Hip Fracture Surgery in Severe Aortic Stenosis: A Study of Factors Affecting Mortality.

Background: In elderly patients with hip fracture, the prevalence of severe aortic stenosis (valve area <1 cm2) is close to 5%. Few studies have evaluated the prognostic role of aortic stenosis in hip fracture surgery and none has considered the effects of the postoperative setting (intensive care unit vs general ward) on clinical outcome. Purpose: The aim of the present study was to evaluate the factors affecting mortality in patients with severe aortic stenosis undergoing surgery for hip fracture. We also evaluated whether postoperative monitoring in the intensive care unit may affect the prognosis in comparison to return to the general ward after surgery. Patients and Methods: All 2274 patients referred for hip fracture to our tertiary teaching hospital between January 1 2015 and December 31 2019 were screened for the presence of severe aortic stenosis, defined by an aortic valve area <1.0 cm2. Results: The study included 66 patients (27 males, 39 females) with a mean±SD age of 85±7 years. The average time between trauma and surgery was 2.6±3 days. The mean aortic valve area was 0.74±0.15 cm2. Seven patients died during hospitalization (10.4%). Diabetes, having two or more comorbidities, a low degree of autonomy, heart failure, history of coronary artery disease, atrial fibrillation, postoperative delirium and pulmonary hypertension were associated with poorer outcome. In logistic multivariate analysis, the number of diseases and values of pulmonary artery pressure were the only independent factors related to mortality. In hospital mortality (12 and 9%, respectively) and complication rates were not statistically different between patients referred to the intensive care unit for postoperative monitoring and patients returned to the general ward after surgery. Conclusion: In patients undergoing hip fracture surgery, severe aortic stenosis is associated with high hospital mortality, and two or more comorbidities and pulmonary hypertension are associated with a worse prognosis. The postoperative setting (intensive care unit or general ward) does not affect outcome.

Independent, Differential Effects of Delirium on Disability and Mortality Risk After Hip Fracture.

OBJECTIVES: To assess the independent effect of delirium on mortality and disability after 1 year of follow-up, in consecutive older patients with hip fracture hospitalized for surgical repair. DESIGN: This is a prospective observational study. SETTING AND PARTICIPANTS: Patients aged older than 65 years consecutively admitted for hip fracture to the Trauma and Orthopedics Centre of a third-level hospital, between March and October 2014. METHODS: Patients were evaluated by a multidisciplinary team. A comprehensive geriatric assessment was performed on admission. Delirium was assessed before and after surgical repair according to the Confusion Assessment Method. Mortality and disability status were collected at 3 months and 1 year after hospital discharge. RESULTS: Of 411 patients with hip fracture, 387 (mean age 82 years, female 72%) were enrolled. Delirium was assessed in 50% of the enrolled population. Patients with delirium were older, frequently affected by dementia, severe prefracture disability, history of falls, and polypharmacy. One-year mortality was 19% in all populations, and higher in patients with delirium, although delirium did not show an independent association with mortality, in multivariable analysis. Conversely, delirium was identified as an independent prognostic factor of long-term disability (B-1.605, SE 0.211, P < .001). CONCLUSION AND IMPLICATIONS: This study identifies delirium as an independent long-term disability generator, regardless of associated clinical conditions and premorbid cognitive and functional status. This emphasises the importance of delirium prevention through a multidisciplinary approach and the potential role of systematic treatment of risk factors in reducing functional decline, even in subjects with preexistent disability and dementia. Moreover, these data call for research on rehabilitation interventions specifically targeted to these complex patients, with the aim of identifying approaches effective in reducing long-term disability. Conversely, a high level of clinical alertness is required in patients with delirium, as an appropriate treatment of acute diseases should reduce their high mortality risk.

Management of ongoing direct anticoagulant treatment in patients with hip fracture.

Aim of the present study was to investigate the effects of ongoing treatment with DOACs on time from trauma to surgery and on in-hospital clinical outcomes (blood losses, need for transfusion, mortality) in patients with hip fracture. Moreover we evaluated the adherence to current guidelines regarding the time from last drug intake and surgery. In this observational retrospective study clinical records of patients admitted for hip fracture from January 2016 to January 2019 were reviewed. 74 patients were in treatment with DOACs at hospital admission. Demographic data, comorbidities and functional status before trauma were retrieved. As control group we evaluated 206 patients not on anticoagulants matched for age, gender, type of fracture and ASA score. Time to surgery was significantly longer in patients treated with DOACs (3.6 + 2.7 vs. 2.15 ± 1.07 days, p < 0.0001) and treatment within 48 h was 47% vs. 80% in control group (p < 0.0001). The adherence to guidelines' suggested time from last drug intake to surgery was 46%. Neither anticipation nor delay in surgery did result in increased mortality, length of stay or complication rates with the exception of larger perioperative blood loss (Hb levels < 8 g/dl) in DOACs patients (34% vs 9% p < 0.0001). Present results suggest that time to surgery is significantly longer in DOAC patients in comparison to controls and adherence to guidelines still limited.

Postoperative atrial fibrillation is related to a worse outcome in patients undergoing surgery for hip fracture.

Few information exist about incidence and prognostic significance of postoperative atrial fibrillation (POAF) in patients undergoing hip fracture surgery. In the period comprised between January 2012 and December 2016, we evaluated 3129 patients referred for hip fracture. At hospital admission 277 were in permanent atrial fibrillation and were excluded from the study. POAF was defined as symptomatic or asymptomatic AF of duration > 10 min occurring during hospitalization after hip surgery. In-hospital and 1-year outcomes of POAF patients were compared to that of an age- and sex-matched hip fracture control group. Survival rates were estimated by Kaplan-Meier curves and differences between groups compared by log-rank test. One hundred and four patients (mean age 83.7 years, men 27%) developed POAF (3.6%). Time of onset after surgery was on average 2 days after surgery. Eight POAF patients died during hospitalization. 81.7% were discharged in sinus rhythm. Patients with POAF had a longer time to surgery (3.8 ± 3.3 vs. 2.4 ± 1.6 days, p = 0.0007) and length of hospital stay (19.7 ± 10.4 vs. 14.4 ± 5.1 days p < 0.0001) in comparison to control group. Eight patients had AF recurrence during follow-up. 1-year mortality was significantly higher in POAF group in comparison to control group (39.3. vs 20.9%, p < 0.001). Postoperative atrial fibrillation in patients undergoing hip fracture surgery is associated with a longer length of hospital stay in comparison to patients who maintain stable sinus rhythm. Moreover, these patients had a significant higher mortality at 1-year follow-up.