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• Despite much focus on quality-improvement, there has been little change in time to hip fracture surgery in Ireland over the last five years. • Patient comorbidity, procedure type and timing/ route of hospital presentation are key factors associated with time to surgery in the country. • Low surgical capacity locally and nationally may also be contributing to delays. • Further exploration of interventions to improve this quality indicator is needed. In hip fracture care, time to surgery (TTS) is a commonly used quality indicator associated with patient outcomes including mortality. This study aimed to identify patient and hospital-level characteristics associated with TTS in Ireland. National data from the Irish Hip Fracture Database (IHFD) (2016–2020) were analysed along with hospital-level characteristics obtained from a 2020 organisational survey. Generalised linear model regression was used to explore the association of TTS with case-mix, surgical details, hospital-level staffing and specific protocols recommended to expedite surgery. A total of 14,951 patients with surgically treated hip fracture from 16 hospitals were included (Mean age= 80.6 years (SD=8.8), 70.4% female). Mean TTS was 40.9 h (SD=60.3 h). Case-mix factors associated with longer TTS were male sex and higher American Society of Anaesthesiologists (ASA) grade. Other factors found to be associated with longer TTS included low pre-morbid mobility, inter-hospital transfer, weekday presentation, pre-operative medical physician assessment, intracapsular fracture type, arthroplasty surgery, general anaesthesia, consultant grade of surgeon and lower hospital-level orthopaedic surgical capacity. The oldest age-group and pre-fracture nursing home residence were associated with shorter TTS when adjusted for other case-mix factors. None of four explored protocols for expediting surgery were associated with TTS. Patients with more comorbidity experience longer surgical delay after hip fracture in Ireland, in line with international research. Low availability of senior orthopaedic surgeons in Ireland may be delaying hip fracture surgery. Pathway of presentation, including via inter-hospital transfer or hospital bypass, is an important factor that requires further exploration. Further research is required to identify successful system-level protocols and interventions that may expedite hip fracture surgery within this setting. [ABSTRACT FROM AUTHOR]

• The level of evidence in the perioperative management of elderly trauma patients is poor. • A comparison between spinal and general anesthesia from the Geriatric Trauma Registry of the German Trauma Society (DGU®) was conducted. • Spinal anesthesia does not extend time to surgery. • Patients with spinal anesthesia had a significantly lower mortality rate and a better quality of life. • Patients with spinal anesthesia had a better walking ability on the seventh day after surgery and a shorter length of stay in hospital. Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU). A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models. A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 – 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 – 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group. SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS. [ABSTRACT FROM AUTHOR]

Guidewire breakage during a surgical procedure is uncommon but still challenging for orthopedic surgeons. Due to the potential for harmful complications, surgeons prefer to remove broken wires near the joint surface or neurovascular bundle in the hip region. Due to the depth of the location, the retrieval procedure is arduous, time-consuming, and potentially dangerous. This study describes a case of a sub-capital femoral neck fracture that was fixed with a cannulated screw. However, three years later, the distal portion of the guidewire broke and migrated into the hip joint, where it became entrapped. This study describes a method for removing a broken wire from the hip region and a relevant literature review. In brief, initially, we untightened the screw and removed it. Afterward, the broken wire was reached by reaming in the direction of the screw. Ultimately, we advanced the arthroscopic grasper to the broken wire for removal under fluoroscopic guidance. The study's findings indicate that this method could provide a promising outcome with minimal complications. [ABSTRACT FROM AUTHOR]

Objective: Postoperative pneumonia is among the most common complications in elderly patients after hip fracture surgery. We implemented a proactive postoperative pneumonia prevention protocol and analyzed the incidence of postoperative pneumonia in elderly patients (≥70 years of age) receiving this protocol after hip fracture surgery versus those receiving usual care before the protocol's implementation at our institution.Materials and Methods: From November 2018 to October 2019, the proactive postoperative pneumonia prevention protocol was implemented. The treatment included intensified physical therapy, postoperative pulmonary exercises and oral care, in addition to the usual surgical treatment for elderly patients with hip fracture. The intervention cohort data were compared with a historical control cohort treated from July 2017 to June 2018. The primary outcome of this study was the incidence of postoperative pneumonia in both groups, diagnosed according to the presence of two of three of the following: elevated infection parameters, radiologic examination confirmation of pneumonia of the chest or clinical suspicion.Results: A total of 494 patients (n= 249 in the historical control cohort and n=245 in the intervention cohort) were included. A total of 69 patients developed postoperative pneumonia. The incidence of postoperative pneumonia was significantly lower (6.7 percentage points) in the group receiving the proactive postoperative pneumonia prevention protocol (17.3% in the historical control cohort vs 10.6% in the intervention cohort; p=0.033).Discussion and Conclusion: A proactive postoperative pneumonia prevention protocol showed promise in decreasing the occurrence of postoperative pneumonia after hip fracture surgery in elderly patients. [ABSTRACT FROM AUTHOR]

Introduction: Identification of high-risk hip fracture patients in an early stage is vital for guiding surgical management and shared decision making. To objective of this study was to perform an external international validation study of the U-HIP prediction model for in-hospital mortality in geriatric patients with a hip fracture undergoing surgery.Materials and Methods: In this retrospective cohort study, data were used from The American College of Surgeons National Surgical Quality Improvement Program. Patients aged 70 years or above undergoing hip fracture surgery were included. The discrimination (c-statistic) and calibration of the model were investigated.Results: A total of 25,502 patients were included, of whom 618 (2.4%) died. The mean predicted probability of in-hospital mortality was 3.9% (range 0%-55%). The c-statistic of the model was 0.74 (95% CI 0.72-0.76), which was comparable to the c-statistic of 0.78 (95% CI 0.71-0.85) that was found in the development cohort. The calibration plot indicated that the model was slightly overfitted, with a calibration-in-the-large of 0.015 and a calibration slope of 0.780. Within the subgroup of patients aged between 70 and 85, however, the c-statistic was 0.78 (95% CI 0.75-0.81), with good calibration (calibration slope 0.934).Discussion and Conclusion: The U-HIP model for in-hospital mortality in geriatric hip fractures was externally validated in a large international cohort, and showed a good discrimination and fair calibration. This model is freely available online and can be used to predict the risk of mortality, identify high-risk patients and aid clinical decision making. [ABSTRACT FROM AUTHOR]

