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• Current guidelines recommend hip fracture surgery within 48 h to decrease morbidity/mortality. • Multiple studies have identified medical optimization as the key component of time to surgery. • We found that time from optimization to surgery is not associated with increased complications/mortality. • Our median TMOS was 16.2 h, with few exceptions we adhered to 48 h time window from injury to hip surgery. Current U.S./Canadian guidelines recommend hip fracture surgery within 48 h of injury to decrease morbidity/mortality. Multiple studies have identified medical optimization as the key component of time to surgery, but have inherent bias as patients with multiple co-morbidities often take longer to optimize. This study aimed to evaluate time from medical optimization to surgery (TMOS) to determine if "real surgical delay" is associated with: 1) mortality and 2) complications for geriatric hip fracture patients. A retrospective chart review of geriatric hip fractures treated from 2015–2018 at a single, level-1 trauma center was conducted. Univariate logistic regression was performed to identify association between TMOS and post-operative complication rates. For mortality, the Wilcoxon test was used to compare TMOS for patients discharged following surgery to those who were not. A total of 884 hip fractures were treated operatively, with median TMOS 16.2 h (5.0–22.5, 1st-3rd quartiles). Univariate logistic regression models did not identify an association between TMOS and complication rates. For patients successfully discharged, median TMOS was 16.2 h (5.0–22.3, 1st-3rd quartiles). For the cohort of patients not successfully discharged, median TMOS was 19.1 h (10.1–25.9, 1st-3rd quartiles, p = 0.16). "Real surgical delay", or TMOS is not associated with increased complications or with inpatient mortality for geriatric hip fracture patients. With few exceptions, our institution adhered to the 48-hour time window from injury to hip surgery. We maintain the belief timely surgery following optimization plays a crucial role in the geriatric hip fracture patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To compare the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) Physical Status Classification used in two prediction models for 30-day mortality after hip fracture surgery.Study Design and Setting: Data from 3651 patients (mean age: 83 years) from a Norwegian University Hospital were retrospectively obtained and randomly divided into two cohorts: a model cohort (n = 1825) to develop two prediction models with CCI and ASA as the main predictors, and a validation cohort (n = 1826) to assess the predictive ability of both models. A receiver operating characteristic (ROC) curve determined the best model to predict mortality.Results: Area under the ROC curve at 30 days was 0.726 (p = 0.988) for both the CCI- and ASA-model. The chosen cut-off-points on the ROC curve for CCI- and ASA-model corresponded to similar model sensitivities of 0.657 and specificities of 0.680 and 0.679, respectively. Hence, each model predicts correctly 66% (n = 96) of the mortalities and 68% (n = 1132 and n = 1131) of the survivals. 23% (n = 33) of the mortalities were predicted by neither model.Conclusion: The CCI- and ASA-model had equal predictive ability of 30-day mortality after hip fracture. Considering the effort involved in calculating Charlson Comorbidity Index score, the ASA score may be the preferred tool to predict the 30-day mortality after hip fracture. [ABSTRACT FROM AUTHOR]

