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Aims: The primary aim of this study is to compare mobility status of patients receiving oral oxycodone with those receiving subcutaneous alfentanil as analgesic methods prior to mobilization to help physiotherapy compliance after hip fracture surgery. The secondary aims are to assess postoperative pain, health-related quality of life, in-hospital length of stay, total use of analgesia over postoperative days 1 and 2 (POD 1 and POD 2), complication rates within 30 days, and 30-day mortality rates. Methods: A single-centre, prospective cohort study of 64 patients will be undertaken. Patients undergoing surgery for femoral neck fractures at the study centre will be recruited. Patients with a hip fracture meeting the inclusion/exclusion criteria will be enrolled on admission. Patients who have been administered oral oxycodone will be compared to those prescribed alfentanil for pain prior to mobilization with physiotherapists on POD 1 and POD 2. Which drug a patient receives is reliant of the prescriptions given by the medical team, and in current practice this varies at approximately 50:50. Mobilization will be defined as the ability to stand on and weightbear both feet with or without assistance. Results: Visual analogue scale pain scores, mobility status, and total analgesia use will be assessed on POD 1 and POD 2. EuroQol five-dimension health questionnaire scores, complication rates, and mortality rates will be assessed up to 30 days following surgery (POD 1, 2, 7, and 30). Conclusion: This study will help to build a wider protocol aiming to improve early mobilization after hip fracture surgery. The results of this study will provide pain scores and mobility status which will either support use of subcutaneous alfentanil as the standard analgesic modality prior to physiotherapy sessions, or highlight its limitations compared to the standard oral oxycodone. Secondary outcomes will also help to assess if early mobilization improves outcomes compared to delayed mobilization. Cite this article: Bone Jt Open 2025;6(1):53–61.

Abstract Objective To explore the relationship between anion gap (AG) and length of stay (LOS) in patients undergoing hip fracture surgery. Methods Clinical data of patients diagnosed with hip fracture and undergoing surgery were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Logistic regression analysis by adjusting different covariables and threshold effect analysis were used to analyze the relationship between AG and LOS. Subgroup analysis and interaction test were also performed to detect their relationship. Receiver Operating Characteristic (ROC) analysis was performed to identify the prediction performance and cutoff value of AG.Kaplan-Meier (KM) survival analysis was used to explore the influence of AG on overall survival. Results A total of 1508 patients were enrolled and the median LOS was 4.9 days. The correlation between AG and LOS > 7 days was observed among 3 regression models when regarding AG as continuous variables (all OR > 1, all P 7 days gradually increased with increasing AG quartiles (all P for trend 0.05). ROC analysis identified 14.5 as the cutoff value of AG for predicted LOS > 7 days. Survival analysis found that patients in the AG 7 days. The cutoff value can favorably distinguish the survival difference of patients.

Yan-fei Lu,1,* Ji-min Wu,2,* Hai-yan Lan,2 Qiao-min Xu,2 Shu-qi Shi,2 Gong-chen Duan2 1Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, People’s Republic of China; 2Department of Anesthesiology, Lishui People’s Hospital, Wenzhou Medical University Lishui Hospital, Lishui, People’s Republic of China*These authors contributed equally to this workCorrespondence: Gong-chen Duan, Department of Anesthesiology, Lishui People’s Hospital, Wenzhou Medical University Lishui Hospital, No. 1188, Liyang Street, Lishui, Zhejiang, 323000, People’s Republic of China, Tel/Fax +8618957093030, Email 981225178@qq.comBackground: Ciprofol is a new intravenous sedative / anesthetic drug. In recent years, many clinical studies have also confirmed the sedative effect of ciprofol. However, more clinical research is still needed on its clinical application characteristics in special populations.Objective: The aim of this study was to compare the clinical effects of ciprofol and propofol in general anesthesia induction of elderly patients.Methods: 60 elderly (aged ≥ 75 years) patients underwent hip fracture surgery were randomly into two groups of a 1:1 ratio. Group C (ciprofol group): 0.3mg/kg ciprofol was infused. Group P (propofol group): 1.5mg/kg propofol was infused. The observation period was from the infusion of test drug to 5 min after endotracheal intubation. The primary outcomes included the incidence of severe hypotension and hypotension during the observation period. The secondary outcomes were as follows: the success rate of general anesthesia induction, the number of additional sedation, the time of loss of consciousness (LOC), Δ MAP, Δ HR, adverse events and the frequency of vasoactive drugs used.Results: Finally, 60 subjects completed the study. Compared with Group P, the incidence of severe hypotension in Group C was lower (26.7% vs 53.3%, P = 0.035), the incidence of hypotension was also lower (36.7% vs 63.3%, P = 0.037), Δ MAP in Group C was significantly lower (31.4 ± 11.4 vs 39.6 ± 15.7, P = 0.025), the frequency of ephedrine used and the incidence of injection pain in Group C were also significantly lower.Conclusion: Ciprofol showed similar efficacy to propofol when used for general anesthesia induction in elderly patients underwent hip fracture surgery and could maintain more stable blood pressure.Keywords: Ciprofol, elderly, Hip fracture surgery, general anesthesia, hypotension