Background: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF.Materials and Methods: We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH.Results: The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding.Conclusions: Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH. [ABSTRACT FROM AUTHOR]

Introduction: The long-term risk of cardiovascular events caused by chronic kidney disease (CKD) is well described in the general population. Less is known concerning the risk of postoperative cardiovascular events in geriatric hip fracture patients with CKD.Methods: This study involved patients at least 65 years of age who received surgery for acute hip fracture between January 2000 and April 2016. We identified CKD patients with a baseline diagnosis of CKD or an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at admission. Each CKD patient was matched, for age, gender, fracture type, and year of admission, with 4 control non-CKD patients. The primary endpoint was a compositepostoperative cardiovascular events, including pulmonary embolism, angina pectoris, myocardial infarction, heart failure, arrhythmia, stroke, and death. Conditional logistic regression was used to evaluate the association between CKD and the outcome after adjusting for potential confounders including age, gender, fracture type, body mass index, preexisting comorbidities, history of cardiovascular events, and the Charlson Comorbidity Index (CCI).Results: Three hundred and seventy-five CKD patients were matched with 1,438 non-CKD patients. The mean age of the CKD patients was 81.9 ± 7.0 (mean ± SD), 69.9% were females, and 59.2% had an intertrochanteric fracture. Compared to non-CKD patients, CKD patients had a higher proportion of preexisting comorbidities, including hypertension, coronary heart disease, heart failure, and type 2 diabetes (all p < 0.05). The risk of postoperative cardiovascular events was 125.3 per 1000 persons (95%CI, 91.8-158.8) in CKD patients and 64.7 per 1000 persons (95%CI, 52.0-77.4) in non-CKD patients. A 1.96-fold risk of cardiovascular events after hip fracture surgery was found in CKD patients than those without CKD (adjusted OR, 1.96; 95%CI, 1.23-3.12).Conclusion: Patients with CKD were more likely to have cardiovascular events after hip fracture surgery than those without CKD. Appropriate preoperative cardiovascular risk assessment and corresponding preventive and therapeutic measures should be given to this vulnerable population to mitigate such complications. [ABSTRACT FROM AUTHOR]

Introduction In this study, we aim to assess the intra-operative effect of dexmedetomidine administration on the hemodynamic parameters and bleeding volume during hip fracture surgery. Patients and methods we designed and implemented a triple-blinded randomized clinical trial to objectively compare the effects of 0.5 µg/kg/h infusion of dexmedetomidine with placebo (equal amount of normal saline) during hip fracture surgery. All included cases were between 30 and 70 years old and underwent surgery for fixation of a proximal femur fracture from September 26, 2020 until February 15, 2021. They were all ASA class I or II with preoperative hemoglobin levels of 10 mg/dL or higher. Surgical blood loss and hemodynamic parameters were documented. Results 76 patients were enrolled. There were no significant differences in baseline patient characteristics. The bleeding rate was 620 ± 190.0 mL for the normal saline group and 476 ± 177.98 mL in the dexmedetomidine group (P = 0.04). No significant effect on hemodynamic parameters was observed. Conclusion Based on the current study, intravenous infusion of dexmedetomidine during hip fracture surgery under general anesthesia reduced the amount of intraoperative bleeding without causing any significant hemodynamic disturbances. Registration number IRCT20191222045857N1 (Iranian Registry of Clinical Trials). [ABSTRACT FROM AUTHOR]

Aim: The objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages.Methods: A systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri‑operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events' incidence. A subgroup analysis was performed with respect to TXA dosage.Results: Out of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between "single" and "multiple doses" studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg.Conclusions: This meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes. [ABSTRACT FROM AUTHOR]

• 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]

• Hip precautions are unnecessary and potentially detrimental to patient outcomes following hemiarthroplasty. • Replacing hip precautions with a pose avoidance protocol after hemiarthroplasty is safe and saves on the cost of adaptive equipment. • Choose the anterolateral over the posterior approach to perform hip hemiarthroplasty to minimise the risk of dislocation. After hip arthroplasty surgery, hip precautions are often implemented to minimise the risk of dislocation, although existing evidence does not support their effectiveness. At our institution, we replaced post-operative precautions with a novel pose avoidance protocol in patients undergoing hip hemiarthroplasty for neck of femur fracture. The objectives of our study were to validate this new protocol by assessing the incidence of dislocation before and after its introduction and evaluating its impact on the length of hospital stay. Between 20th September 2021 and 19th March 2023, 200 patients underwent 203 hip hemiarthroplasties. Hip precautions were replaced with the new pose avoidance protocol on 20th June 2022. Data were retrospectively collected and included patient demographics, Abbreviated Mental Test Score, American Society of Anaesthesiologists grade, surgical approach, prosthesis, dislocation, and mortality. The incidence of dislocation within 90 days after hip hemiarthroplasty decreased from seven out of 98 cases (7.1%) before 20th June 2022 to one out of 105 cases (1.0%), p-value 0.030. However, there was no significant difference in the length of stay, with a median (interquartile range) of 19 (10 – 29) days before 20th June 2022, and 16 (11 – 22) days thereafter, p -value 0.242. A multivariate logistic regression confirmed the pose avoidance protocol and the anterolateral approach to be independent negative predictors of dislocation, p -value 0.030 (Odds Ratio [OR] 0.077) and p -value 0.005 (OR 0.022), respectively. Hip precautions are unnecessary and potentially detrimental to patient outcomes following hemiarthroplasty. Replacing these precautions with our new pose avoidance protocol may have led to a significant reduction in dislocation rates and saved on the cost of adaptive equipment. We advocate for the anterolateral over the posterior approach in hip hemiarthroplasty to further mitigate the risk of dislocation. IV [ABSTRACT FROM AUTHOR]

Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Retrospective propensity score matched cohort. Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts. After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 – 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 – 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 – 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 – 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 – 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 – 3.06). Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population. III. [ABSTRACT FROM AUTHOR]

Hip fracture patients are recommended to undergo surgery within 24–36 h. The present study aimed to analyze the current status of hip fracture surgery among the elderly in China. The baseline information, such as the patient's age, gender, place of residence, place of treatment, fracture type, admission, and operation time, of hip fracture patients >65-years-old were retrieved from the hospital quality monitoring system (HQMS) database from 2013 to 2017 and analyzed. A total of 304,279 patients >65-years-old with hip fractures were included in this study. The average length of hospital stay was 15 days, and the average waiting time for surgery after admission was 96 h. The average surgery rate of elderly hip fractures in China was 59.6 %, of which the lowest was recorded in the Northwest China (46.4 %). The major issues in diagnosing and treating elderly patients with hip fractures in China are the long waiting time for surgery and the low surgery rate. [ABSTRACT FROM AUTHOR]

Introduction: Hip fractures in the elderly impact negatively on functional dependence, and carry great social costs and morbidity. We assessed the decline in muscle mass and functional outcomes following hip fracture surgery .Material and Methods: Thirty patients with a hip fracture (mean age: 80.8 years) were assessed using dual-energy X-ray absorptiometry and reassessed for changes in body composition 1 year after hip surgery. Baseline demographic data, sarcopenia, and bone mineral density were recorded. Body mass index (BMI), handgrip strength, appendicular skeletal muscle mass (ASM), total body fat percentage, and responses to questionnaires measuring quality of life and activities of daily living (ADL) before injury and 1 year after hip surgery were analyzed to identify changes. Associations with changes in ADL or quality of life were analyzed with time-variant independent variables.Results: Significant losses in ADL were identified at the 1-year follow-up, at which time only 43% of patients had regained their preinjury ADL status. Additionally, the participants had lost an average of 4.63% of ASM. ASM loss was significantly higher in patients with baseline sarcopenia than in those without (mean loss: 9.18% and 1.15%, respectively). When confounders were controlled for, a greater loss of ASM and handgrip strength and larger increase in BMI were associated with greater decrease in ADL 1 year after hip surgery.Conclusion: Geriatric hip fracture patients may experience a significant loss of muscle mass, associated with impaired functional recovery 1 year after hip surgery, highlighting a potential treatment target of maintaining muscle mass to improve prognosis in these patients. [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]

Tranexamic acid (TXA) is a cheap and powerful drug that has several uses in surgery and is well established in elective orthopaedic surgery. At present, limited small studies have looked into its role in the acute hip fracture. Transfusion in the geriatric population presents risks and increased costs to healthcare systems around the world. Our retrospective study looks at the role of TXA administration at induction for both intracapsular fracture requiring hemiarthroplasty and our preferred method of fixation of extracapsular fracture by intramedullary nail (IM nail). We show a statistically significant reduction in the number of patients requiring transfusion as well as mean haemoglobin (Hb) drop in those undergoing hemiarthroplasty. This was not replicated in those undergoing IM nail fixation. Both groups showed no increase in 1-year mortality or thromboembolic events following TXA administration. These results support the use of TXA for hemiarthroplasty for intracapsular hip fractures over the age of 60.Objectives: The aim of this pre and post interventional study looks at the effects of intravenous administration of tranexamic acid on induction for elderly patients undergoing hemiarthroplasty or intramedullary nail fixation for hip fractures.Design: Pre and post interventional, randomised observational study SETTING: Large hip fracture unit, Level 2 Trauma Centre, single centre PATIENTS: Two arms of the study looking at those aged above the age of 60 undergoing hemiarthroplasty and intramedullary nail fixation without and with tranexamic acid on induction.Results: 12.1% of hemiarthroplasties required post-operative transfusion without tranexamic acid compared to 2.6% of those with tranexamic acid (n=15 vs n=3 respectively, p=0.006). Equally, the mean Hb drop in g/L is reduced in those with tranexamic acid compared to those without (mean Hb = 14.6 vs 17.7 respectively, p=0.034). This was not replicated in the IM nail group between those without and those with tranexamic acid (n=31 vs n=20 respectively, p= 0.16). The mean Hb drop in g/L was not statistically significant in the tranexamic acid arm compared to without (mean Hb = 19.2 vs mean Hb = 21.9, p=0.11). Gross reporting of thromboembolic events did not demonstrate an increase in the number of those with DVT, PE, MI or stroke. 1-year mortality was not statistically significant in either hemiarthroplasty or IM nail fixation following tranexamic acid administration.Conclusions: Tranexamic acid both statistically significantly reduces the number of patients requiring transfusion post hemiarthroplasty and also the value of mean Hb drop without appearing to increase in thromboembolic events or 1 year mortality rates. This does not appear to be emulated in the IM nail fixation although both thrombotic events and 1-year mortality rates are also not affected by administration of TXA. We propose that TXA has a role in hemiarthroplasty surgery in reducing post-operative transfusions.Level Of Evidence: Level 3 - retrospective cohort study. [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]

