (TXA) has shown to significantly reduce perioperative blood loss in elective orthopedic joint replacement surgery but is yet not implemented in acute hip fracture surgery for elderly patients who are particularly vulnerable to perioperative blood loss and postoperative anemia. Aim of this study is to answer the following questions: 1. Does TXA reduce bleeding associated complications in elderly patients? 2. Does TXA induce thromboembolic complications in elderly patients? HYPOTHESIS: TXA reduces perioperative blood loss and associated complications in acute hip fracture surgery in geriatric patients. PATIENTS AND METHODS: In this observational cohort study with prospectively enrolled patients over 65 years of age who received an acute hip hemiarthroplasty, the primary outcome was blood loss, also described as Δ hemoglobin. Secondary outcomes were bleeding associated complications as hematomas. Also, the occurrence of thromboembolic events and mortality were examined. RESULTS: In total 864 geriatric patients were included of which 235 received TXA and 629 did not. Multivariable analysis showed reduced Δ hemoglobin loss [-0.24 (-0.39; -0.09), p=0.002] and hematomas (OR 0.44 (0.21; 0.91), p=0.026). Pulmonary embolism were diagnosed more frequently after administration of TXA (2% versus 0.3%, p=0.008), without an association with increased 30-day mortality rate (6% versus 8%, p=0.3). DISCUSSION: TXA reduced perioperative blood loss and associated complications. However, adverse effects of TXA as pulmonary embolisms were found more frequently without effecting postoperative mortality rates. More research is needed to assess adverse effects of intravenous TXA and topical TXA as an alternative for systemic TXA to prevent systemic adverse effects. LEVEL OF EVIDENCE: III, Observational cohort study.

Drain versus no drain after hip hemi-arthroplasty for femoral neck fractures; differences in clinical outcomes.

PURPOSE: The routine use of surgical drains in elective hip arthroplasty has been abandoned. Also in acute hip arthroplasty for femoral neck fractures drain use reduces. Question is, whether this is justified in geriatric patients, where the incidence of anticoagulation use is high. Therefore, the aim of this study is to compare the clinical outcomes in patients with and without the use of a wound drain after hip hemiarthroplasty. METHODS: Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records at two level II trauma centers between January 1st 2010 and May 16th 2016. Patients with a femoral neck fracture requiring hip hemiarthroplasty were included in the study. RESULTS: This study cohort included 900 patients (68% female), with a median age of 83.5 (IQR 78-88), of which 544 (60%) had a wound drain. Patients with a wound drain needed more days to be ready for discharged (10.0 days (SD ± 43.3), P = < 0.001) compared to patients without a drain (5.3 days (SD ± 4.2). With a drain more hemoglobin loss was found, 2.66 g/dL versus 2.4 g/dL (P = 0.008) and also more packed cells were supplemented, 0.29 versus 0.13 (P = 0.0016). Wound drain placement showed a statistically significant inverse relation with post-operative hematoma; odds ratio (OR 0.61, 95% CI 0.39; 0.94, P = 0.024), but no reduced risk of post-operative deep surgical site infection, (OR 1.09, 95% CI 0.43; 2.72, P = 0.862). CONCLUSION: Surgical drain placement was not associated with a reduced risk of post-operative deep surgical site infections, nor one-year mortality. However, a decreased risk of post-operative wound hematoma was observed. Furthermore, patients with a drain needed more days to be ready for discharge, show more hemoglobin loss and need more packed cell supplementation during admission.

Validation of the Nottingham Hip Fracture Score (NHFS) in Patients with Hip Fracture: A Prospective Cohort Study in the Netherlands.