Gamze Ertaş,1 Hamiyet Şenol Çakmak,1 Sevda Akdeniz,1 Alparslan Yurtbay,2 Ebru Polat,2 Yavuz Yigit,3,4 Nezih Sertöz,5 Serkan Tulgar1 1Department of Anesthesiology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkiye; 2Department of Orthopedic Surgery, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkiye; 3Department of Emergency Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; 4Blizard Institute, Queen Mary University, London, UK; 5Department of Anesthesiology and Reanimation, Ege University, Faculty of Medicine, İzmir, TurkiyeCorrespondence: Yavuz Yigit, Hamad Medical Corporation,Hamad General Hospital, Department of Emergency Medicine, Hamad General Hospital, Emergency Department, Doha, 3050, Qatar, Tel +97430616054, Email yyigit@hamad.qaIntroduction: Hip fracture surgeries in patients present significant challenges, particularly in managing pain during spinal anesthesia positioning. The Pericapsular Nerve Group Block (PENG) has shown promise in addressing this issue, but the ideal volume of local anesthetic for PENG is still uncertain. In our study, we aimed to analyze the effects of administering PENG block with two different volumes on analgesic quality for patients undergoing hip fracture surgery.Methods: In this prospective, randomized controlled trial, the effects of administering a PENG block with 20 mL versus 30 mL of local anesthetic in patients undergoing hip fracture surgery under spinal anesthesia were compared. The primary outcome was pain during spinal anesthesia positioning, and secondary outcomes included postoperative pain scores and opioid consumption.Results: A total of 60 patients were analyzed, with 30 in each group. Critical parameters such as the time of spinal anesthesia administration and the satisfaction of the anesthesiologist showed no significant differences (p=0.918; p=0.741, respectively). NRS scores recorded before, during, and after the positioning for spinal anesthesia exhibited similar patterns (p=0.290; p=0.247; p=0.288, respectively). The cumulative opioid requirements did not exhibit a statistically significant difference at 24 hours (p = 0.098). Quadriceps weakness was significantly more in the PENG-30 group 6 hours after surgery but had recovered by the 9th hour (p= 0.004).Conclusion: In patients undergoing hip fracture surgery, the effects of applying the PENG block with 20 mL or 30 mL of local anesthetic are comparable in terms of positioning for spinal anesthesia and postoperative analgesic requirements.Keywords: hip fracture surgery, pericapsular nerve group block, PENG, spinal anesthesia positioning, postoperative analgesia, local anesthetic volume

