Impact of surgical timing and type of operative procedure on outcomes in periprosthetic hip fractures: an observational study at an NHS trust centre in the UK.

PURPOSE: There is a global trend of increased periprosthetic fractures due to the growing number of arthroplasty procedures. The present study assessed the impact of factors such as time to surgery and type of surgery on the outcomes, which have been seldom evaluated for periprosthetic fractures. METHODS: An observational study was conducted on consecutive 87 patients within an NHS district hospital trust in the UK. Patients who underwent a complete hip replacement prior to the fracture, received fixation therapy, or underwent revision surgery within the specified time were screened. Patients were grouped in two ways: based on time to surgery and based on surgery type. Logistic regression models were performed to assess for statistically significant differences in post-operative complication, 30-day, and 1-year mortality rates between groups, whilst adjusting for age, gender, and ASA grade. RESULTS: Forty-one patients underwent open reduction and internal fixation (ORIF), 29 patients underwent revision arthroplasty, and 17 patients were subjected to both, ORIF and revision arthroplasty. Sixty of the 87 patients were operated on > 48 h of injury. The median hospital stay was significantly lower in the ORIF plus revision arthroplasty group, versus other surgical groups (p < 0.05) whilst it was significantly higher in the group of patients who underwent surgery after 48 h of injury (p < 0.05). Numerically higher mortality was noted in the revision arthroplasty group (31.03%, p > 0.05). The group that was operated after 48 h of injury showed greater mortality but was comparable to the other group (25% vs. 14.81%, p > 0.05). For post-operative complications, none of the variables were significantly predictive (p > 0.05). However, for 30-day mortality, ASA grade (p = 0.04) and intra-operative complications (p = 0.0001) were significantly predictive. Additionally, for 1-year mortality, ASA grade (p = 0.004) was noted to be significantly predictive. CONCLUSION: Revision and delayed periprosthetic fracture management (> 48 h after injury) group showed a numerically greater mortality risk; however, this finding was not statistically significant. ASA grading at baseline is predictive of mortality for periprosthetic fractures.

Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days.

Distal femur fractures (DFFs) are common injuries with significant morbidity. Surgical options include open reduction and internal fixation (ORIF) with plates and/or intramedullary devices or a distal femur endoprosthesis (distal femur replacement [DFR]). A paucity of studies exist that compare the two modalities. The present study utilized a 1:2 propensity score match to compare 30-day outcomes of geriatric patients with DFFs who underwent an ORIF or DFR. The National Surgical Quality Improvement Program data from 2008 to 2019 were utilized to identify all patients who sustained a DFF and underwent either ORIF or DFR. This yielded 3,197 patients who underwent an ORIF versus 121 patients who underwent a DFR. A final sample of 363 patients (242 patients with ORIF vs. 121 with DFR) was obtained after a 1:2 propensity score match. Costs were obtained from the National Inpatient Sample database using multiple regression analysis and validated with a 7:3 train-test algorithm. Independent samples t-tests and chi-square analysis were conducted to assess cost and outcome differences, respectively. Patients who received a DFR had higher transfusion rates than ORIF (p = 0.021) and higher mean inpatient hospital costs (p = 0.001). Subgroup analysis for patients 80 years of age or older revealed higher 30-day unplanned readmission (0 vs. 18.2%; p < 0.001) and 30-day mortality (0 vs. 18.2%; p < 0.001) rates for patients undergoing ORIF compared with DFR. The total number of DFR cases needed to prevent one ORIF-related 30-day mortality for DFR for patients 80 years of age was 6 (95% confidence interval: 3.02-19.9). The mean hospital costs associated with preventing one case of death within 30 days from operation by undergoing DFR compared with ORIF was $176,021.39. Our results demonstrate higher rates of transfusion and increased inpatient costs among the DFR cohort compared with ORIF. However, we demonstrate lower rates of mortality for patients 80 years and older who underwent DFR versus ORIF. Future studies randomized controlled trials are necessary to validate the results of this study.

Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience.

