Beyond Mortality: Severely Frail Femur Fracture Patients Can Regain Independence after Surgery.

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

Shared decision-making for non-operative management versus operative management of hip fractures in selected frail older adults with a limited life expectancy: a protocol for a nationwide implementation study.

BACKGROUND AND PURPOSE: Recent research has highlighted non-operative management (NOM) as a viable alternative for frail older adults with hip fractures in the final phase of life. This study aims to guide Dutch physicians and hospitals nationwide in a standardised implementation of shared decision-making regarding surgery or NOM in selected frail older adults with a hip fracture. METHODS AND ANALYSIS: The patient population for implementation includes frail older adults aged ≥70 years with an acute proximal femoral fracture, nursing home care or a similar level of care elsewhere and at least one additional criterion (ie, malnutrition, severe mobility impairment or ASA≥4). The 2-year implementation study will be conducted in four phases. In phases 1 and 2, barriers and facilitators for implementation will be identified and an implementation protocol, educational materials and patient information will be developed. Phase 3 will involve an implementation pilot in 14 hospitals across the Netherlands. The protocol and educational material will be improved based on healthcare provider and patient experiences gathered through interviews. Phase 4 will focus on upscaling to nationwide implementation and the effect of the implementation on NOM rate will be measured using data from the Dutch Hip Fracture Audit. ETHICS AND DISSEMINATION: The study was exempted by the local Medical Research Ethics Committee (MEC-2023-0270, 10 May 2023) and Medical Ethics Committee United (W23.083, 26 April 2023). The study's results will be submitted to an open access international peer-reviewed journal. Its protocols, tools and results will be presented at several national and international academic conferences of relevant orthogeriatric (scientific) associations. TRIAL REGISTRATION NUMBER: NCT06079905 .

The Impact of Implementation of Palliative, Non-Operative Management on Mortality of Operatively Treated Geriatric Hip Fracture Patients: A Retrospective Cohort Study.

(1) Background: Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2) Methods: Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3) Results: Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%, p = 0.139; 22.4% vs. 20.2%, p = 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%, p = 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%, p = 0.025). (4) Conclusions: The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy.

Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

PURPOSE: Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. METHODS: Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). RESULTS: In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11 years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of - 1.00 follow-up appointments (95% Confidence Interval (CI) - 0.92 to - 1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): - 1.17 follow-up appointments, 95% CI - 1.09 to - 1.26). CONCLUSION: Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

Identification of neutrophil phenotype categories in geriatric hip fracture patients aids in personalized medicine.

Objectives: The number of geriatric hip fracture patients is high and expected to rise in the coming years, and many are frail and at risk for adverse outcomes. Early identification of high-risk patients is crucial to balance treatment and optimize outcome, but remains challenging. Previous research in patients with multitrauma suggested that neutrophil phenotype analysis could aid in early identification of high-risk patients. This pilot study investigated the feasibility and clinical value of neutrophil phenotype analysis in geriatric patients with a hip fracture. Methods: A prospective study was conducted in a regional teaching hospital in the Netherlands. At the emergency department, blood samples were collected from geriatric patients with a hip fracture and analyzed using automated flow cytometry. Flow cytometry data were processed using an automated clustering algorithm. Neutrophil activation data were compared with a healthy control cohort. Neutrophil phenotype categories were assessed based on two-dimensional visual assessment of CD16/CD62L expression. Results: Blood samples from 45 geriatric patients with a hip fracture were included. Neutrophils showed an increased activation profile and decreased responsiveness to formyl peptides when compared to healthy controls. The neutrophil phenotype of all patients was categorized. The incidence of severe adverse outcome was significantly different between the different categories (P = 0.0331). Moreover, patients with neutrophil phenotype category 0 developed no severe adverse outcomes. Conclusions: Using point-of-care fully automated flow cytometry to analyze the neutrophil compartment in geriatric hip fracture patients is feasible and holds clinical value in determining patients at risk for adverse outcome. This study is a first step toward immuno-based precision medicine for identifying geriatric hip fracture patients that are deemed fit for surgery.

Study Quality and Patient Inclusion in Geriatric Orthopaedic Trauma Research: A Scoping Review.