Introduction: Acute myocardial infarction (AMI) is a common cause of death following hip fracture surgery. This study aimed to determine the incidence and timing of perioperative AMI treated with percutaneous coronary intervention (PCI) in hip fracture patients, and to compare in-hospital mortality and complications between hip fracture patients who did not have an AMI, those who sustained a perioperative AMI and did not undergo PCI, and those who sustained an AMI and underwent PCI.Methods: The National Inpatient Sample (NIS) was queried from 2010 through the third quarter of 2015 to identify all patients undergoing hip fracture surgery. Patients were stratified into three cohorts: perioperative AMI but no PCI (no PCI cohort), perioperative AMI with PCI (PCI cohort), and no perioperative AMI or PCI (no AMI cohort). Patient demographics, comorbidities, in-hospital mortality, and complications were compared between cohorts. Multivariable logistic regression adjusting for age, sex, procedure, and Elixhauser score was used to assess the relative odds of in-hospital mortality for each cohort.Results: A total of 1,535,917 hip fracture cases were identified, with 1.9% in the no PCI cohort, 0.01% in the PCI cohort, and 98.0% in the no AMI cohort. In-hospital mortality was lower in the PCI cohort than in the no PCI cohort (8.8% vs. 14%), and was greater for both than in the no AMI cohort (1.6%, p < 0.001 for all). Both the no PCI cohort (OR, 6.1; 95% CI, 5.6-6.6) and PCI cohort (OR, 4.1; 95% CI, 2.8-6.0) had increased adjusted odds of in-hospital mortality compared to the no AMI cohort. The PCI cohort had a higher rate of bleeding complications than both other cohorts, and the no PCI cohort had a higher rate of transfusion than both other cohorts.Conclusions: Perioperative AMI both with and without PCI independently increases the risk of mortality in hip fracture patients, with the highest risk of mortality in those with AMI without PCI. Providers should understand the increased morbidity and mortality associated with AMI in hip fracture patients, as well as the risks and benefits of perioperative PCI, in order to better counsel and manage these patients.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Introduction: Although several risk stratification models have been developed to predict hip fracture mortality, efforts are still being placed in this area. Our aim is to (1) construct a risk prediction model for long-term mortality after hip fracture utilizing the RSF method and (2) to evaluate the changing effects over time of individual pre- and post-treatment variables on predicting mortality.Methods: 1330 hip fracture surgical patients were included. Forty-five admission and in-hospital variables were analyzed as potential predictors of all-cause mortality. A random survival forest (RSF) algorithm was applied in predictors identification. Cox regression models were then constructed. Sensitivity analyses and internal validation were performed to assess the performance of each model. C statistics were calculated and model calibrations were further assessed.Results: Our machine-learning RSF algorithm achieved a c statistic of 0.83 for 30-day prediction and 0.75 for 1-year mortality. Additionally, a COX model was also constructed by using the variables selected by RSF, c statistics were shown as 0.75 and 0.72 when applying in 2-year and 4-year mortality prediction. The presence of post-operative complications remained as the strongest risk factor for both short- and long-term mortality. Variables including fracture location, high serum creatinine, age, hypertension, anemia, ASA, hypoproteinemia, abnormal BUN, and RDW became more important as the length of follow-up increased.Conclusion: The RSF machine-learning algorithm represents a novel approach to identify important risk factors and a risk stratification models for patients undergoing hip fracture surgery is built through this approach to identify those at high risk of long-term mortality. [ABSTRACT FROM AUTHOR]

Introduction: Early mortality following hip fracture surgery remains a significant issue with a much studied, multifactorial aetiology. This study designed to test the variables affecting 30 day mortality in a socially deprived cohort against national models, and secondarily aimed to uncover and quantify new risk factors.Methods: This was a single centre retrospective study based on National Hip Fracture Database (NHFD) data for 3176 hip fracture patients from 1st May 2008 to December 31st 2017. Data was condensed into a single anonymised workbook and logistic regression used to analyse associations with 30 day mortality. Firstly, the 6 casemix variables used by the NHFD were modelled. Secondarily, a new optimised model based on our data was created.Results: Gross mortality was 11.1% since May 2008 (344/3074). There were 1978 patients in our cohort with sufficient data to run the NHFD casemix model. Overall, this proved fair with a similar area under ROC curve to nationally (0.75 vs. 0.76), although the Odds Ratios (OR) of individual variables differed. The optimised casemix model suggested two powerful prognostic indicators for 30 day mortality, namely delay to theatre for clinical reasons (OR =3.98, p-value=0.02) and whether the patient was mobilised day one post op (OR=0.21, p-value=0.00). Delay to theatre for non clinical reasons conveyed only a marginal and statistically insignificant increase in risk (OR=1.15, p-value=0.77).Conclusion: This study has confirmed the NHFD casemix adjusted model is a fair barometer for units treating a socially deprived cohort. It also has shown a clear differentiation between risk conveyed by delay to theatre for clinical reasons and suggests delay for non-clinical reasons, although clearly not desired, may not have a significant effect on death rate. Finally, it both amplifies and prompts further investigation into the potential benefit of early mobilisation. [ABSTRACT FROM AUTHOR]