Background: Hip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common.Materials and Methods: This study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients.Results: Mortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p = 0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007). Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences. A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant. Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score.Conclusion: We believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs. [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]

Purpose: In elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.Methods: We conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.Results: Among the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusions: preoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results. [ABSTRACT FROM AUTHOR]

Introduction: . Early hip fracture surgery (<48 hours) has shown to improve mortality for geriatric patients and is recommended in national hip fracture guidelines. However, this may be at the expense of surgery being performed out-of-hours where concerns about mortality risk exist. A systematic review and meta-analysis were performed to determine the mortality risk for hip fracture surgery performed in-hours (IH) compared to out-of-hours (OH), and on weekdays (WD) compared to weekends (WE).Materials and Methods: . A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from the dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.Results: . A total of 13 studies with 177,090 patients were included for analysis. Overall, there was no statistically significant difference for 30-day or inpatient mortality in IH vs OH groups (RR 0.93, p=0.46 and RR 1.16, p=0.63) and for WD vs WE groups (RR 0.98, p=0.73 and RR 0.76, p=0.67). There was no difference in length of stay between groups (p>0.05). The number of patients with American Society of Anaesthesiology (ASA) physical status classification ≥3 and male gender between the groups were similar (p>0.05).Conclusion: . Performing hip fracture surgery OH or on the WE does not appear to increase the risk of 30-day or inpatient mortality or post-operative complications. Consideration should be given to performing hip fracture surgery out-of-hours to meet national guidelines (<48 hours). [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]

Objective: To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients.Background: Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival.Methods: A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age.Results: Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment.Conclusions: Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account. [ABSTRACT FROM AUTHOR]

Background: As the aging population progresses, the number of elderly hip fracture patients is increasing. Elderly patients with hip fractures have a high risk of perioperative complications. One of the major complications after surgery is surgical site infection (SSI), which requires additional surgical interventions and is associated with increased mortality. Previous literature has shown that the risk of SSI is higher during the summer season in orthopedic surgery. However, little is known about the seasonal differences in the risk of SSI after hip fracture surgery. In this study, we aimed to identify the association between seasonality and SSI.Methods: We enrolled a total of 330,803 patients undergoing hip fracture surgery (65 years or older) using the Japanese Diagnosis Procedure Combination database. The study period was from April 1, 2011, to March 31, 2016. The data were analyzed to determine the association between seasonality and the incidence of SSI, debridement procedure. The primary outcome was the incidence of SSI and debridement. Other risk factors of SSI and debridement were investigated including seasons and confounders such as sex, age, BMI, smoking status, anticoagulant intake, comorbidities, surgical procedure based on medical diagnosis, waiting times for the surgery, and hospital surgical volume based on the previous literature, the risk of SSI and debridement.Results: Hip fracture surgeries performed in summer showed the highest risk for SSI and debridement. The risk for SSI was significantly associated with spring, and summer compared to winter (odds ratio [OR], 1.18; p, 0.016; OR, 1.19; p, 0.012, respectively). The incidence of debridement procedures after the initial surgery was also associated with spring, summer, and fall: the risk was the highest in summer (OR, 1.34; p, <0.001). Obesity, smoking history, number of comorbidities, anticoagulant intake before surgery, longer waiting time for surgery, and small hospital surgical volume were significantly associated with the risk of SSI.Conclusions: We found a significant association between SSI after surgery for hip fractures and seasonality. Surgeries performed in summer had the highest risk for SSI and subsequent debridement procedures. [ABSTRACT FROM AUTHOR]

Introduction: The origin and content of prolonged wound drainage (PWD) after arthroplasty remain uncertain. In this study, we performed the biochemical, biological and advanced proteomic analysis of the drainage fluid collected from PWD patients following hip hemiarthroplasty (HA).Methods: Data of 28 patients who developed PWD after HA were prospectively analyzed. After examining the biochemical content of the drainage fluid collected on postoperative day 6, to find out if the drainage fluid was transudate or exudate, it was compared with the patient's serum values according to the Light criteria. Subsequently, biological and proteomic analyzes of both drainage fluid and serum were performed. The similarities and differences in terms of protein concentrations, protein identities were examined. In the drainage fluid, we analyzed lymph-specific proteins.Results: 16 patients with PWD were male (61.1%), 12 were female (38.9%), and the mean age of all patients was 79.64 ± 8.44 (65-95). Biochemical test results of the drainage fluid / serum were as follows: Total protein: 2.1 / 5.2 g/dl, albumin: 1.3 / 3.1 g/dl, lactate dehydrogenase (LDH): 121/324 U/l, cholesterol: 28/160 mg/dl, triglyceride: 37/122 mg/dl, sodium (Na): 140/ 140mg/dl, potassium (K): 4.1/ 4.1 mg/dl. pH of the drainage fluid was 7.6. According to these biochemical values, drainage fluid was classified as transudate. As a result of protein identification, fibrinogen beta chain, keratin type 1, creatine kinase M-type protein were detected in drainage fluid. Subsequent western analysis revealed that, gliseraldehyde-3-phosphate dehydrogenase (GAPDH) and beta actin antibody were detected in the drainage fluid but not in serum.Conclusion: Despite the similarity in serum and transudative PWD fluid in terms of biochemical content, we found that when we carried out further proteomic analysis, PWD contains lymph-specific proteins. Unlike PWD, these proteins were not determined in serum. PWD fluid can be also called as lymphorrhea. PWD fluid with abundant proteins may also provide an appropriate environment for the growth of microorganisms. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to summarize the predictors of acute kidney injury (AKI) in patients after hip surgery.Methods: A literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science for studies assessing the predictors of AKI after hip fracture surgery. Pooled odds ratio (OR) and mean difference (MD) of those who experienced AKI compared to those who did not were calculated for each variable. Evidence was assessed using the Newcastle-Ottawa Scale.Results: Ten studies with 34 potential factors were included in the meta-analysis. In the primary analysis, 12 factors were associated with AKI, comprising males (OR 1.25; 95% confidence interval (CI) 1.14-1.36), advanced age (MD 2.28; 95% CI 0.80-3.75), myocardial infarction (OR 1.39; 95% CI 1.18-1.63), hypertension (OR 1.46; 95% CI 1.13-1.89), diabetes (OR 1.84; 95% CI 1.40-2.42), chronic kidney disease (OR 3.66; 95% CI 2.21-6.07), hip arthroplasty (OR 1.35; 95% CI 1.22-1.50), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers use (OR 2.28; 95% CI 1.68-3.08), more intraoperative blood loss (MD 44.06; 95% CI 2.88-85.24), higher preoperative blood urea nitrogen levels (MD 5.29; 95% CI 3.38-7.20), higher preoperative serum creatinine levels (MD 0.4; 95% CI 0.26-0.53), and lower preoperative estimated glomerular filtration rate (MD -19.59; 95% CI -26.92--12.26). Another 13 factors related to AKI in individual studies were identified in the systematic review.Conclusion: Related prophylaxis strategies should be implemented in patients involved with the above-mentioned characteristics to prevent AKI after hip surgery. [ABSTRACT FROM AUTHOR]