INTRODUCTION: The Nottingham Hip Fracture Score (NHFS) was developed to predict 30-day mortality for patients with hip fracture. This study aimed to validate the NHFS in a cohort with sufficient statistical power. METHODS: Data were extracted from a prospective hip-fracture database (FAMMI). Patients were included between January 1, 2018 and January 11, 2021. All consecutively admitted patients ≥18 years of age with a hip fracture (ie, femoral neck fracture, intertrochanteric fracture, and subtrochanteric fracture) were included. Mann-Whitney's U values were calculated to find potential miscalibration of the NHFS formula. Discrimination evaluation was performed using the concordance statistic as an equivalent to area under the receiver-operating curve. RESULTS: In total, 2,458 patients were included. Mean age was 80±12 years, and 66% were women (n=1,631). Median NHFS was 5 (4-6) and overall 30-day mortality 7.9% (n=195). Overall goodness of fit was tested with Pearson's ?2 (11.8, df 10; P=0.297). No statistically significant signs of miscalibration were found (Mann-Whitney U, P=0.08). Discrimination was tested with area under the receiver- operating curve, which was 72.1% (95% CI 68.7%-75.4%). However, observed 30-day mortality in our population of hip-fracture patients was slightly higher than the NHFS prediction. CONCLUSION: The NHFS seemed to predict 30-day mortality with reasonable accuracy for patients with a hip fracture in a population within the Netherlands.

Antithrombotics in Patients With a Femoral Neck Fracture: Evaluating Daily Practice in an Observational Cohort Study.

INTRODUCTION: Geriatric hip fracture patients are characterized by frailty due to multiple comorbidities, such as cardiovascular disease, in which the use of antithrombotics is frequent. The aim of this study is to assess the effect of antithrombotics on perioperative care and patient outcomes after hip hemiarthroplasty following current guidelines. MATERIALS AND METHODS: This observational cohort study included all consecutively admitted patients with a femoral neck fracture requiring hip hemiarthroplasty between January 1st 2010, and May 16th 2016, in two level II trauma teaching hospitals. Patients with multiple trauma injuries were excluded. RESULTS: In total, n = 907 patients (68% female (n = 615), median age 84 years) were included of which n = 142 used a vitamin K antagonist (VKA) and n = 213 used antiplatelet (AP) therapy. Both were associated with more packed cell supplementation (.4 ± 1.1 units and .3 ± .8 units vs .2 ± .6 units, P < .001 and P = .03, respectively). VKA was associated with more hematomas compared no antithrombotics (23% vs 11%, P = .001). VKA had a longer time to surgery compared to no antithrombotics and AP (24 hours vs 19 and 20 hours, P < .001 and P < .001, respectively) and longer admission duration (9 days vs 7 days P < .001. There were no differences in 30 day mortality nor in 1-year mortality rates. DISCUSSION: All modifiable causes for deep SSI, such as hematomas, should be prevented in acute hip fracture surgery. Since antithrombotics are associated with hematomas, an optimal handling in perioperative setting is necessary. CONCLUSION: VKA was associated with longer time to surgery, more hematomas, and longer admission duration. VKA and AP were associated with more packed cell supplementation.

Prospective cohort protocol examining the perioperative indicators for complications and early mortality following hip fracture surgery in the frail patient.

INTRODUCTION: The primary aim is to validate earlier suggested risk factors and to find new associated risk factors for (30-day) mortality after a hip fracture in the frail population. The secondary aim is to determine the factors associated with perioperative complications. At last we want to develop and validate a more specific 30-day mortality prediction tool compared with the Nottingham Hip Fracture Score. The 30-day mortality prediction can help inform surgical risk and guide shared decision-making among patients, family and physicians. METHODS AND ANALYSIS: The study is designed as a prospective multicentre cohort study within the area of Rotterdam, the Netherlands starting from January 2018. All patients over 65 years of age, with an acute proximal hip fracture, are included. Treatment of patients will be by standard practice of care using the latest national and international guidelines. Inclusion will be continued at least until January 2021 and including at least 2500 patients. In this large cohort we hope to have sufficient strength and quality to identify risk factors of 30-day mortality and to compare them to known risk factors in literature. Moreover, we plan to develop and validate a 30-day mortality prediction tool, which identifies patients with a high probability of 30-day mortality. ETHICS AND DISSEMINATION: Ethical approval for this protocol was given by the Ethics Committee of the Maasstad Hospital (TWOR). Patient data are stored anonymously using the Castor data management system. No external funding is used for this study. Results will be published in peer-reviewed publications and at international conferences. TRIAL REGISTRATION NUMBER: NL8313.