Background: In 2040 the estimated number of people with a hip fracture in the Netherlands will be about 24,000. The medical care for this group of patients is complicated and challenging. Multidisciplinary approaches aim to improve clinical outcome. Quality indicators that gain insight in the treatment and outcome of hip fracture patients may help to optimize and monitor the standard of medical care. The Dutch Hip Fracture Audit (DHFA) is a new multidisciplinary quality indicator that is implemented in the Dutch hospitals in 2017.Aim: The aim of this study was to determine the effect of the implementation of the DHFA on 30-day mortality, length of hospital stay and time until surgery in elderly with a hip fracture in the Netherlands.Methods: A multicenter retrospective comparative cohort study was conducted and data were extracted from the Dutch Nationwide Trauma Registration (LTR). Included were patients aged 60 years and older with a hip fracture (femoral neck and trochanteric) and admitted in one of the ten participating hospitals registered in 2015 and 2017. Data from 2015, before implementation of DHFA, were compared with data from 2017, when the DHFA was implemented. The primary outcome was 30-day mortality; secondary outcomes were length of hospital stay and time until surgery. Multivariable regression models were used to compare outcomes between groups.Results: 3808 patients were included, 1839 in the 2015 cohort and 1969 in the 2017 cohort. 29% was male; mean age 82 years. The multilevel analysis showed a positive non-significant difference between groups on the primary outcome30-day mortality (OR adjusted 1.23, 95%CI 0.93 - 1.63). The secondary outcomes length of hospital stay (adjusted effect estimates -0.002, 95%CI -0.03 - 0.03) and time until surgery (adjusted effect estimates 0.292, 95%CI -2.68 - 3.26) showed no differences between groups.Conclusions: Implementation of the DHFA quality indicator does have a positive non-significant trend on 30-day mortality, but showed no impact on length of hospital stay and time until surgery. More research on relevant quality indicators seems therefore mandatory. [ABSTRACT FROM AUTHOR]

Background: Hip fracture causes disability and excess mortality in the aging population. Acute kidney injury (AKI), is known to diminish survival of critically ill and trauma patients. AKI is also a common perioperative complication among surgical patients. We examined the effect of AKI on the survival of hip fracture patients in a Finnish hip fracture population and the risk factors for AKI in a prospective study.Methods: The study cohort constituted of 486 consecutive low-energy trauma hip fracture patients referred to Satakunta Central Hospital (Pori, Finland) and Turku University Hospital (Turku, Finland). The patients underwent standard diagnostics and treatment in the emergency department (ER) and were operated according to the local treatment protocol. Serum creatinine (sCr) was analyzed daily pre- and post-operatively during the hospital stay. Patients were divided into groups; AKI and non-AKI based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria.Results: The incidence of AKI in the study cohort was 8.4% (40/475). Eleven patients were excluded due to missing sCr data. The baseline characteristics of AKI and non-AKI groups differed significantly concerning baseline sCr but were otherwise similar. At 90-day follow-up, the overall mortality was 14.4%. Patients with AKI had a significantly higher mortality (35.0%) than those with no AKI (12.7%) (p < 0.001). Dementia, preoperative sCr and any stage of AKI were independent predictors for mortality. Dementia and preoperative sCr were independently associated with post-operative AKI.Conclusion: In this study AKI was a significant factor associated with a 3 -fold mortality during the first three months after surgery for low-energy trauma hip fracture. [ABSTRACT FROM AUTHOR]

• After hip fracture surgery, the incidence of sepsis was 1.0%, and the incidence of septic shock was 0.6%. • Patients with sepsis and septic shock had 30-day mortality rates of 16.2% and 40.8%, respectively. • Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. • Prevention, early identification, and treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery. There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population. The ACS-NSQIP (2015–2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality. Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%). The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery. [ABSTRACT FROM AUTHOR]