Hip fractures are a serious health concern and a major contributor to healthcare resource utilisation. We aimed to investigate nationwide trends in the USA in patient characteristics and outcomes in patients after hip fracture repair surgery. From the Premier Healthcare dataset, we extracted patient encounters for surgical hip fracture repair from 2016 to 2021. Patient characteristics, comorbidities, complications, and anaesthetic and surgical details were analysed. Cochran–Armitage trend tests and simple linear regression were used to determine trends. We included 347 086 hip fracture repair encounters. Notable trends included the following: median patient age declined from 82 yr [interquartile range: 73–88 yr] to 81 yr [interquartile range: 73–88 yr], (P -value=0.002), the proportion of female patients decreased from 68% to 66.2% (P -value=0.019); internal fixation was the most common intervention initially, but with a declining percentage from 49.9% to 43.8% (P -value <0.001); in general, patients carried a greater comorbidity burden, with the proportion with three or more Elixhauser comorbidities increasing from 56.4% to 58.6% (P -value=0.006); general anaesthesia remained the most common anaesthetic technique, from 68.90% to 56.80% without a significant trend; per 1000 inpatient days, the most common complication remained acute renal failure; despite a higher comorbidity burden, no complication showed a statistically significant upward trend, and many showed downward trends. Over the 6-yr period from 2016 to 2021, a majority of hip fracture repairs continued to be performed under general anaesthesia but with that percentage declining over time. Notable trends included a lower percentage of female patients, an increase in femoral neck fractures, a higher comorbidity burden among patients, and a decrease in complications. [ABSTRACT FROM AUTHOR]

Objective: To explore the relationship between anion gap (AG) and length of stay (LOS) in patients undergoing hip fracture surgery. Methods: Clinical data of patients diagnosed with hip fracture and undergoing surgery were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Logistic regression analysis by adjusting different covariables and threshold effect analysis were used to analyze the relationship between AG and LOS. Subgroup analysis and interaction test were also performed to detect their relationship. Receiver Operating Characteristic (ROC) analysis was performed to identify the prediction performance and cutoff value of AG.Kaplan-Meier (KM) survival analysis was used to explore the influence of AG on overall survival. Results: A total of 1508 patients were enrolled and the median LOS was 4.9 days. The correlation between AG and LOS > 7 days was observed among 3 regression models when regarding AG as continuous variables (all OR > 1, all P < 0.05). After stratifying samples with AG quartiles, their relationship was only presented in the Q4 group both in model 1 and model 2 (all P < 0.001). The risk of LOS > 7 days gradually increased with increasing AG quartiles (all P for trend < 0.05). Further, threshold effect analysis found that their association was mainly observed when AG ≥ 14 mEq/L (OR = 1.122, P < 0.001). Subgroup analysis showed that their correlation was not influenced by sex, age, BMI, ethnicity, classification of fracture, therapeutic method, CHD, hypertension, osteoporosis, diabetes and admitted to the ICU (all P for interaction > 0.05). ROC analysis identified 14.5 as the cutoff value of AG for predicted LOS > 7 days. Survival analysis found that patients in the AG < 14.5 group had better overall survival. Conclusion: In patients undergoing hip fracture surgery, the AG was positively correlated with LOS, and 14.5 mEq/L AG was the cutoff value for predicting LOS > 7 days. The cutoff value can favorably distinguish the survival difference of patients. [ABSTRACT FROM AUTHOR]

Abstract Background The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications. Methods A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes. Results The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51–2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96–1.11). Conclusion The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

In this retrospective cohort study, we investigated: (1) The impact of comorbid chronic kidney disease (CKD) on postoperative mortality in patients with a hip fracture; (2) mortality variations by dialysis type, potentially indicating CKD stage; (3) the efficacy of different hip fracture surgical methods in reducing mortality for patients with CKD. This study included 25,760 patients from the Korean National Health Insurance Service-Senior cohort (2002–2019) who underwent hip fracture surgery. Participants were categorized as CKD and Non-CKD. Mortality rate was determined using a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) through a Cox proportional-hazard model. During follow-up, we ascertained that 978 patients (3.8%) had CKD preoperatively. Compared to the Non-CKD group, the mortality risk (HR) in the CKD group was 2.17 times higher (95% confidence interval [CI], 1.99–2.37). In sensitivity analysis, the mortality risk of in patients who received peritoneal dialysis and hemodialysis was 6.21 (95% CI, 3.90–9.87) and 3.62 times (95% CI, 3.11–4.20) higher than that of patients who received conservative care. Mortality risk varied by surgical method: hip hemiarthroplasty (HR, 2.11; 95% CI, 1.86–2.40), open reduction and internal fixation (HR, 2.21; 95% CI, 1.94–2.51), total hip replacement (HR, 2.27; 95% CI, 1.60–3.24), and closed reduction and percutaneous fixation (HR, 3.08; 95% CI, 1.88–5.06). Older patients with CKD undergoing hip fracture surgery had elevated mortality risk, necessitating comprehensive pre- and postoperative assessments and management. [ABSTRACT FROM AUTHOR]