BACKGROUND: Fragility fractures of the pelvis (FFP) represent an increasing clinical entity. Until today, there are no guidelines for treatment of FFP. In our center, recommendation for operative treatment was given to all patients, who suffered an FFP type III and IV and to patients with an FFP type IIwith unsuccessful non-operative treatment. We performed a retrospective observational study and investigated differences between fracture classes and management alternatives. We hypothetized that operative treatment may reduce mortality. MATERIALS AND METHODS: The medical charts and radiographs of 362 patients were analysed. Patient demographics, FFP-classification, length of hospital stay (LoS), type of treatment, general and surgery-related complications, mortality, Short Form-8 physical component score (SF-8 PCS) and mental component score (SF-8 MCS), Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were documented. RESULTS: 238 patients had FFP type II and 124 FFP type III and IV. 52 patients with FFP type II (21.8%) and 86 patients with FFP type III and IV (69.4%) were treated operatively (p<0.001). Overall mortality did not differ between the fracture classes (p = 0.127) but was significantly lower in the operative group (p<0.001). Median LoS was significantly higher in FFP type III and IV (p<0.001) and in operated patients (p<0.001). There were more in-hospital complications in patients with FFP type III and IV (p = 0.001) and in the operative group (p = 0.006). More patients of the non-operative group were mobile (p<0.001) and independent (p<0.001) at discharge. Half of the patients could not return in their living environment.203 of the 235 surviving patients (86%) answered the questionnaires after a mean follow-up time of 38 months. SF-8 PCS, SF-8 MCS and PMS did not differ between the fracture classes and treatment groups. Pain perception was higher in the operated group (p = 0.013). CONCLUSION: In our study, we observed that operative treatment of FFP provides low mortality rates, although LoS and in-hospital complications were higher in the operative group. At discharge, the non-operative group was more mobile and independent. At follow up, quality of life and mobility were comparable between the groups. Further prospective studies are needed to clarify the impact of operative treatment of FFP on mortality and functional outcome.

Lower 1-Year Postoperative Mortality After Acetabular Versus Proximal Femoral Fractures in Elderly Patients.

BACKGROUND: Geriatric acetabular fractures are becoming more common due to demographic changes. Compared with proximal femoral fractures, surgical treatment is more complex and often does not allow full-weight-bearing. The aims of this study were to compare operatively treated acetabular and proximal femoral fractures with regard to (1) cumulative 1-year mortality, (2) perioperative complications, and (3) predictive factors associated with a higher 1-year mortality. METHODS: This institutional review board-approved comparative study included 486 consecutive surgically treated elderly patients (136 acetabular and 350 proximal femoral fractures). After matching, 2 comparable groups of 129 acetabular and 129 proximal femoral fractures were analyzed. Cumulative 1-year mortality was evaluated through Kaplan-Meier survivorship analysis, and perioperative complications were documented and graded. After confirming that the proportionality assumption was met, Cox proportional hazard modeling was conducted to identify factors associated with increased 1-year mortality. RESULTS: The acetabular fracture group had a significantly lower cumulative 1-year mortality before matching (18% compared with 33% for proximal femoral fractures, log-rank p = 0.001) and after matching (18% compared with 36%, log-rank p = 0.005). Nevertheless, it had a significantly higher overall perioperative complication rate (68% compared with 48%, p < 0.001). In our multivariable Cox regression analysis, older age, perioperative blood loss of >1 L, and wheelchair mobilization were associated with lower survival rates after acetabular fracture surgery. Older age and a higher 5-item modified frailty index were associated with a higher 1-year mortality rate after proximal femoral fractures, whereas postoperative full weight-bearing was protective. CONCLUSIONS: Despite the complexity of operative treatment and a higher complication rate after acetabular fractures in the elderly, the 1-year mortality rate is lower than that after operative treatment of proximal femoral fractures, even after adjustment for comorbidities. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation implants for intracapsular hip fractures in older adults.

BACKGROUND: Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures. OBJECTIVES: To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE. MAIN RESULTS: We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium. AUTHORS' CONCLUSIONS: There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome.

BACKGROUND: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome. METHODS: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs. RESULTS: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome. CONCLUSION: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture.

BACKGROUND: A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs. METHODS: The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed. RESULTS: 14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529). CONCLUSIONS: Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.

Prognostic Implications of Preoperative Pneumonia for Geriatric Patients Undergoing Hip Fracture Surgery or Arthroplasty.