• Early hip fracture surgery is recommended to decrease mortality, however the impact of a delay in surgery due to previous treatment with direct oral anticoagulants (DOA) is unknown. • Our objective with this retrospective study was to determine if early surgery, defined as surgery within 48 h of hospital admission is associated with decreased postoperative mortality even in patients previously on DOA. • Early hip fracture surgery was associated with improved survival in patients previously treated with DOAs. Early hip fracture surgery is recommended to decrease mortality, however the impact of a delay in surgery due to previous treatment with direct oral anticoagulants (DOA) is unknown. Our objective was to determine if early surgery, defined as surgery within 48 h of hospital admission is associated with decreased postoperative mortality. We tested the hypothesis that early surgery was beneficial with regard for mortality in patients treated with direct oral anticoagulants. Retrospective cohort study in a French University Hospital including patient admitted for Hip fracture. The main exposure was wait time for surgery defined as the total time, in hours, between hospital admission and surgery. The main outcome was mortality within 30 days after hip fracture surgery. In 3429 patients, the overall 30-day mortality was 4.1% (95% CI 3.5%; 4.9%). In DOA + patients, the 30-day mortality rates in the early and delayed surgery groups were 1.2% and 5.9%, respectively, with estimated risk difference of -4.4 (with a 2% probability of this difference is > 0). In the DOA + group, early surgery tended to be associated with a higher percentage receiving red-blood cells (64.6% vs 54.8%, respectively, estimated risk difference of 9.9% with a 93% probability of this difference is > 0) and lower risk of pneumonia (1.2% vs 8.2%, respectively; estimated difference of -6.7% with 0.3% probability of superiority). Early hip fracture surgery was associated with improved survival in patients previously treated with DOAs. [ABSTRACT FROM AUTHOR]

Introduction: Delays to surgery after hip fracture have been associated with mortality Uncertainty remains as to what timing benchmark should be utilized as a marker of quality of care and how other patient factors might also influence the impact of time to surgery on mortality. The goal of this study was to determine how time to surgery affects 30- and 90-day mortality by age and to explore the impact of preoperative comorbid burden and sex.Participants: We used population-based administrative data from a Canadian province collected from 01April2008 to 31March2015. Of 12,713 Albertans 50-years and older who experienced a hip fracture and underwent surgery within 100 h of admission, 11,996 (94.8%) provided data.Methods: Time to surgery was analyzed in hours from admission to surgery. Age and the interaction between age and time to surgery were evaluated using logistic regression. Charlson co-morbidity score and sex were also considered in the analysis. Survival was evaluated at 30-and 90-days post hip fracture using a provincial registry.Results: The average age of the cohort was 79.6 ± 11.2 years and 8,412 (70.1%) were female. Overall, 586 (4.9%) patients died within 30-days and 1,023 (8.5%) died within 90-days of hip fracture. Mortality increased significantly with increasing time to surgery (30-day mortality odds ratio [OR] = 1.03; 95%CI 1.01-1.05: 90-day mortality OR = 1.03; 95% CI 1.01-1.04). Mortality also increased substantially with increasing age; those ≥85 years were 19.63 (95% CI 6.83-67.33) and 15.66 (95%CI 7.20-37.16) times the odds more likely to die relative to those between 50-64 years of age at 30-days and 90-days postoperatively respectively. Further, those who were ≥85 years were more significantly affected by increasing time to surgery than those who were 50-64 years of age at both 30-days (p = 0.04) and 90-days (p = 0.025) post-fracture. Males and those with a higher comorbid burden also had higher odds of dying after controlling for time to surgery (p < 0.001) CONCLUSION: Time to surgery following hip fracture may have a differential effect on 30- and 90-day survival dependent on age. Older patients appear to be at higher risk of dying with surgical delays than younger patients. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF-POMS).Methods: A prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated.Results: A 12-domain HF-POMS tool was developed with acceptable construct validity on all HF-POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF-POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90-5.26, p = 0.005) and 15.81 days (95% CI 13.35-18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF-POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS.Conclusion: Many patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions. [ABSTRACT FROM AUTHOR]