Background: The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications. Methods: A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes. Results: The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51–2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96–1.11). Conclusion: The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes. [ABSTRACT FROM AUTHOR]

Background & Objectives: Frailty status and delirium are common findings in the elderly in the perioperative period, and are associated with higher frequency of complications and poor outcomes after surgery. This study aimed to determine the rate and relationship between preoperative frailty and postoperative delirium (POD) in elderly people scheduled for hip surgery. Methodology: A cross-sectional observational study was conducted on 104 elderly patients scheduled for hip surgery from October 2022 to November 2023 at the Centre for Anesthesia and Surgical Intensive Care, Bach Mai Hospital. The Modified Frailty Index (mFI) was used to assess the frailty. It includes 22 clinical and paraclinical variables and is useful to assess the preoperative frailty. We assessed postoperative delirium (POD) using the Confusion Assessment Method for the ICU (CAM-ICU) flow sheet during the first 4 days after surgery. Univariate and multivariate regression analyses were used to determine the association between frailty and delirium. Results: A total of 104 patients were included in the analysis, and the proportion of patients with preoperative frailty (mFI ≥ 0.25) was 36.5%. Postoperative delirium occurred in 32 patients (30.8%). The frail patient group had a higher rate of postoperative delirium and a significantly longer average duration of delirium than the non-frail group (60.5% vs. 13.6% and 1.26 days vs. 0.35 days, respectively, P < 0.05). Multivariate regression analysis showed that mFI ≥ 0.25 was associated with POD status 4 days after surgery (aOR = 6.29; 95% CI = 1.43-27.6; P < 0.05). Conclusions: The incidences of preoperative frailty and postoperative delirium in elderly patients undergoing elective hip surgery were 36.5% and 30.8%, respectively. Preoperative frailty is an independent risk factor for increased postoperative delirium. [ABSTRACT FROM AUTHOR]

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Background: Hip fractures in elderly patients are a significant health-care concern due to their high morbidity and mortality rates. Aims and Objectives: This study aims to analyze post-operative complications in this demographic to improve care strategies. Materials and Methods: This observational study included 100 patients aged between 65 and 90 years, undergoing hip fracture surgery. The cohort comprised 40% males and 60% females. Patients underwent either total hip replacement (30%) or internal fixation (70%). We tracked post-operative complications within the first 30 days, mortality and reoperation rates, and recovery and rehabilitation outcomes over 6 months. Results: Post-operative complications were reported in several categories: Infection (10%), cardiovascular (15%), respiratory (12%), renal (5%), neurological (8%), and gastrointestinal (6%). The most common infections were superficial wound infections (6%) and deep infections (4%). Cardiovascular complications included arrhythmias (8%), myocardial infarction (4%), and venous thromboembolism (3%). Pneumonia (7%), acute respiratory distress syndrome (3%), and pulmonary embolism (2%) were the primary respiratory complications. The study also recorded a 4% 30-day mortality rate and a 7% reoperation rate. The average hospital stay was 7 days, with 60% of patients requiring post-discharge rehabilitation. At 6-month post-surgery, 70% of patients had achieved complete recovery. Conclusion: The study highlights a significant incidence of post-operative complications among elderly patients undergoing hip fracture surgery. The findings underscore the need for comprehensive perioperative care and vigilant monitoring to mitigate these risks. The data also stress the importance of post-discharge rehabilitation in enhancing recovery outcomes.

Aims and background: The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery. Materials and methods: This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay. Results: 108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups. Conclusion: This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate. [ABSTRACT FROM AUTHOR]