OBJECTIVES: To evaluate the quality of evidence published in geriatric traumatology, to investigate how many studies include patients with cognitive impairment, and to investigate which methods are used to determine cognitive impairment. DATA SOURCES: A search was conducted in PubMed for all publications in English in 154 selected journals between 01/01/2017 and 01/01/2020. STUDY SELECTION: Clinical studies investigating patients 65 years of age and older with fractures in the appendicular skeleton or pelvis were included. DATA EXTRACTION: Two independent reviewers performed full-text screening and data extraction for all articles. DATA SYNTHESIS: A comparative analysis was performed for prospective cohort studies and RCTs. The results are discussed in a narrative review. CONCLUSIONS: A total of 2711 publications were screened for eligibility, and after exclusion, a total of 723 articles were included. There is a focus on retrospective studies investigating mortality and complications. Studies are often small in sample size, and there are relatively few prospective studies, RCT studies, patient-reported outcomes, and quality of life. Patients with cognitive impairment are selectively excluded from clinical studies, and no consensus exists on how cognitive impairment is diagnosed. This review identified pitfalls and provides recommendations to navigate these issues for future studies. Many studies exclude cognitively impaired patients, which may result in selection bias and inability to extrapolate results. The lack of use of objective measures to define cognitive impairment and lack appropriate outcome measures for the cognitively impaired is an important issue that needs to be addressed in future research.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis.

PURPOSE: There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. METHODS: A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score. RESULTS: Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25). CONCLUSION: Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Proxy-reported experiences of palliative, non-operative management of geriatric patients after a hip fracture: a qualitative study.

OBJECTIVE: The objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to the most important factors in the process, as reported by a proxy. DESIGN: Semistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data. SETTING AND PARTICIPANTS: Patients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview. RESULTS: A total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83-94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4-26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient-relative interaction and (4) the active dying. CONCLUSIONS: With the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture.

Healthcare utilization and satisfaction with treatment before and after direct discharge from the Emergency Department of simple stable musculoskeletal injuries in the Netherlands.

PURPOSE: To evaluate healthcare utilization and satisfaction with treatment before and after implementing direct discharge (DD) from the Emergency Department (ED) of patients with simple, stable musculoskeletal injuries. METHODS: Patients with simple, stable musculoskeletal injuries were included in two Dutch hospitals, both level-2 trauma centers: OLVG and Sint Antonius (SA), before (pre-DD-cohort) and after implementing DD (DD-cohort). With DD, no routine follow-up appointments are scheduled after the ED visit, supported by information leaflets, a smartphone application and a telephone helpline. Outcomes included: secondary healthcare utilization (follow-up appointments and X-ray/CT/MRI); satisfaction with treatment (scale 1-10); primary healthcare utilization (general practitioner (GP) or physiotherapist visited, yes/no). Linear regression was used to compare secondary healthcare utilization for all patients and per injury subgroup. Satisfaction and primary healthcare utilization were analyzed descriptively. RESULTS: A total of 2033 (OLVG = 1686; SA = 347) and 1616 (OLVG = 1396; SA = 220) patients were included in the pre-DD-cohort and DD-cohort, respectively. After DD, the mean number of follow-up appointments per patient reduced by 1.06 (1.13-0.99; p < 0.001) in OLVG and 1.07 (1.02-0.93; p < 0.001) in SA. Follow-up appointments reduced significantly for all injury subgroups. Mean number of follow-up X-rays per patient reduced by 0.17 in OLVG (p < 0.001) and 0.18 in SA (p < 0.001). Numbers of CT/MRI scans were low and comparable. In OLVG, mean satisfaction with treatment was 8.1 (pre-DD-cohort) versus 7.95 (DD-cohort), versus 7.75 in SA (DD-cohort only). In OLVG, 23.6% of pre-DD-cohort patients visited their GP, versus 26.1% in the DD-cohort, versus 13.3% in SA (DD-cohort only). Physiotherapist use was comparable. CONCLUSION: This study performed in a large population and additional hospital confirms earlier pilot results, i.e., that DD has the potential to effectively reduce healthcare utilization, while maintaining high levels of satisfaction. LEVEL OF EVIDENCE: II.