Introduction: Hip fractures are a common problem of the elderly population with significant mortality and morbidity. The choice between total hip arthroplasty (THA) and hemiarthroplasty depends on multiple factors including comorbidity. The Swedish Hip Arthroplasty Register (SHAR) provides a unique opportunity to study mortality and revision rates in this population. Linkage with government databases allow for in-depth research into the factors that influence risk of revision surgery and death in the hip fracture patient.Patients and Methods: Data was linked between SHAR, Statistics Sweden and the National Board of Health and Welfare. Data was collected on 38,912 patients who received a fracture-related hip arthroplasty between 2005 and 2012. A multistate analysis was performed and three states were identified: primary hip surgery and alive (state 1), revision after primary hip surgery (state 2) and death (state 3). These were marking points in the longitudinal outcome study.Results: 38,912 patients who received an arthroplasty for an acute hip fracture were included. By the end of the study period 1309 (3.4%) of these patients underwent a revision and 17,365 (45.1%) patients died. Patients with THA had a reduced risk of death from primary operation compared to hemiarthroplasty (HR = 0.49) and a decreased revision risk (HR = 0.69). Female patients had a statistically significant reduced mortality (HR = 0.6) compared to men. There was no statistically significant difference in risk of revision surgery between direct lateral and posterior approach.Conclusion: We identified an influence of type of surgery, sex, age and Elixhauser Comorbidity Index (ECI) on risk of revision and mortality. Males, greater comorbidity burden and older patients had higher mortality risks. The posterior approach did not have a significant influence on revision risk. Further research could include all patients who had reoperation(s) to further strengthen our findings. Patients who had a THA had lower revision rate and mortality. The latter is likely due to selection. [ABSTRACT FROM AUTHOR]

Introduction: Direct oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral.Materials and Methods: This is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients.Results: Patients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015).Conclusions: DOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay. [ABSTRACT FROM AUTHOR]

Introduction: Although early surgery for elderly patients with hip fracture is recommended in existing clinical guidelines, the results of previous studies are inconsistent. The aim of this study was to compare postoperative outcomes of early and delayed surgery for elderly patients with hip fracture.Materials and Methods: In this retrospective study using a national inpatient database in Japan, patients aged 65 years or older who underwent surgery for hip fracture between July 2010 and March 2014 were included. Early surgery was defined as surgery on the day or the next day of admission. Assessed outcomes included death within 30 days and hospital-acquired pneumonia.Results: In this cohort, 47,073 (22.5%) patients underwent surgery for hip fractures within two days of admission (early surgery group) and 161,805 (77.5%) underwent surgery for hip fractures thereafter (delayed surgery group). Early surgery was significantly associated with lower odds for hospital-acquired pneumonia (odds ratio, 0.42; 95% confidence interval, 0.25-0.69) and pressure ulcers (odds ratio, 0.56, 95%CI: 0.33-0.96, p = 0.035), but was not associated with 30-day mortality (odds ratio, 0.96; 95% confidence interval, 0.49-1.86) or pulmonary embolism (odds ratio, 1.62, 95%CI: 0.58-4.52, p = 0.357).Conclusions: These results support current guidelines, which recommend early surgery for elderly hip fractures patients. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are a public health problem worldwide, and several factors are involved with post-operative mortality. The aim of this study was to identify the pre-operative factors associated with increased mortality in elderly patients with hip fractures in a developing country during the first post-operative year.Methods: An ambidirectional cohort study was conducted with patients ≥ 65 years of age who underwent hip surgery due to a hip fracture caused by a fall from a standing position. Socio-demographic data, time to surgery, and comorbidities measured by the Charlson Comorbidity Index (CCI) were recorded. One-year mortality from all causes was the primary outcome, and 30-day and 6-month mortality were the secondary outcomes. Log-rank test was used to evaluate survival, and Cox's proportional hazard regression was used to detect the factors associated with increased mortality.Results: 478 patients who underwent hip surgery were included in this study. The mean age was 80.2 ± 9.9, and 297 (62%) were females. There were 150 (31.4%) deaths at the end of the first follow-up year, and the mean of surgical delay was 8.8 days ± 6.4. Patients who underwent surgery during the first 4 days (Log-rank test < 0.001) after hip fracture occurred and patients with a CCI ≤ 2 (Log-rank test < 0.001) showed better survival (90%), comparing to mortality (52%) of patients with a CCI ≥ 3 and surgical delay > 4 days. The age ≥ 80 years (Hazard ratio 2.55 (HR), 95% confidence interval (CI) 1.70 to 3.84, p < 0.001), CCI ≥ 3 (HR 1.61, 95% CI 1.14-2.26, p 0.006), surgical delay > 4 days (HR 2.41, 95% CI 1.38-4.21, p 0.006), and haemoglobin < 10 g/dl (HR 1.51, 95% CI 1.06-2.15, p 0.02) were associated with increased 1-year mortality. In addition, 30-day mortality was associated with age ≥ 80 years (HR 4.15, 95% CI 1.98-8.70, p < 0.001), CCI ≥ 3 (HR 1.80, 95% CI 1.08-2.99, p 0.023), pre-surgical time >48 h (HR 3.0, 95% CI 1.58-5.92, p 0.001), and surgical delay > 4 days (HR 3.0, 95% CI 1.33-6.81, p 0.008); and 6-month mortality was associated with surgical delay > 4 days (HR 2.72, 95% CI 1.42-5.23, p 0.003), and haemoglobin < 10 g/dl (HR 1.56, 95% CI 1.04-2.33, p < 0.028).Conclusions: Surgical delay greater than 4 days and Charlson Comorbidity Index ≥ 3 were found as factors associated with increased mortality, along with anaemia < 10 g/dl and age ≥ 80 years. A similar mortality rate was found in this study compared to the rates reported by the literature, despite a surgical delay of 8.8 days. [ABSTRACT FROM AUTHOR]