The prevalence of surgical site infections (SSIs) following hip fracture surgery poses a substantial challenge, compounding patient morbidity and healthcare costs. This systematic review and meta‐analysis investigate the potential correlation between perioperative urinary tract infections (UTIs) and the subsequent risk of SSIs, aiming to illuminate the impact of UTIs on postoperative outcomes in this vulnerable population. We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, utilising the PICO framework to define our search strategy across PubMed, Embase, Web of Science and the Cochrane Library. Our inclusion criteria encompassed randomised controlled trials, cohort studies and case–control studies that reported on SSIs following hip fracture surgery in patients with UTIs. Quality was assessed using the Newcastle‐Ottawa Scale, and heterogeneity was quantified using the I2 statistic. A random‐effects model was applied due to significant heterogeneity, and a sensitivity analysis assessed the stability of the results. Six studies met the inclusion criteria, demonstrating high methodological quality. The analysis included studies from 2016 to 2021, with sample sizes ranging from 402 to 31 621 participants. A significant association was found between UTIs and SSIs, with an odds ratio of 2.79 (95% CI: 1.72–4.54, p < 0.001). Sensitivity analysis confirmed the robustness of the results, and no publication bias was detected. Perioperative UTIs significantly increase the risk of SSIs in patients undergoing hip fracture surgery. Proactive treatment of UTIs may be crucial for reducing the incidence of SSIs and improving surgical outcomes in this demographic. [ABSTRACT FROM AUTHOR]

Background: Hip fractures in elderly patients are a significant health-care concern due to their high morbidity and mortality rates. Aims and Objectives: This study aims to analyze post-operative complications in this demographic to improve care strategies. Materials and Methods: This observational study included 100 patients aged between 65 and 90 years, undergoing hip fracture surgery. The cohort comprised 40% males and 60% females. Patients underwent either total hip replacement (30%) or internal fixation (70%). We tracked post-operative complications within the first 30 days, mortality and reoperation rates, and recovery and rehabilitation outcomes over 6 months. Results: Post-operative complications were reported in several categories: Infection (10%), cardiovascular (15%), respiratory (12%), renal (5%), neurological (8%), and gastrointestinal (6%). The most common infections were superficial wound infections (6%) and deep infections (4%). Cardiovascular complications included arrhythmias (8%), myocardial infarction (4%), and venous thromboembolism (3%). Pneumonia (7%), acute respiratory distress syndrome (3%), and pulmonary embolism (2%) were the primary respiratory complications. The study also recorded a 4% 30-day mortality rate and a 7% reoperation rate. The average hospital stay was 7 days, with 60% of patients requiring post-discharge rehabilitation. At 6-month postsurgery, 70% of patients had achieved complete recovery. Conclusion: The study highlights a significant incidence of post-operative complications among elderly patients undergoing hip fracture surgery. The findings underscore the need for comprehensive perioperative care and vigilant monitoring to mitigate these risks. The data also stress the importance of post-discharge rehabilitation in enhancing recovery outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures. Methods A retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS. Results From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p

Hip fracture surgeries are challenging, with postoperative pain management being a critical component of patient care. This systematic review and meta‐analysis aimed to compare the effectiveness of Pericapsular nerve group block (PENGB) and fascia iliac compartment block (FICB) in postoperative wound pain management for patients undergoing hip fracture surgery. The study followed the PRISMA guidelines and was structured around the PICO framework. Comprehensive searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library. Inclusion criteria were limited to RCTs comparing the effectiveness of PENGB and FICB in adult patients undergoing hip fracture surgery. Key outcomes included pain control effectiveness, safety, and complication incidence. The quality of studies was assessed using the Cochrane Collaboration's risk of bias tool. Statistical heterogeneity was evaluated using I2 statistics, and meta‐analysis effect values were calculated using random‐effects or fixed‐effect models, depending on the degree of heterogeneity. The search identified 1095 articles, with 5 studies meeting inclusion criteria. The meta‐analysis revealed that PENGB and FICB were comparable in managing postoperative pain and opioid consumption. However, PENGB significantly reduced the incidence of quadriceps muscle weakness (RR = 0.12, p < 0.05) and did not increase the risk of PONV (RR = 1.36, p = 0.51), suggesting its advantage in maintaining motor function without adding to PONV complications. No significant publication bias was detected. PENGB is comparable to FICB in pain and opioid consumption management after hip fracture surgeries. Its significant benefit lies in reducing the incidence of quadriceps muscle weakness, facilitating better postoperative mobility. Additionally, PENGB does not increase the risk of postoperative nausea and vomiting, underlining its suitability for comprehensive postoperative care in hip fracture patients. [ABSTRACT FROM AUTHOR]