Is the Parker Mobility Score in the older patient with a traumatic hip fracture associated with discharge disposition after surgery? A retrospective cohort study.

PURPOSE: The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance. METHODS: A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ2 automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination. RESULTS: The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ2 = 22.409, p < 0.001) after age (χ2 = 79.094, p < 0.001). Regarding the tree analysis of HLOS, of all variables in the analysis, PMS had the most significant association with HLOS (F = 14.891, p < 0.001). Patients who were discharged home had a mean HLOS of 6.5 days (SD 8.0), whereas patients who were discharged to an institutional care facility had a mean HLOS of 9.7 days (SD 6.4; p < 0.001). CONCLUSION: This study shows that the PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS. LEVEL OF EVIDENCE: Level III, diagnostic.

Robot-assisted fracture fixation in orthopaedic trauma surgery: a systematic review.

To investigate the applications of robot-assisted surgery and its effect on surgical outcomes in orthopaedic trauma patients. DATA SOURCES: A search was performed in PubMed and Embase for articles in English, Dutch, German, or French, without restrictions on follow-up times, study size, or year of publication. STUDY SELECTION: Studies were included if they investigated patients undergoing robot-assisted fracture fixation surgery for orthopaedic trauma. DATA EXTRACTION: Outcomes studied were operating time, fluoroscopy time/frequency, complications, functional outcomes, intraoperative blood loss, fracture healing, and screw placement accuracy. Critical appraisal was done by using the Methodological Index for Non-Randomized Studies. DATA SYNTHESIS: Narrative review. CONCLUSIONS: A total of 3832 hits were identified with the search and 8 studies were included with a combined total of 437 included patients, 3 retrospective cohort studies, 2 prospective cohort studies, 1 cohort study not otherwise specified, 1 case series, and 1 randomized controlled trial. Four studies investigated pelvic ring fractures, 3 studies investigated femur fractures, and 1 study investigated scaphoid fractures. Seven investigated percutaneous screw fixation and 1 studied intramedullary nail fixation. One robotic system was used across all studies, the TiRobot, and all procedures were performed in China. The limited evidence suggests that that robot-assisted orthopaedic trauma surgery may reduce operating time, use of fluoroscopy, intraoperative blood loss, and improve screw placement accuracy, but the overall quality of evidence was low with a high risk of bias. Robot-assisted fracture fixation does not appear to lead to better functional outcomes for the patient.Level of evidence: III.

A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures.

ABSTRACT: Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.

Does the frailty index predict discharge disposition and length of stay at the hospital and rehabilitation facilities?

INTRODUCTION: Many geriatric hip fracture patients utilize significant healthcare resources and require an extensive recovery period after surgery. There is an increasing awareness that measuring frailty in geriatric patients may be useful in predicting mortality and perioperative complications and may be useful in helping guide treatment decisions. The primary purpose of the study is to investigate whether the frailty index predicts discharge disposition from the hospital and discharge facility and length of stay. METHODS: In this retrospective cohort study, patients aged 65 years and older presenting to a level 1 trauma center with a hip fracture and a calculated frailty index were eligible for inclusion. The primary outcome was discharge disposition. Secondary outcomes were hospital and discharge facility length of stay, 90-day hospital mortality and readmissions, and return to home. RESULTS: A total of 313 patients were included. The frailty index was a robust predictor of discharge to a skilled nursing facility (OR 1.440 per 0.1 point increase). Patients with a higher frailty index were at higher risk of 90-day mortality and less likely to return to home at the end of follow-up. There was a very weak correlation between the frailty index and hospital length of stay (ρ=0.30) and rehab length of stay (ρ=0.26). CONCLUSION: The frailty index can be used to predict discharge destination from both the hospital and rehabilitation facility, 90-day mortality, and return to home after rehabilitation. In this study, the frailty index had a very weak correlation with length of stay in the hospital and in discharge destination. The frailty index can be used to help guide medical decision making, goals of care discussions, and to determine which patients benefit from intensive rehabilitation.