The concept of enhanced recovery after surgery (ERAS) has been proposed in recent years, which indeed bring about evident convenience for the patients. This prospective cohort study was aimed to investigate the impact of ERAS on the clinical outcome of patients who undergoing total hip arthroplasty due to displaced femoral neck fractures. Patients in two periods were included in our research, before ERAS (n = 194) and after ERAS (n = 65). The clinical outcome, such as patient statistics, details of perioperative management, length of stay (LOS), pain, Harris hip score, in-hospital complications, and interim postoperative survival were collected. This retrospective observational study addressed confounding bias using propensity score matching (PSM) analysis. With PSM, 55 pairs of well-matched patients were generated for comparison (conventional vs. ERAS). LOS decreased to 13.0 ± 3.2 days for the ERAS group, compared to 15.7 ± 3.5 days in the conventional group. VAS pain scores decreased significantly in both groups, and the decrease in the ERAS group was more significant than that in the conventional group at 3, 7, and 14 days postoperatively. The Harris scores of both groups significantly improved, but were better for the ERAS group than the conventional group at 7 and 14 days and 1 month postoperatively. However, no significant difference was observed at 6 months postoperatively. Additionally, the incidence of complications during hospitalization was lower in the ERAS group than that in the conventional group. No significant difference was observed in the medium-term survival between the two groups. ERAS apparently benefit patients in early rehabilitation by reducing complications and shortening hospital stays but not for the long-term hip function or survival. [ABSTRACT FROM AUTHOR]

• High-rate mortality rates are observed among patients with COVID-19 taken to urgent surgery. • Despite the high mortality rates observed among COVID-19 patients taken to surgery for hip fracture, it is important to provide timely treatment with particular attention to safety protocols. • Hip fracture surgery practices in Colombia correspond to what is recommended by international reference institutions despite health system differences. The COVID-19 epidemic generated major changes in general surgical management protocols. The literature has reported high mortality rates for hip fracture surgery in patients with COVID-19. This study describes the morbidity and mortality in patients undergoing surgery due to hip fractures in 12 Colombian institutions between March and September 2020. This was a retrospective observational descriptive study. Medical records of 12 hospitals were reviewed. Consecutive patients who underwent hip fracture surgery from March 6 to September 6, 2020, were included. Data collected were sociodemographic profile, type of fracture, surgical treatment, complications, and early (1 month) or mid-term (1–6 months) mortality associated or not with COVID-19. Five hundred twenty patients with hip fractures requiring surgery in the 12 institutions were included. 364 (70%) were women; mean age was 77.7 years (SD: 13.8), mean BMI was 25.1, 91.73% of patients had at least one comorbidity, 60.38% were classified as ASA II and 25.77% as ASA III. There were 267 (51.34%) pertrochanteric fractures, 227 (43.65%) femoral neck fractures, and 26 (5.0%) subtrochanteric fractures. 274 (52.69%) patients were treated with osteosynthesis, 244 (46.92%) with arthroplasty, and 2 (0.38%) with girdlestone. Surgery was performed less than 24 h after the fracture for 115 (22.11%) patients, between 24 and 72 h for 208 (40.0%) patients, and more than 72 h for 197 (37.88%) patients. One hundred six patients in total suffered a medical or surgical complication throughout the different follow-up stages, amongst the most frequent were respiratory failure, coronary events, surgical site infection, cutting-out and peri‑implant fracture. 25 (4.8%) patients required attention in the Intensive Care Unit (ICU). 13 patients had COVID-19 throughout the follow-up period. 27 patients died due to any cause, and 3 of them had reported a positive COVID-19 test any time during follow-up period, of which one died during the first month, and two died between 1 and 6 months. Statistically significant associations were found between age older than 75 years old, ASA classification, ICU requirement, and death. 520 patients received surgical treatment for hip fracture during the first six months of the COVID-19 pandemic in 12 medical centers in Colombia. 21.10% suffered a complication during the early stage (30 days) and 4.77% during the midterm stage (1–6 months). 4.8% were admitted in the ICU during the early stage. All-cause death was 27 patients, early death was 11 (40.74%) and midterm death was 16 (59.25%). 13 patients were positive for COVID-19, 3 died, one (1/5=20%) on the first 30 days and the other two (2/8=25%) from month 1 to 6. [ABSTRACT FROM AUTHOR]