Lumbar plexus blocks (LPBs) are routinely employed for analgesia in hip fracture surgery; however, a novel regional technique, the pericapsular nerve group (PENG) block, potentially offers comparable pain reduction while preserving motor function. Patients aged 45–90 years who underwent hip fracture surgery were allocated to receive either a PENG block or an LPB for analgesia. The primary outcome was the incidence of quadriceps motor block (defined as the paresis or paralysis of the knee extension) at 12 h postoperatively. The secondary outcomes included the performance time, the time to first analgesic requirement, postoperative intravenous (IV) fentanyl consumption, the ability to undergo physiotherapy at 24 and 48 h, complications, sensory and motor block assessments, postoperative numeric rating scale (NRS) pain scores, and patient outcome questionnaires. There was a significantly lower incidence of quadriceps motor block at 6 h (26.7% vs. 80.0%; p < 0.001) and at 12 h (20.0% vs. 56.7%; p = 0.010). The PENG block provided better preservation of the sensory block as well as better performance time (p < 0.001) and time to first analgesia requirement (p = 0.034), whereas the LPB resulted in lower postoperative IV fentanyl consumption at 24 h (p = 0.013). The PENG block demonstrated superiority over the LPB in preserving quadriceps strength and patient satisfaction without any substantial complications, despite higher opioid consumption within the first 24 h post-surgery. [ABSTRACT FROM AUTHOR]

Purpose: Early reports of 30-day mortality in COVID-positive patients with hip fracture were often over 30% and were higher than historical rates of 10% in pre-COVID studies. We conducted a multi-institutional retrospective cohort study to determine whether the incidence of 30-day mortality and complications in COVID-positive patients undergoing hip fracture surgery is as high as initially reported. Methods: A retrospective chart review was performed at 11 level I trauma centers from January 1, 2020 to May 1, 2022. Patients 50 years or older undergoing hip fracture surgery with a positive COVID test at the time of surgery were included. The primary outcome measurements were the incidence of 30-day mortality and complications. Post-operative outcomes were reported using proportions with 95% confidence interval (C.I.). Results: Forty patients with a median age of 71.5 years (interquartile range, 50–87 years) met the criteria. Within 30-days, four patients (10%; 95% C.I. 3–24%) died, four developed pneumonia, three developed thromboembolism, and three remained intubated post-operatively. Increased age was a statistically significant predictor of 30-day mortality (p = 0.01), with all deaths occurring in patients over 80 years. Conclusion: In this multi-institutional analysis of COVID-positive patients undergoing hip fracture surgery, 30-day mortality was 10%. The 95% C.I. did not include 30%, suggesting that survival may be better than initially reported. While COVID-positive patients with hip fractures have high short-term mortality, the clinical situation may not be as dire as initially described, which may reflect initial publication bias, selection bias introduced by testing, or other issues. Levels of Evidence: Therapeutic Level III. [ABSTRACT FROM AUTHOR]

Aims: To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods: This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results: Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion: Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611.

PurposeContralateral hip refracture following initial hip fracture surgery is life-threatening in the elderly with high incidence and mortality. This study investigated the associated independent risk factors and established a nomogram prediction model.MethodsTotally 734 elderly patients with hip fractures who underwent surgical treatment (January 2016–December 2020) were enrolled. Following analyses on demographic variables, clinical characteristics, and laboratory examination, independent risk factors of contralateral hip fractures in the elderly were identified through the least absolute shrinkage and selection operator (LASSO) regression, and univariate and multivariate logistic regression. Patients were randomly allocated into training (n = 513) and validation sets (n = 221). A training set-based nomogram prediction model was established and assessed for predictability, discriminatory ability, and clinical applicability using the receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) in both sets.ResultsContralateral hip refractures occurred in 7.08% (52/734) patients within 2 years after surgery. Age, hemoglobin (Hb), heart disease, neurovascular disease, Parkinson’s disease (PD), Alzheimer’s disease (AD), chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD) were independent risk factors. The nomogram prediction model had a favorable discriminatory ability, as indicated by the areas under the ROC curves (AUC): 0.906 (95% CI, 0.845–0.967) in the training set and 0.956 (95% CI, 0.927–0.985) in the validation set. The calibration curves demonstrated a good consistency between the actual subsequent contralateral hip fracture incidence and the predicted probability. The DCA of the nomogram demonstrated the model’s excellent clinical efficacy.ConclusionThe nomogram model enabled accurate individualized prediction for the occurrence of subsequent contralateral hip fracture in the elderly within 2 years after surgical treatment, which might help clinicians with precise references for appropriate perioperative management and rehabilitation education following initial hip surgery for their patients.