Functional Outcome following Headless Compression Screw Fixation for Hamate Fractures.

Hamate fractures can be treated nonoperatively, with the percutaneous Kirschner wire (K-wire) fixation, or with excision of a fractured hook of the hamate. Screw fixation is less popular owing to the risk of iatrogenic ulnar nerve injury. The aim of this study was to present the functional results of patients with hamate fractures treated with headless compression screws (HCS). The primary outcome was the Michigan Hand Outcome Questionnaire (MHOQ) after at least 4 months of follow-up. Nine patients were included in this retrospective cohort study. A median MHOQ total score of 67% was reported (interquartile range [IQR]: 44-76). No complications were found during follow-up. HCS fixation is a safe alternative to treat hamate fractures with good functional outcome. This is a Level IV study.

Radiation exposure during direct versus indirect image acquisition during fluoroscopy-controlled internal fixation of a hip fracture: Results of a randomized controlled trial.

BACKGROUND: Intra-operative image acquisition can be obtained indirectly (via verbal request to a technician) or directly (executed at the tableside, by a surgeon stepping on a foot pedal). Direct image acquisition could reduce the exposure time and thus the risk of radiation damage. The aim of this randomized controlled trial was to compare direct surgeon-controlled fluoroscopy with indirect technician-operated fluoroscopy during internal fixation of a hip fracture. METHODS: From March 5, 2014 to August 19, 2015, 100 patients who had sustained a hip fracture that required internal fixation were enrolled. Patients were randomized between direct surgeon-controlled image acquisition using a foot pedal (n = 52) and indirect image acquisition by a radiology technician (n = 48). The primary outcome measure was the radiation exposure time; secondary outcome measures were the associated effective radiation dose and the dose area product. (DAP) RESULTS: A total of 96 patients (with a median age of 84 years) were enrolled in this study. Eighty-nine (93%) patients had a pertrochanteric fracture. No statistically significant differences between direct image acquisition and indirect image acquisition were found for overall radiation time, total radiation dose or DAP for the total population. When adjusted for potential confounders, a difference in overall radiation time of 18.50 s (95% CI 2.19; 34.81, p = 0.027) was found in favour of indirect image acquisition. CONCLUSION: This study showed statistically significantly lower radiation duration using indirect fluoroscopy for the total population and the pertrochanteric fracture subgroup when adjusted for several confounders. No significant effect on radiation dose and DAP was found.

Delirium after hip hemiarthroplasty for proximal femoral fractures in elderly patients: risk factors and clinical outcomes.

BACKGROUND: The primary aim of the present study was to verify the potential risk factors for developing a delirium after hip fracture surgery. The secondary aim of this study was to examine the related clinical outcomes after a delirium developed post-hip fracture surgery. PATIENTS AND METHODS: Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 463 patients undergoing hip fracture (hip hemiarthroplasty) surgery in a level II trauma teaching hospital between January 2011 and May 2016 were included. Delirium was measured using the Delirium Observation Screening Scale, the confusion assessment method, and an observatory judgment by geriatric medicine specialists. RESULTS: The results showed that 26% of the patients (n=121) developed a delirium during hospital stay with a median duration during admission of 5 days (IQR 3-7). The multivariable model showed that the development of delirium was significantly explained by dementia (OR 2.75, P=0.001), age (OR 1.06, P=0.005), and an infection during admission (pneumonia, deep surgical site infection, or urinary tract infection) (OR 1.23, P=0.046). After 1 year of follow-up, patients who developed delirium after hip fracture surgery were significantly more discharged to (semi-independent) nursing homes (P<0.001) and had a significantly higher mortality rate (P<0.001) compared to patients without delirium after hip fracture surgery. CONCLUSIONS: The results showed that 26% of the patients undergoing hip fracture surgery developed a delirium. The risk factors including age, dementia, and infection during admission significantly predicted the development of the delirium. No association was confirmed between delirium and time of admission or time to surgery. The development of delirium after hip fracture surgery was subsequently found to be a significant predictor of admission to a nursing home and mortality after 1 year.