Purpose: Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs.Methods: In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates.Results: Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98-1.18) for thirty-day mortality, 1.12 (95% CI 1.04-1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88-1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6-8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly.Conclusions: Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines. [ABSTRACT FROM AUTHOR]

Purpose: To analyze prospectively the influence of the timing of surgery on morbidity and mortality, and to assess whether the early surgery within 2 days admission may be a reliably healthcare quality indicator.Methods: Prospective observational study of 628 patients age 60 or older who had been co-managed between surgeons and internists. Based on the literature, many potential factors influencing outcomes were collected to control confounding regard to surgery delay, complications and mortality. Multivariate logistic regression and Cox regression models were used to assess effects on the delay and mortality, respectively.Results: Mean Charlson index was 2.3, and 284 patients had at least 3 comorbidities. Mean timing of surgery was 3.6 days (range 0-20). 418 patients were fit for surgery, of which 180 underwent surgery within 2 days. Delay for surgery more than 2 days was significantly associated with ASA >2, Charlson >2 and anticoagulant therapy. Medical complications were not significantly associated with delayed surgery more than 2 days. Mortality rate was 0.9% in-hospital, 3.4 at 1 month, 7.0% at 3 months, and 13.6% at 12 months. There were no significant differences in in-hospital, 3-month or 1-year mortality between patients operated within 2 days and those operated at 3-4 days, but delayed more than 4 days was associated with higher 1-year mortality. Likewise, patients readmitted within 30 days had higher in-hospital mortality. Excluding unfit for surgery patients at admission, there was no significant difference in 3-month or 1-year mortality between patients operated within 2 days and those with delayed surgery.Conclusions: Delaying surgery up to 4 days was not associated with higher morbidity or mortality rates. We recommend concentrating more on preoperative optimizing the condition of patient with sufficient medical treatment rather than being bound by a universal timing of surgery. [ABSTRACT FROM AUTHOR]

Introduction: Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.Methods: The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).Results: Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58).Conclusion: PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded. [ABSTRACT FROM AUTHOR]

Introduction One-year mortality after hip fracture may exceed 30% with a very large number of reported risk factors. Determinants of mortality beyond 1 year are rarely described. This study employs multiple data linkages to examine mortality rates, risk factor profiles and age-specific excess mortality at intervals from 30 days to 4 years. Methods Retrospective cohort study of linked administrative datasets describing hospital episodes, residential aged care (RAC) admissions and date of death for 2552 Australian veterans and war widows hospitalised for hip fracture in 2008–09. Associations between time to death and patient age, sex, pre-fracture accommodation, fracture type, treatment options, selected comorbidities and complications were tested in Cox proportional hazards models. Results In a population with mean age of 86.6 years (range 54–100 years), overall death rate was 11% at 30 days, 34% at 1 year, 47% at 2 years and 67% after 4 years. For males hospitalised from RAC 1-year mortality was 72%, contrasting with 19% for females from the community. Risk of death within 1 year was increased by male sex, increasing age, pre-fracture RAC residency, transfer to intensive care and coexistent cancer, cardiac and renal failure, cerebrovascular disease and pressure ulcers. Patients selected for rehabilitation had lower mortality rates. Patterns of determinants for mortality changed over time. Above-expected age-specific mortality was sustained for 4 years except for males 90 years and older. Conclusion Pre-fracture RAC residence was the strongest determinant factor for mortality. Patients selected for rehabilitation had lower mortality rates. The profiles of explanatory variables for death altered with increasing time from the index fracture event. [ABSTRACT FROM AUTHOR]