OBJECTIVE: To report outcomes of geriatric patients undergoing hip fracture surgery or arthroplasty with or without preoperative pneumonia and to evaluate the influence of pneumonia severity on patient prognosis. METHODS: In this single center retrospective study, we included geriatric patients (≥60 years old) who had undergone hip fracture surgery or arthroplasty at Peking University People's Hospital from January 2008 to September 2018. Patients with fractures caused by neoplasms or patients with incomplete clinical data were excluded. Using logistic regression and the CURB-65 (confusion, uremia, respiratory rate, blood pressure, and age ≥65 years) score as a prediction tool of 1-year mortality, the effect of preoperative pneumonia on 1-year mortality was evaluated. Survival of patients with different response to pneumonia-specific therapy and survival of patients with different pneumonia severity (evaluated with CURB-65 score) were analyzed using Cox regression. RESULTS: A total of 1386 patients were included; among them, 109 patients (7.86%) were diagnosed with preoperative pneumonia. Outcomes were evaluated in August 2019 (at least 1 year after surgery for all patients). Compared to patients without preoperative pneumonia, patients with this condition had higher 30-day mortality (11.9% vs 5%, P = 0.002) and 1-year mortality rates (33.9% vs 16.3%, P < 0.001) and higher incidence of acute heart failure (7.3% vs 3.4%, P = 0.034) and acute kidney injury (5.5% vs 1.8%, P = 0.009). In multivariate regression, preoperative pneumonia was identified as an independent predictor of 1-year mortality (odds ratio [OR], 1.45; 95% confidence interval [CI] 1.39-3.52; P = 0.021), with other factors including age (≥84 years, OR, 1.46; 95% CI 1.08-1.60; P = 0.027), body mass index (<18.5 kg/m2 , OR 2.23; 95% CI 1.52-3.17, P < 0.001), anesthesia type (regional, OR 0.87; 95% CI 0.19-0.97, P = 0.042), preoperative pneumonia (OR 1.45; 95% CI 1.39-3.52; P = 0.002), congestive heart failure (OR 2.05, 95% CI 1.57-6.21, P < 0.001), chronic kidney disease (OR 1.73; 95% CI 1.50-2.62; P < 0.001). There was a trend of increased 1-year mortality as the CURB-65 score elevated (P for trend = 0.006). Cox regression reveals a higher risk of mortality in patient with preoperative pneumonia, especially in patients with no radiologic improvements after therapy (log-rank, P = 0.035). Analysis of the impact of pneumonia severity on patient survival using Cox regression reveals that a CURB-65 score ≥3 indicated a lower rate of survival (CURB-65 score of 3: hazard ratio [HR] 3.12, 95% CI 1.39-7.03, P = 0.006; score of 4: HR 3.41, 95% CI 1.69-6.92, P = 0.001; score of 5: HR 6.28, 95% CI 2.95-13.35, P < 0.001). CONCLUSION: In this single center retrospective study, preoperative pneumonia was identified as an independent risk factor of 1-year mortality in geriatric patients undergoing hip fracture surgery or arthroplasty. A CURB-65 score ≥3 indicated a higher risk of mortality.

Dynamic hip screws versus cannulated screws for femoral neck fractures: a systematic review and meta-analysis.

OBJECTIVE: Dynamic hip screw (DHS) and cannulated screws (CS) are widely used for femoral neck fractures. However, there is no definite result as to which surgical method bring less complications. We performed this study to compare the complication (mortality, non-union, avascular necrosis (AVN), and revision) of DHS and CS for the treatment of femoral neck fractures patients. METHODS: We searched Pubmed, Ovid, Cochrane Central Register of Controlled Trials, and other relevant studies related the comparison of DHS versus CS for femoral neck fractures from inception to Jan 7, 2020. The quality of the included randomized controlled trials (RCTs) and retrospective studies were assessed using the Cochrane Collaboration tool and Newcastle-Ottawa (NOS), respectively. The meta-analysis was performed by the RevMan 5.2 software. RESULTS: Nine RCTs and seven retrospective cohort studies were included for meta-analysis. CS was found to be superior to DHS with respect to AVN rate (OR 1.47; 95% CI 1.08-1.99; p = 0.01, I2 = 0%). There were no significant between-group differences with respect to mortality, non-union, and revision (p > 0.05). CONCLUSION: DHS and CS have similar complication including mortality, revision rate, and non-union, but CS has superior to DHS on ANV. However, further studies are required to provide more robust evidence owing to some limitations.

Association of Computer-Assisted Virtual Preoperative Planning With Postoperative Mortality and Complications in Older Patients With Intertrochanteric Hip Fracture.

