Increased Mortality in Hip Fracture Patients With Aortic Stenosis and Pulmonary Hypertension Compared to Aortic Stenosis Alone.

INTRODUCTION: Hip fractures are one of the most common traumatic injuries in the United States, secondary to an aging population. Multiple comorbidities are found in patients who present to trauma centers (TCs) with isolated hip fractures (IHFs) including significant cardiac disease. Aortic stenosis (AS) among these patients has been recently shown to increase mortality. However, factors leading to death from AS are unknown. We hypothesize that pulmonary hypertension (PH) is a significant mechanism of death among IHF patients with AS. METHODS: This is a multicenter retrospective cohort study examining IHF patients treated at Level I and II TCs within a large hospital system from 2015 to 2019. Patients who had IHFs and AS were compared to those who had IHFs, AS, and PH. Multivariable logistic regression was used to risk adjust by age, race, insurance status, and comorbidities. The primary outcome was inpatient mortality. The secondary outcomes were hospital-acquired complications. RESULTS: A total of 1388 IHF patients with AS were included in the study. Eleven percent of these patients also had PH. The crude mortality rate was higher if IHF patients had both AS and PH compared to IHF with AS alone (9% vs 3.7%, P-value .003). After risk adjustment, a higher risk of mortality was still significant (aOR 2.56 [95% CI 1.28, 5.11]). In addition, IHF patients with both AS and PH had higher complication rates; the exposure group had higher percentage of pulmonary embolism (1.4% vs .2%, adjusted P-value .03), new-onset congestive heart failure (4.1% vs 1%, adjusted P-value .01), and sepsis/septicemia (3.5% vs 1.4%, adjusted P-value .05). CONCLUSION: In patients with IHFs, PH and AS increase the likelihood of inpatient mortality by 2.5 times compared to AS alone. Pulmonary hypertension among IHF patients with AS is an important risk factor to identify in the preoperative period. Early identification may lead to better perioperative management and counseling of patients at higher risk of complications.

Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation.

INTRODUCTION: Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes. STUDY DESIGN: We conducted a retrospective cohort study using our level-1 trauma center's trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test. RESULTS: We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001). CONCLUSION: TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Isolated hip fracture in the elderly and time to surgery: is there an outcome difference?

BACKGROUND: Early operative intervention for hip fractures in the elderly is advised to reduce mortality and morbidity. Postoperative complications impose a significant burden on patient outcomes and cost of medical care. Our aim was to determine the relationship between time to surgery and postoperative complications/mortality in patients with hip fracture. METHODS: This is a retrospective review of data collected from our institution's trauma registry for patients ≥65 years old with isolated hip fracture and subsequent surgery from 2015 to 2017. Patients were stratified into two groups based on time to surgery after admission: group 1: <48 hours versus group 2: >48 hours. Demographic variables included age, gender, race, and Injury Severity Score (ISS). The outcome variables included intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), pulmonary embolism (PE) rate, mortality, and 30-day readmission rates. Analysis of variance was used for analysis, with significance defined as a p value <0.05. RESULTS: A total of 485 patients with isolated hip fracture required surgical intervention. Of those, 460 had surgery <48 hours and 25 had surgery >48 hours postadmission. The average ISS was the same in both groups. The average ICU-LOS was significantly higher in the >48 hours group compared with the <48 hours group (4.0 vs. 2.0, p<0.0002). There was no statistically significant difference between groups when comparing DVTand PE rate, 30-day readmission, or mortality rates. DISCUSSION: Time to surgery may affect overall ICU-LOS in patients with hip fracture requiring surgical intervention. Time to surgery does not affect complication rates, 30-day readmission, or mortality. Future research should investigate long-term outcomes such as functional status and disability-adjusted life years. LEVEL OF EVIDENCE: III. Retrospective/ prognostic cohort study.

Do trauma center levels matter in older isolated hip fracture patients?

BACKGROUND: Younger, multi-trauma patients have improved survival when treated at a trauma center. Many regions now propose that older patients be triaged to a higher level trauma centers (HLTCs-level I or II) versus lower level trauma centers (LLTCs-level III or nondesignated TC), even for isolated injury, despite the absence of an established benefit in this elderly cohort. We therefore sought to determine if older isolated hip fracture patients have improved survival outcomes based on trauma center level. METHODS: A retrospective cohort of 1.07 million patients in The Nationwide Emergency Department Sample from 2006-2010 was used to identify 239,288 isolated hip fracture patients aged ≥65 y. Multivariable logistic regression was performed controlling for patient- and hospital-level variables. The main outcome measures were inhospital mortality and discharge disposition. RESULTS: Unadjusted logistic regression analyses revealed 8% higher odds of mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.16) and 10% lower odds of being discharged home (OR, 0.90; 95% CI, 0.80-1.00) among patients admitted to an HLTC versus LLTC. After controlling for patient- and hospital-level factors, neither the odds of mortality (OR, 1.06; 95% CI, 0.97-1.15) nor the odds of discharge to home (OR, 0.98; 95% CI, 0.85-1.12) differed significantly between patients treated at an HLTC versus LLTC. CONCLUSIONS: Among patients with isolated hip fractures admitted to HLTCs, mortality and discharge disposition do not differ from similar patients admitted to LLTCs. These findings have important implications for trauma systems and triage protocols.