Low predictive power of comorbidity indices identified for mortality after acute arthroplasty surgery undertaken for femoral neck fracture.

AIMS: Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture. PATIENTS AND METHODS: We analyzed data from 42 354 patients from the Swedish Hip Arthroplasty Register between 2005 and 2012. Only the first operated hip was included for patients with bilateral arthroplasty. We obtained comorbidity data by linkage from the Swedish National Patient Register, as well as death dates from the national population register. We used univariable Cox regression models to predict mortality based on the comorbidity indices, as well as multivariable regression with age and gender. Predictive power was evaluated by a concordance index, ranging from 0.5 to 1 (with the higher value being the better predictive power). A concordance index less than 0.7 was considered poor. We used bootstrapping for internal validation of the results. RESULTS: The predictive power of mortality was poor for both the Elixhauser and Charlson comorbidity indices (concordance indices less than 0.7). The Charlson Comorbidity Index was superior to Elixhauser, and a model with age and gender was superior to both indices. CONCLUSION: Preoperative comorbidity from administrative data did not predict mortality for patients with a hip fracture treated by arthroplasty. This was true even if association on group level existed.

Multi-state analysis of hemi- and total hip arthroplasty for hip fractures in the Swedish population-Results from a Swedish national database study of 38,912 patients.

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.

Hip fracture, mortality risk, and cause of death over two decades.

UNLABELLED: Men and women with hip fracture have higher short-term mortality. This study investigated mortality risk over two decades post-fracture; excess mortality remained high in women up to 10 years and in men up to 20 years. Cardiovascular disease (CVD) and pneumonia were leading causes of death with a long-term doubling of risk. INTRODUCTION: Hip fractures are associated with increased mortality, particularly short term. In this study with a two-decade follow-up, we examined mortality and cause of death compared to the background population. METHODS: We followed 1013 hip fracture patients and 2026 matched community controls for 22 years. Mortality, excess mortality, and cause of death were analyzed and stratified for age and sex. Hazard ratio (HR) was estimated by Cox regression. A competing risk model was fitted to estimate HR for common causes of death (CVD, cancer, pneumonia) in the short and long term (>1 year). RESULTS: For both sexes and at all ages, mortality was higher in hip fracture patients across the observation period with men losing most life years (p < 0.001). Mortality risk was higher for up to 15 years (women (risk ratio (RR) 1.9 [95 % confidence interval (CI) 1.7-2.1]); men (RR 2.8 [2.2-3.5])) and until end of follow-up ((RR 1.8 [1.6-2.0]); (RR 2.7 [2.1-3.3])). Excess mortality by time intervals, censored for the first year, was evident in women (<80 years, up to 10 years; >80 years, for 5 years) and in men <80 years throughout. CVD and pneumonia were predominant causes of death in men and women with an associated higher risk in all age groups. Pneumonia caused excess mortality in men over the entire observation period. CONCLUSION: In a remaining lifetime perspective, all-cause and excess mortality after hip fracture was higher even over two decades of follow-up. CVD and pneumonia reduce life expectancy for the remaining lifetime and highlights the need to further improve post-fracture management.

The surgical approach for hemiarthroplasty does not influence patient-reported outcome : a national survey of 2118 patients with one-year follow-up.

AIMS: Hemiarthroplasty of the hip is usually carried out through either a direct lateral or posterior approach. The aim of this prospective observational study was to determine any differences in patient-reported outcomes between the two surgical approaches. PATIENTS AND METHODS: From the Swedish Hip Arthroplasty Register we identified patients of 70 years and above who were recorded as having had a hemiarthroplasty during 2009. Only patients who had been treated with modern prostheses were included. A questionnaire was posted to those who remained alive one year after surgery. A total of 2118 patients (78% of those available) with a mean age of 85 years (70 to 102) returned the questionnaire. RESULTS: Patients who had undergone surgery through a posterior approach reported a higher health-related quality of life (HRQoL, EQ-5D mean 0.52 versus 0.47, p = 0.009), less pain (visual analogue scale mean 17 versus 19, p = 0.02) and greater satisfaction with the result of surgery (visual analogue scale mean 22 versus 24, p = 0.02) than those who had a direct lateral approach. However, after adjusting for age, gender, cognitive impairment and American Society of Anesthesiologists grade, no association was found between surgical approach and HRQoL, residual pain or patient satisfaction. TAKE HOME MESSAGE: The surgical approach for hemiarthroplasty does not seem to affect the patient-perceived HRQoL, residual pain or patient satisfaction one year after surgery on elderly patients. The choice of approach should be based on other factors, such as the risk of dislocation.

Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients.

UNLABELLED: This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available. The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty. The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases. TAKE HOME MESSAGE: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: results at ten years in a randomised study of 450 patients.

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Outcome after primary and secondary replacement for subcapital fracture of the hip in 10 264 patients.

Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation. After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups. Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.

A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years.

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age.

Incidence of hip fractures in Malmö, Sweden, 1992-1995. A trend-break.

The incidence of hip fractures in Malmö, Sweden, has been studied since 1924. Predictions based on material from the 1950s to the 1980s have shown an almost exponential increase in incidence. During 1992-1995, 2,268 patients aged 50 and older, with hip fractures, were admitted to Malmö University Hospital, the only hospital in the city treating hip fractures. 76% were women with a mean age of 81 (SD 8) years, and the mean age of men was 78 (SD 9) years. 47% of the fractures were cervical. The annual incidences per 10,000 inhabitants were 36 in men and 85 in women. The corresponding numbers of subjects over 80 years were 170 men and 297 women. These findings show that the incidence is no longer increasing. The causes of such a trend-break could be successful osteoporosis prevention, an increasing proportion of non-Scandinavian immigrants with a lower genetic risk of osteoporotic fractures, or a healthier elderly population. Increasing number of the population at risk already have two operated hips, due to previous fractures or arthrosis. Other causes may be fewer prescriptions of sedatives and higher winter temperatures.