Background: Intraoperative use of tranexamic acid (TXA) has been proven to reduce the administration of allogenic blood transfusion in total joint arthroplasty (TJA) patients. Data on TXA efficacy in reducing blood loss in trauma patients undergoing hip hemiarthroplasty are sparse, and its use is not yet well-established. The purpose of this study was to assess the efficacy and safety of intraoperative TXA use in patients undergoing hip hemiarthroplasty as treatment for intracapsular femoral neck fracture.Methods: This is a historical cohort of patients who underwent hip hemiarthroplasty in a tertiary medical center between 2011 and 2019, with minimum follow-up of one year. The cohort was divided into one group of patients who received intraoperative TXA treatment and another group that did not. Blood loss, peri‑ and postoperative complications, readmissions, and short- and long-term mortality were compared between groups.Results: Of the 1722 consecutive patients (601 males and 1121 females) who underwent hip hemiarthroplasty who were included in this study, 504 were in the "TXA" group and 1218 were in the "non-TXA" group. TXA use significantly reduced 30-day mortality (4.6% vs 7.3%, respectively, p < 0.046) and perioperative blood loss, as indicated by changes in hemoglobin levels before and after surgery (Δ-1.38 gr/dL vs Δ-1.76 gr/dL, p < 0.001), and by administration of allogenic blood transfusions (17.5% vs 44.4%, p < 0.001).Conclusions: Similar to the known effect of TXA in TJA patients, the use of TXA treatment in patients undergoing hip hemiarthroplasty led to a significant reduction in 30-day mortality, in postoperative blood loss and in the proportion of patients requiring allogenic blood transfusions. [ABSTRACT FROM AUTHOR]

Introduction: Sustaining a hip fracture is a life changing event for many elderlies. While doctors and researchers tend to be preoccupied with mortality and complication rates, patients are more concerned by other aspects e.g. loss of independence and ability to remain in their own home. This study aimed to i) determine age-stratified one-year event rates of admission to nursing home after discharge, and ii) identify risk factors associated with nursing home admission.Methods: Community dwelling patients aged 60-100 years undergoing their first hip fracture surgery in 2005 - 2015 were identified in nationwide administrative registries. Outcome was admission to nursing home within one year of discharge. To assess risk factors, we performed age-stratified cumulative incidence curves and multivariate cause specific cox regression models adjusted for age, sex, social factors, and comorbidities.Results: A total of 53,157 patients were included. One-year risk increased with advancing age from 3.2% of patients aged 60 to 69, up to 22.4% in the eldest group aged 90-100 years. Living alone and dementia were strong risk factors HR 9.22 [95% CI 5.60-15.18, p = <0.0001] and HR 6.73 [95% CI 4.80- 9.44, p = 0.0001] respectively for patients aged 60 to 69 years, the effect decreased with higher age down to HR 2.75 [95% CI 2.12- 3.57, p = <0.0001] and HR 2.15 [95% CI 1.88- 2.46, p = <0.0001] for patients ≥ 90 years. Other important risk factors were pre-injury home care, Parkinson's disease and depression. Surprisingly, physical comorbidities i.e. kidney disease, chronic obstructive pulmonary disease, diabetes and cancer did not increase the risk of nursing home admission.Conclusion: Future initiatives aimed to reduce loss of independence and nursing home admission, among patients with first time hip fracture, should devote attention to living settings and cognitive impairment rather than physical comorbidity. [ABSTRACT FROM AUTHOR]

Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery. [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]

Introduction: Femoral head impaction defects are observed with variable severity, as a result of traumatic hip dislocations which can be caused by traffic accidents or seen in professional athletes amongst other mechanisms. Compression of the articular cartilage and the subchondral bone into the femoral head results in irregular articular surfaces influencing the outcome with predisposition to osteoarthritis, and being predictive for the need for delayed total hip replacement. This study reports the outcome after a minimum follow-up (FU) of five years in a consecutive series treated with transfer of osteochondral shell autografts in hips (TOSAH) from the head-neck junction into the defect using surgical hip dislocation.Patients and Methods: Between 06/2007 and 03/2014 a series of twelve consecutive patients (mean age: 35yrs, range 18-53; median Injury Severity Score: 12, range 9-27) sustained a traumatic posterior hip dislocation in combination with acetabular and/or Pipkin fractures and were inter alia treated using TOSAH using surgical hip dislocation. Conversion to total hip replacement (THR) during FU was noted as failure. Patients were clinically (Merle d'Aubigné score) and radiographically assessed for occurrence of osteoarthritis (OA), avascular necrosis (AVN) and/or heterotopic ossification (HO) at a minimal follow-up of five years.Results: Mean follow-up was 6.9 years (5.0-11.6). At five-year follow-up, we found a survivorship of 57.1% (95% Confidence interval {CI}, 46.7-100%). Four patients required conversion to a total hip replacement at 11, 16, 28 and 44 months respectively after the TOSAH procedure due to osteoarthritis progression. One patient required conversion to a total hip replacement 12 months after TOSAH procedure due to AVN. One patient was lost to follow-up after 2.7 years. The remaining six patients with preserved hips presented with a median Merle-d'Aubigné score of 16 points (range: 14-18) and no AVN. Two patients showed asymptomatic grade I osteoarthritis according to Tönnis at latest follow-up and three patients showed mild asymptomatic HO according to Brooker (Grade I-II).Conclusion: The presented technique can be used as a salvage procedure for severely injured hip joints and to preserve the hip joint at midterm with satisfying clinical and radiological outcomes. [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]