Predictors of 30-day mortality in orthogeriatric fracture patients aged 85 years or above admitted from the emergency department.

PURPOSE: Orthogeriatric trauma patients are at risk for functional decline and mortality. It is important to identify high-risk patients in an early stage, to improve outcomes and make better informed treatment decisions. The aim of this study was to identify independent risk factors for 30-day mortality in patients aged 85 years or above admitted from the emergency department with a fracture. METHODS: All orthopaedic trauma patients 85 years or above admitted from the emergency department were included. After a 30-day follow-up, mortality was determined by consulting the patient records. Multivariable logistics regression analysis generated odd ratios for mortality risk factors. A subgroup analysis was performed for patients undergoing hip fracture surgery. RESULTS: The 30-day mortality in geriatric fracture patients admitted to the hospital was 12%. Risk factors for 30-day mortality were: increased age, male sex, decreased hemoglobin levels, living in an institutional care facility and a decreased BMI. For geriatric patients undergoing hip fracture surgery 30-day mortality was 11%. Independent risk factors for this group were: increased age, male sex, and a decreased BMI. CONCLUSION: Orthopaedic trauma patients aged 85 years or above who are admitted to the hospital with a fracture are at high risk for mortality. This study identified older age, male sex, and decreased BMI as predictors of 30-day mortality in admitted geriatric fracture patients and in geriatric hip fracture patients undergoing surgery.

Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients.

INTRODUCTION: An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit. MATERIALS AND METHODS: This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay. RESULTS: A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029). CONCLUSIONS: This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies. LEVEL OF EVIDENCE: Level III.

Development and Internal Validation of a Prediction Model for In-Hospital Mortality in Geriatric Patients With a Hip Fracture.

OBJECTIVE: To develop and validate a prediction model for in-hospital mortality in patients with hip fracture 85 years of age or older undergoing surgery. DESIGN: A multicenter prospective cohort study. SETTING: Six Dutch trauma centers, level 2 and 3. PARTICIPANTS: Patients with hip fracture 85 years of age or older undergoing surgery. INTERVENTION: Hip fracture surgery. MAIN OUTCOME MEASUREMENTS: In-hospital mortality. RESULTS: The development cohort consisted of 1014 patients. In-hospital mortality was 4%. Age, male sex, American Society of Anesthesiologists classification, and hemoglobin levels at presentation were independent predictors of in-hospital mortality. The bootstrap adjusted performance showed good discrimination with a c-statistic of 0.77. CONCLUSION: Age, male sex, higher American Society of Anesthesiologists classification, and lower hemoglobin levels at presentation are robust independent predictors of in-hospital mortality in patients with geriatric hip fracture and were incorporated in a simple prediction model with good accuracy and no lack of fit. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fit4SurgeryTV At-home Prehabilitation for Frail Older Patients Planned for Colorectal Cancer Surgery: A Pilot Study.

OBJECTIVE: The preoperative phase is a potential window of opportunity. Although frail elderly patients are known to be more prone to postoperative complications, they are often not considered capable of accomplishing a full prehabilitation program. The aim of this study was to assess the feasibility of Fit4SurgeryTV, an at-home prehabilitation program specifically designed for frail older patients with colorectal cancer. DESIGN: The Fit4SurgeryTV program consisted of a daily elderly adapted computer-supported strength training workout and two protein-rich meals. Frail patients 70 yrs or older with colorectal cancer were included. The program was considered feasible if 80% of the patients would be able to complete 70% of the program. RESULTS: Fourteen patients (median age, 79 yrs; 5 males) participated. At baseline, 86% patients were physically impaired and 64% were at risk for malnourishment. The median duration of the program was 26 days. The program was feasible as patients followed the exercises for 6 (86%) of 7 days and prepared the recipes 5 (71%) of 7 d/wk. Patients specifically appreciated at-home exercises. CONCLUSIONS: This study showed that at-home prehabilitation in frail older patients with colorectal cancer is feasible. As a result, patients might be fitter for surgery and might recover faster. The perioperative period could serve as a pivotal time point in reverting complications of immobility.