Importance: The outcomes of surgical treatment in patients with intertrochanteric hip fractures are unsatisfactory. Computer-assisted virtual preoperative planning may provide an opportunity to solve this treatment dilemma. Virtual preoperative planning is a technique based on dynamic 3-dimensional computed tomographic imaging, which allows precise evaluation of fracture details and simulation of reduction of fracture and internal fixation procedures before surgery is performed. Objective: To evaluate the association of computer-assisted virtual preoperative planning with the risk of 90-day all-cause mortality and postoperative complications. Design, Setting, and Participants: This retrospective cohort study was conducted from using patient data from a level 1 trauma center database. A total of 1445 patients 65 years and older with intertrochanteric hip fractures between January 1, 2009, and March 31, 2018, were identified and divided into 2 cohorts: 558 patients received computer-assisted virtual preoperative planning (virtual planning group), and 887 patients received conventional preoperative planning (conventional planning group). Of the initial 1445 patients, 224 patients (93 patients in the virtual planning group and 131 patients in the conventional planning group) were excluded, resulting in 1221 patients in the final cohort. Data were analyzed from April 5 to October 5, 2019. Exposures: Computer-assisted virtual vs conventional surgical preoperative planning. Main Outcomes and Measures: Primary outcomes were 90-day all-cause mortality and postoperative complications (including myocardial infarction, heart failure, stroke, kidney failure, and sepsis). Secondary outcomes were 90-day outpatient visits, hospital readmissions, and reoperations. Results: Among 1221 patients who underwent hip surgery, the mean (SD) age was 73.2 (12.3) years, and 927 patients (75.9%) were women. A total of 465 patients (38.1%) were in the virtual planning group and 756 patients (61.9%) were in the conventional planning group. Among the 814 patients (407 patients in each group) who were matched by propensity score, the virtual planning group had a lower incidence of mortality (37 patients [9.1%] vs 55 patients [13.5%]; hazard ratio [HR], 0.64; 95% CI, 0.41-0.99; P = .04) and postoperative complications (25 patients [6.1%] vs 44 patients [10.8%]; HR, 0.54; 95% CI, 0.32-0.90; P = .02) compared with the conventional planning group. The incidence of outpatient visits was not substantially different in the virtual planning group (1.51 incidents per 30 person-days) compared with the conventional planning group (1.48 incidents per 30 person-days; incidence rate ratio [IRR], 0.90; 95% CI, 0.49-1.68; P = .75). Similar results were observed for the rate of hospital readmissions (0.99 incidents per 30 person-days in the virtual planning group and 1.01 incidents per 30 person-days in the conventional planning group; IRR, 0.91; 95% CI, 0.49-1.67; P = .76). However, the rate of reoperations was lower in the virtual planning group (0.76 incidents per 30 person-days) than in the conventional planning group (0.97 incidents per 30 person-days; IRR, 0.41; 95% CI, 0.22-0.76; P = .01). Conclusions and Relevance: Among older patients with intertrochanteric hip fractures, computer-assisted virtual preoperative planning was associated with decreases in the risks of all-cause 90-day mortality, postoperative complications, and reoperations compared with conventional preoperative planning.

Mortality and Morbidity of Surgical Management of Geriatric Ankle Fractures.

INTRODUCTION: The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89. METHODS: Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay. RESULTS: Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group. DISCUSSION: After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups. LEVEL OF EVIDENCE: Prognostic level III, retrospective study.

Comparison of Surgical Stabilization Time in Patients with Flail Chest.

BACKGROUND: This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest. METHODS: A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization. RESULTS: A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization. CONCLUSION: Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

Effect on mortality of treatment method and surgery time for hip fracture patients aged over 65 years.

BACKGROUND: This study aimed to evaluate the effects on mortality of implant selection used and time to surgery in patients aged over 65 years operated for hip fractures. METHODS: A total of 301 patients aged over 65 years were investigated in this study. Patients were divided into three groups as follows: Group 1 cemented hemiarthroplasty (CH), Group 2 cementless hemiarthroplasty (CLH), and Group 3 proximal femoral nail (PFN). Time of surgery, fracture and demographic information were retrospectively recorded. RESULTS: After removing 59 patients with missing information, this study included 242 patients. Mean age of patients was 80.5 years. When patient groups were examined according to treatment method, Group 1 (n=146) comprised 60.3%, Group 2 (n=54) comprised 22.3% and Group 3 (n=42) comprised 17.4% of the study group. There was no significant difference in survival between the patients operated in the first 48 hours and the patients operated later (p=0.834). There was an effect on the survival of treatment implant selection (p=0.016). Patients with CH were observed to survive longer than patients with CLH and PFN. CONCLUSION: Operation in the first 48 hours was not observed to affect mortality. Additionally, while sex and age were found to be effective on mortality, implant selection was also concluded to affect mortality.