Background: Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible delay in perioperative anemia detection, accumulated perioperative anemia-associated burden, peripheral perfusion, and their association with patient outcomes in elderly patients with hip fracture.Methods: Elderly patients with acute hip fracture scheduled for surgery were enrolled in this prospective study from August 2016 to December 2016. All patients were monitored continuously for hemoglobin concentration (SpHb) and perfusion index (PI) with the Radical-7® Pulse CO-Oximeter® and Rainbow® R1 Adhesive Multi-parameter Sensors (Masimo Corp., Irvine, CA, US) from 12 h presurgery to 24 h postsurgery.Results: Fifty-one patients were enrolled, and 41 were included in the final analyses. Mean delay in the detection of low Hb (<10 g/dL) using intermittent blood samples, when compared with SpHb, was 1.07 h (standard deviation, ±2.84 h). Median perioperative cumulated time with low SpHb (<10 g/dL for at least one min) was 25 min (interquartile range [IQR]: 21-690). There was a significant association between perioperative time with low SpHb and the occurrence of postoperative delirium (median cumulated time with low SpHb: 162 min in patients with delirium vs 22 min in patients without delirium, P = 0.034) and a nonsignificant trend for an association between perioperative time with low SpHb and 90-day mortality or medical complications (median cumulated time with low SpHb: 119 min for patients with mortality or severe complication vs 22 min for patients without mortality or severe complication, P = 0.104). PI values during the perioperative period were not significantly associated with patient outcomes. Cumulated time with low PI (<0.5) preoperatively (but not perioperatively) was significantly associated with the occurrence of postoperative delirium (P = 0.047).Conclusions: This study showed a delay in transfusion threshold detection, and the presence of significant associations between low SpHb or time with low SpHb and postoperative outcomes. [ABSTRACT FROM AUTHOR]

• Post-traumatic arthritis and avascular necrosis are known sequelae after acetabular fractures and conversion to total hip arthroplasty after acetabular fixation is known to be more technically demanding. • We demonstrate that the direct anterior approach is a safe and viable option for conversion total hip arthroplasty for acetabular fixation. • We did not have an increased rate of complications or adverse events than what has been reported in the literature for other approaches. Total Hip Arthroplasty (THA) after prior acetabular fracture repair is known to be demanding as studies have shown inferior implant survival rates and higher infection rates for these procedures. The direct anterior (DA) approach might help mitigate some of these risks by utilizing a new surgical tissue plane. However, potential criticisms of the DA approach for these surgeries include the inability to access previous acetabular implants or heterotopic ossification (HO) if they were to inhibit implant placement. The goals of this study are to analyze the efficacy of the DA approach for conversion to hip arthroplasty surgery after previous acetabular fixation. After reviewing all records at our institution using current procedural terminology codes, we isolated patients with previous acetabular repair who underwent conversion to THA through the DA approach. Patient records were reviewed, and patients were contacted to obtain Harris Hip Scores. 23 patients (16 males and 7 females) were found with a mean follow-up time of 46 months (range 16–156 months). The mean age was 50 (range 28 – 83) and mean BMI was 28.5 (range 15.2 – 39.2). The average blood loss was 400 ml (range 200 – 900). The average operative time was 140 min (range 85–200 min). In 7 cases (32%) implants were encountered during acetabular reaming but the implants were either removed entirely or removed partially with a burr so that the acetabular cup could be positioned within acceptable parameters. In 2 cases pre-operative HO was encountered and was resected. The average Harris Hip Score at final follow-up was 92 (range 75 – 100). There were no deep infections and no neurovascular injuries encountered. 2 patients (9%) underwent revision surgery for aseptic femoral stem loosening. There was 1 anterior dislocation (4.5%) at 3 days post-operatively that was successfully treated with closed reduction and maintenance of hip precautions. Otherwise, the remaining 19 (86%) patients went on to uncomplicated recovery. This is the largest known cohort analyzing the DA approach for conversion to hip arthroplasty after previous acetabular fixation. Overall, we demonstrate that the DAA is safe for conversion THA after acetabular fixation. [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]

Early mobilization following hip fracture surgery is of superior importance especially in elderly hip fracture patients. Reduced mobilization can result in complications and increased mortality. In this study a gait analysis was performed using force-measuring insoles. We hypothesized, that patients with femoral neck fractures treated with hip replacement surgery load the affected limb more compared to patients with pertrochanteric fractures treated with fracture fixation. All patients (> 65 years) treated for a femoral neck fracture with hip replacement or a pertrochanteric fracture, respectively using fracture fixation with intramedullary nailing, were consecutively included in this study. For gait analysis, specific insole forcesensors (Loadsol®) were inserted into the footwear. Five days after surgery gait analysis was performed with a defined walking distance and all patients were instructed to transpose full weight. 20 patients following hip replacement surgery and 27 patients following intramedullary nailing were included. The hip replacement group loaded the affected limb with an average of 74.01% (SD 13.6) of bodyweight, while the fracture fixation group loaded a significantly reduced average of 62.70% (SD 8.3; p = 0.002). The results of the present study indicate that patients suffering from pertrochanteric fractures following fracture fixation are struggling to fully load the affected leg compared to patients suffering from femoral neck fractures treated with hip replacement surgery. The focus of further studies should concentrate on alternative analgesia and verify the cause of the observed difference in order to facilitate early full weight bearing especially in hip fracture patients following fracture fixation. The results indicate that in elderly patients, the fracture pattern and thus the surgical approach lead to a different weight bearing pattern. The primary therapeutic goal for elderly patients must be early mobilization at full weight bearing. [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: Hip fracture surgery is associated with a considerable amount medical and surgical complications, which adversely impacts the patient's outcome and/or increases costs. We evaluated what risk factors were associated with the occurrence of early readmission due to surgical complications after hip fracture surgery.Material and Methods: A nationwide database with 68,800 hip fracture patients treated between 1999 and 2011 was studied to uncover the association of readmissions with co-morbidities, fracture types, different hospital types and treatment methods using the Cox proportional hazards model.Results: Early readmission within three months due to hip fracture surgery complications occurred at a rate of 4.6%. Increased occurrence of readmission was found among patients with: heavy alcoholism (HR 1.38; 95% CI: 1.23-1.53); Parkinson's disease (PD; HR 1.22; 95% CI: 1.05-1.42); pre-existing osteoarthritis (HR 2.02; 95% CI: 1.83-2.23); rheumatic disease (HR 1.44; 95% CI: 1.27-1.65); as well as those with a fracture of the femur neck, depression, presence of a psychotic disorder, an operative delay of at least three days, or previous treatment with total hip arthroplasty.Conclusion: Our results indicate that there are several factors associated with an increased risk of early readmission. We suggest that in the presence of these factors, the surgical treatment method and postoperative protocol should be carefully planned and performed. [ABSTRACT FROM AUTHOR]