Introduction Hip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes? Methods A systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared. Results For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58–1.38) or 30-day mortality (OR 1.10 95% CI: 0.48–2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00–1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference −7.09 days (95% CI: −10.14 to −4.04). Discussion Early surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings. [ABSTRACT FROM AUTHOR]

Abstract: Background: In April 2004 the Israeli Ministry of Health decided to condition DRG payment for hip surgery by time between hospitalisation and operation, giving a fine for every day's delay beyond 48h. An evaluation study performed 2 years after the reform has shown the positive influence of the reform on patient's survival in the hospital. This study evaluates the impact of the reform on the longer-term mortality of patients. Methods: A retrospective study based on data from nine hospitals of the national trauma registry available for the years 2001–2007, with surveillance on 2-year survival through data of Ministry of the Interior. The study population includes patients aged 65 and above with an isolated hip fracture following trauma. Mortality curves and Cox regression were utilised to compare the influence of different parameters on long-term mortality. Results: Earlier surgery had a significant positive impact on survival through the whole length of the study period. In the period after the introduction of the new reimbursement system for hip fracture surgeries, a significant decrease in the longer-term mortality was observed up to 6 months of follow-up, even when adjusted by patients’ age, gender and the receiving hospital. After 6 months there was no further decrease in relative risk, though the survival advantage remained with patients hospitalised after the reform. Conclusions: The reform appears successful in decreasing the longer-term patient mortality after hip fracture through influencing surgical practice. [Copyright &y& Elsevier]

Abstract: Introduction: Although cemented implants have proven beneficial over uncemented implants for treatment of displaced sub-capital proximal femoral fractures, there are concerns regarding the haemodynamic consequence of using cemented implants in hip fracture patients. National Patient Safety Agency recently issued an alert regarding the use of cement in hip fracture surgery. We compared the incidence and pattern of 48h perioperative mortality between patients receiving cemented and uncemented implants after hip fracture surgery. Methods: Using data prospectively recorded in hospital care records, we retrospectively reviewed the case records of all patients who died in hospital following hip fracture surgery between January 2005 and April 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, perioperative haemodynamic status, time and cause of death. Results: We identified 15 cases of perioperative death (PoD) over a 64-month period. PoD was 1% (15/1402). Eight of 15 deaths occurred following cemented hemiarthroplasty insertion. There were four cases of intra-operative death, two of them were following cemented hemiarthroplasty insertion. PoD following cemented hemiarthroplasty was 2.54% (8/314) and nil (0/168) following uncemented Austin-Moore hemiarthroplasty. Operations were performed by both trainees (six) and consultants (two). Both trainees (five) and consultants (three) anaesthetised the patients. None of the patients belonged to American Society of Anesthesiologists (ASA) I or II (ASA III 5 and IV 3). All patients had significant cardiovascular or pulmonary co-morbidity. Apart from the cases of immediate haemodynamic collapse and death, cemented implant insertion was followed by intra-operative haemodynamic instability in 2/15 and perioperative instability in 3/15 patients. Post-mortem was performed in 3/8 patients: 2/3 demonstrated pulmonary embolism (PE), 1/3 bronchopneumonia. Of the rest, 3/5 had suspected myocardial infarction (MI). Conclusion: There was 1% risk of perioperative death after hip fracture surgery. Risk of perioperative death was significantly higher following cemented implant insertion. Mortality risk was exacerbated in patients with pre-existing cardiovascular morbidity and was independent of the seniority of the surgeon or the anaesthetist. [Copyright &y& Elsevier]