Conservative vs Surgical Treatment of Impacted Femoral Neck Fracture in Patients 75 Years and Older.

OBJECTIVE: To evaluate the safety and effectiveness of conservative treatment (CST), internal fixation (IF), and hemiarthroplasty (HA) in treating patients older than 75 years with impacted femoral neck fracture (IFNF). DESIGN: A randomized clinical trial to compare clinical outcomes of CST, IF, and HA in IFNF patients older than 75 years with a 1:1:1 ratio. SETTING: Nanjing First Hospital, Nanjing Medical University, Nanjing, China. PARTICIPANTS: A total of 154 patients with IFNF aged between 75 and 97 years. INTERVENTION: Patients with IFNF were allocated to CST, IF, and HA. They all received a 36-month follow-up. MEASUREMENTS: All patients were evaluated by Harris hip score (HHS) (primary outcome) for hip function, European Quality of Life-5 Dimensions (EQ-5D) index scores for health-related quality of life, and visual analogue scale score for hip pain. Operation duration, blood loss, mortality, union rate, complications, and reoperation were also recorded. Assessors were blind to the type of treatment. RESULTS: The baseline parameters of the three groups were similar. IF group had much lower blood loss than HA group (P < .05), while no significant difference in operative duration was found between the two groups (P > .05). HHS in HA group was significantly higher at 1, 3, and 6 months (P < .05), but no significant difference in HHS was found between CST and IF groups at any of the time points during the overall follow-up (P > .05). EQ-5D index score was higher in HA group at each follow-up within 1 year (P < .05), but the difference was not significant at 2- and 3-year follow-up (P > .05). There was no significant difference in mortality among the three groups at each follow-up point (P > .05). The nonunion rate was 11.76% (6/51) in CST group and 9.80% (5/51) in IF group and showed no significant difference (P > .05). CONCLUSION: CST may be a feasible way for IFNF in the older patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04219943. J Am Geriatr Soc 68:2214-2221, 2020.

Reoperation rate, mortality and ambulatory ability after internal fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: a study on Korean Hip Fracture Registry.

INTRODUCTION: The treatment of unstable intertrochanteric fracture in elderly patients is challenging and how to treat these patients remains controversial. The purposes of this study were to compare (1) reoperation rate, (2) mortality and (3) the postoperative change of walking ability between patients undergoing internal fixation (IF) and those undergoing bipolar hemiarthroplasty (HA) due to this type of fracture based on the data from the Korean Hip Fracture Registry. MATERIALS AND METHODS: Between July 2014 and June 2016, we extracted 623 unstable intertrochanteric fractures (616 patients aged ≥ 65 years) according to the classification of the Association for the Study of Internal Fixation-American Orthopaedic Trauma Association. Among the 564 patients, 396 were treated with IF (IF group) and 168 with bipolar HA (HA group). We compared the reoperation rate and mortality between IF group and HA group. In patients, who were followed up more than 2 years after the surgery, we compared the postoperative change of walking activity from ambulatory outdoors (Koval's grade 1, 2, 3) to housebound (Koval's grade 4, 5, 6). RESULTS: The rate of reoperation was higher in the IF group (24/396, 6.1%) than in the HA (4/168, 2.4%) (p = 0.046). At the final follow-up, 79 (35.7%) of the 221 IF patients became housebound, whereas 21 (23.3%) of the 90 HA patients became housebound (p = 0.022). CONCLUSION: This study showed HA was associated with lower rate of reoperation and lower decrement rate of walking ability compared to IF in elderly patients with unstable intertrochanteric fractures.

Surgical site infection after hip fracture - mortality and risk factors: an observational cohort study of 1,709 patients.

Background and purpose - Surgical site infection (SSI) is a devastating complication of hip fracture surgery. We studied the contribution of early deep SSI to mortality after hip fracture surgery and the risk factors for deep SSI with emphasis on the duration of surgery.Patients and methods - 1,709 patients (884 hemi-arthroplasties, 825 sliding hip screws), operated from 2012 to 2015 at a single center were included. Data were obtained from the Norwegian Hip Fracture Register, the electronic hospital records, the Norwegian Surveillance System for Antibiotic Use and Hospital-Acquired Infections, and the Central Population Register.Results - The rate of early (≤ 30 days) deep SSI was 2.2% (38/1,709). Additionally, for hemiarthroplasties 7 delayed (> 30 days, ≤ 1 year) deep SSIs were reported. In patients with early deep SSI 90-day mortality tripled (42% vs. 14%, p < 0.001) and 1-year mortality doubled (55% vs. 24%, p < 0.001). In multivariable analysis, early deep SSI was an independent risk factor for mortality (RR 2.4 for 90-day mortality, 1.8 for 1-year mortality, p < 0.001). In univariable analysis, significant risk factors for early and delayed deep SSI were cognitive impairment, an intraoperative complication, and increasing duration of surgery. However, in the multivariable analysis, duration of surgery was no longer a significant risk factor.Interpretation - Early deep SSI is an independent risk factor for 90-day and 1-year mortality after hip fracture surgery. After controlling for observed confounding, the association between duration of surgery and early and delayed deep SSI was not statistically significant.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study.