Background: Hip fracture is common and morbid in elderly patients. Postoperative cognitive dysfunction (POCD) is also very common in these subjects undergoing surgery with an incidence which exceeds 40% in some reports. To date, the evidence is ambiguous as to whether anesthetic technique may affect the patients' outcome as far as postoperative cognitive function is concerned.Objective: The aim of this study was to compare the effect of general and subarachnoid (spinal) anesthesia on the development of POCD up to 30 days after surgery in elderly patients undergoing hip fracture surgery. Methods Subjects over 65 years with hip fracture undergoing surgery were recruited for this study. They were enrolled and randomized to receive either general anesthesia (GA group) or subarachnoid (spinal) anesthesia (S group). Cognitive function was assessed using a battery of neuropsychological tests undertaken preoperatively and at 30 days postoperatively. The incidence of delirium was examined during the same period and their functional status, in terms of activities of daily living was also recorded.Results: A total of seventy patients, 33 men and 37 females, mean age of 76 years were analyzed. Thirty-three patients received general anesthesia (GA group) and 37 subarachnoid (spinal) anesthesia (S group). The two groups of patients were similar with respect to baseline characteristics, comorbidities and perioperative data. The results of neuropsychological testing showed that there were no significant differences between the groups in eight out of ten neurocognitive tests at baseline and 30 days after surgery. There was a statistically significant decline of the Instrumental Activities of Daily Living Scale score in S group compared with group GA on the 30th postoperative day (p = 0.043). A significant decline was also present in Color-Word Task test in S group compared with group GA at baseline (p = 0.014) and 30 days postoperatively (p = 0.003). Postoperative delirium was present in four patients (12%) for the GA group, and in 10 patients (27%) for the group receiving subarachnoid anesthesia.Conclusion: We concluded that the choice of anesthesia modality does not appear to influence the emergence of postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery. [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]

Aim: We aim to assess post-operative CRP serum values in a cohort of patients who underwent surgical treatment for neck of femur fracture (NOF#), and whether CRP is a valid tool for the assessment of these patients post-operatively.Study Design and Methods: Retrospective analysis was carried out on all NOF#'s admitted for surgical fixation between August 2015 and July 2016 in a district general hospital. Primary analysis included serum CRP levels until day 7 post-operatively, with secondary analysis of any documented evidence of post-operative complications (medical and surgical) within 30 days post-operatively.Results: A total of 365 patients were surgically treated for NOF#'s over the study period. CRP serum levels peaked over the first two days post-operatively to median (IQ range) of 226 mg/L (158-299 mg/L), decreasing to 67 mg/L (45.5-104 mg/L) by day 7 post-operatively. 116 patients had documented post-operative complications within 30 daysof operation. CRP levels in patients with and without complications showed no statistical significance in day-1, day-2 and day-3 post-operatively. However, a significant difference was demonstrated on day-4 (p = 0.017), day-5 (p = 0.003), day-6 (p = 0.02) and day-7 (p = 0.031).Conclusions: During the first three days of the postoperative period we cannot recommend routine CRP serum blood test monitoring in NOF# patients, as it is not diagnostic in the acute inflammatory phase for medical or surgical complications. [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]

Introduction: Methicillin resistant staphylococcus aureus (MRSA) eradication by nurses and pre-op induction antibiotics are mandated for emergency surgery, where true status is unknown. We assessed adherence to local MRSA guidelines for patients undergoing emergency hip fracture surgery and employed point of decision prompts to influence clinicians' behaviour.Methods: We undertook a retrospective record review for all patients undergoing emergency hip fracture surgery at a UK major trauma centre over 3-months. Demographics, MRSA eradication therapy and antibiotics were recorded. Admission-to-MRSA swab result time was compared to the admit-to-operation time. Posters on induction antibiotics were placed in anaesthetic rooms, stickers on MRSA eradication therapy on nursing care bundles and standards re-audited after 6 months.Results: The case-mix was similar in both audit cycles: initial audit (n=69, mean age 76.9, range 33-94), re-audit (n=77, mean age 73.8, range 18-95). There was a small rise in adherence to eradication therapy prescription (1% vs 8%) after sticker distribution, although compliance was poor pre and post intervention. Correct antibiotic choice for MRSA unknown patients (18% vs 94%) improved significantly after poster intervention. Operations occurred at a median of 24.05h (Q1 17.6, Q3 32.3) from admission but MRSA swab results returned at a median of 48h (Q1 41.5, Q3 59.5) p=<0.0001.Conclusion: Providing reminders at the points where decisions are to be made are effective. Audit interventions should be easily undertaken and will become habitual if connected in sequence to old behaviours. [ABSTRACT FROM AUTHOR]