Abstract: Background: Hip fractures are always associated with a high postoperative mortality, the preoperative predictors for mortality have neither been well identified or summarised. This systematic review and meta-analysis was performed to identify the preoperative non-interventional predictors for mortality in hip fracture patients, especially focused on 1year mortality. Methods: Non-interventional studies were searched in Pubmed, Embase, Cochrane central database (all to February 26th, 2011). Only prospective studies and retrospective studies with prospective collected data were included. Qualities of included studies were assessed by a standardised scale previous reported for observational studies. The effects of individual studies were combined with the study quality score using a previous reported model of best-evidence synthesis. The hazard ratios of strong evidence predictors were combined only by high quality studies. Results: 75 included studies with 94 publications involving 64,316 patients were included and the available observations was a heterogeneous group. The overall inpatient or 1month mortality was 13.3%, 3–6months was 15.8%, 1year 24.5% and 2years 34.5%. There were strong evidence for 12 predictors, including advanced age, male gender, nursing home or facility residence, poor preoperative walking capacity, poor activities of daily living, higher ASA grading, poor mental state, multiple comorbidities, dementia or cognitive impairment, diabetes, cancer and cardiac disease. We also identified 7 moderate evidence and 12 limited evidence mortality predictors, and only the race was identified as the conflicting evidence predictor. Conclusion: Whilst there is no conclusive evidence of the preoperative predictors for mortality following hip fractures, special attention should be paid to the above 12 strong evidence predictors. Future researches were still needed to evaluate the effects of these predictors. [Copyright &y& Elsevier]

Abstract: Objectives: Research has shown that early surgical intervention for hip fractures serves to decrease mortality. In 2004 the Ministry of Health decided to condition the reimbursement regime at the time of operation. The objectives of this study were to examine whether the reform succeeded to decrease inpatient mortality of hip fracture casualties. Method: The study utilised data drawn from the Israeli Trauma Registry (ITR) for the years 1999–2006. The study population included patients aged 65 and older with an isolated diagnosis of hip fracture following trauma. Results: Two years after the reform, the inpatient mortality decreased by 34% amongst patients undergoing fixation surgery, and by 30% amongst all operated patients. Median LOS decreased by 2 days. The proportion of patients undergoing hip fracture fixation surgery within 48h increased by 35%. Conclusions: The implementation of a payment limited by time for hip fracture fixation surgery increased the number of patients being operated within 48h, shortened patient LOS, and decreased inpatient mortality. [Copyright &y& Elsevier]

In this retrospective study, we looked at the difference in 1 year mortality between two groups of patients who were operated for fracture of the hip. Patients and methods: In cohort 1, 72% of the patients underwent surgery on the same day of admission, 15% of the patients were operated on the next day, the remaining 13% of the patients waited more than 1 day for surgery. The mean waiting time was 0.47 day. The percentage of patients who were operated on the same day of admission in cohort 2 was 18%. Sixty-nine percent of the patients had to wait 1 day before they were operated and 13% waited 2 days or more. The average waiting time was 1.01 days. The date of death for both the 166 patients in cohort 1 and the 197 patients in cohort 2, was obtained from the national mortality register and the 1 year mortality was calculated. These two groups of patients were from separate 12 month periods and the operations performed were either Dynamic Hip Screw (DHS) or hemiarthroplasty. The two groups were comparable in gender, age distribution and the types of operations. Results: There was an increase of 10.1% (P<0.025, χ2, 1 d.f.; 95% CI 1.7–18.5) in the mortality of patients in cohort 2. The mortality data of the two cohorts was also analysed after dividing the patients into three groups according to their age. A statistically significant increase in mortality of 16.9% in patients over 80 years of age in cohort 2 was found. The difference in mortality was still statistically significant when only patients over 80 years of age and having a DHS operation were compared. Total mortality at 2 years after the operation was the same in the two cohorts. Mortality rate for patients in cohort 2 was less than that for cohort 1 patients during the second post-operative year. Conclusion: This study shows that survival at 1 year is better when patients who are medically fit for surgery are operated on the same day of admission. This survival advantage is more pronounced for patients who are over 80 years of age. [Copyright &y& Elsevier]