BACKGROUND/OBJECTIVE: The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. METHODS: The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. RESULTS: a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). CONCLUSIONS: In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Double-plate compound osteosynthesis for pathological fractures of the proximal femur: high survivorship and low complication rate.

INTRODUCTION: Management of pathological fractures of the proximal femur is often challenging. Compound double-plate osteosynthesis has been specifically developed for surgical treatment of these pathological fractures. To our knowledge, this study represents the largest series to date of double-plate compound osteosynthesis with the longest follow-up. MATERIALS AND METHODS: Using our institutional digital database, we identified 61 procedures in 53 patients at the proximal femur. Patients were divided into two groups. A 'primary' group with all cases in which a double-plate compound osteosynthesis was performed as initial procedure (n = 46) and a 'revision' group with all cases in which a double-plate compound osteosynthesis was performed as revision procedure after failed previous attempts of internal fixation (n = 15). (1) The survivorship of the hip was calculated using the Kaplan-Meier survivorship analysis. (2) Complications were graded using Sink's classification. (3) The functional outcome was quantified with the Merle d'Aubigné and Postel score. (4) Risk factors were identified based on a multivariate Cox-regression analysis. RESULTS: The cumulative Kaplan-Meier survivorship of the primary group was 96% at 6 months, 90% at 1 year, 5 years and thereafter and 83% at 6 months, 74% at 1 year, 53% at 2 years for the 'revision' group (p = 0.0008). According to the classification of Sink et al., the rate of grade III and IV complications was significantly lower in the primary group (p < 0.0001). The mean Merle d'Aubigné score was 14 ± 7 at 0-3 months, 13 ± 3 at 3-6 months, 15 ± 3 at 6-12 months and 15 ± 4 thereafter (p = 0.54). The only multivariate negative predictor was previous surgery with a hazard ratio of 9.2 (p < 0.006). CONCLUSION: Double-plate compound osteosynthesis is a valuable treatment option for pathological fractures in proximal femur with good functional results.

Cephalomedullary nailing versus sliding hip screws for Intertrochanteric and basicervical hip fractures: a propensity-matched study of short-term outcomes in over 17,000 patients.

BACKGROUND: Hip fractures are associated with poor mortality and morbidity outcomes. Controversy exists over what the preferred treatment is between sliding hips screws (SHSs) and cephalomedullary nails (CMNs) for stable intertrochanteric (IT) and basicervical (BC) hip fractures. The purpose of this study was to compare early postoperative outcomes and complications in patients treated with SHS to those treated with CMN in IT and BC hip fractures. METHODS: We used the National Surgical Quality Improvement Program database to identify IT and BC hip fractures, excluding subtrochanteric hip fractures treated with a SHS and CMN for 2008 to 2016. After propensity score matching, there were 8505 patients in the SHS cohort and 8505 in the CMN cohort. Propensity score-adjusted multivariate regression models assed SHS as an independent risk factor for the following 30-day outcomes: mortality, postoperative major and minor complications, discharge disposition, readmission and reoperation, length of hospital stay (LOS), and operative time. RESULTS: No difference in mortality was encountered between SHS and CMN (p = 0.440). Compared to CMN, the SHS cohort had an 11.6% decreased likelihood of a minor complication (p < 0.001); however, no difference was found between CMN and SHS for major complications (p = 0.117). SHS patients were less likely to have transfusion (p < 0.001), DVT (p = 0.007), and MI (0.024). SHS patients were 12.5% more likely to go home (p = 0.002). No association was discovered between being treated with a SHS and reoperation (p = 0.449) and readmission (p = 0.588). SHS patients had almost a quarter of a day longer LOS (p = 0.041). Patients treated with SHS had a statistically significant (p < 0.001), but clinically irrelevant 2-min longer procedure. LEVEL OF EVIDENCE: III.