Background: Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures. Methods: A retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS. Results: From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p < 0.001). Risk factors such as congestive heart failure (OR, 2.3[CI, 2.1–2.6]), age above 85 years (OR, 3.2[CI, 2.2–4.7]), cardiac arrhythmias (OR, 2.4[CI, 2.2–2.6]), end-stage renal disease (OR, 3.4[CI, 2.7–4.1]), malnutrition (OR, 2.3[CI, 2.1–2.7]) and AS (OR, 1.2[CI, 1.08–1.5] were associated with increased adjusted odds of postoperative mortality. AS was linked to higher adjusted odds of postoperative mortality (OR, 1.2 [CI, 1.1–1.5]) and complications such as acute myocardial infarction (OR, 1.2 [CI, 1.01–1.4]), cardiogenic shock (OR, 2.0[CI, 1.4–2.9]) and acute renal failure (OR, 1.1[CI, 1.02–1.2]). While hospital stay duration was comparable in both groups (average 5 days), the AS group incurred higher costs (mean $50,673 vs $44,607). The presence of acute heart failure in patients with AS and hip fracture significantly increased mortality, hospital stay, and cost. A notable decline in postoperative in-hospital mortality was observed in both groups from 2008–2019 though the rate of major in-hospital complications rose. Conclusion: AS significantly influences postoperative in-hospital mortality and complication rates in hip fracture patients. While a reduction in postoperative mortality was observed in both AS and non-AS cohorts, the incidence of major in-hospital complications increased across both groups. [ABSTRACT FROM AUTHOR]

Background: hip fractures commonly have an impact on older adults' health. Surgical treatment aims to reduce pain and promote functional ability. However, developing adverse health outcomes or complications post-hip surgery may impede older patients' recovery to return to functional ability as pre-fracture. We aimed to examine the association of personal factors and adverse health outcomes during hospitalization and post-hospital discharge on the functional ability of older people undergoing hip surgery. Methods: a total of 120 older people with hip fractures who were scheduled for surgery at three tertiary hospitals and met the inclusion criteria were recruited for this study. Data were obtained at admission, before discharge, and during the two-week postoperative follow-up using the Demographic, Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement, the Confusion Assessment Method (CAM) Thai version, and Health Outcome Questionnaires. Descriptive statistics and multiple logistic regression analyses were performed to analyze the data. Results: most participants were female, with a mean age of 78.10 years (range = 60–93; SD = 8.37). The most common adverse health outcome during hospitalization was urinary tract infection, followed by delirium, pneumonia, deep vein thrombosis, and surgical site infection. At two weeks immediately post-hospital discharge, 16 participants experienced unpleasant events, including delirium, urinary tract infection, surgical site infection, and pneumonia. The significant predictors of poor functional ability at two weeks immediately post-hospital discharge were old age (OR = 1.114, p = 0.001), subtrochanteric fracture (OR = 13.48, p = 0.008), and type of surgery (OR = 4.105, p = 0.049). [ABSTRACT FROM AUTHOR]

The aim of our study was to evaluate the efficacy of the pericapsular nerve group block (PENG) versus the supra-inguinal fascia iliaca compartment block (SI-FICB) to improve analgesia during positioning for spinal anesthesia (SA) for hip fracture surgery. We conducted a prospective randomized clinical trial involving patients who will undergo hip fracture surgery under SA and randomized into two groups: the PENG group: patients who received PENG block with 10 ml of 0.25% bupivacaine and 10 ml of 2% lidocaine and the SI-FICB group: patients who received SI-FICB block with the same solution. Our primary outcome was the Visual Analogue Scale (VAS) score at positioning for SA. Secondary outcomes were VAS after the block, the ease of spinal positioning (EOSP), the time to perform the block, the postoperative morphine consumption, and the VAS score at the 3rd, 6th, 12th, and 24th postoperative hours. Eighty-nine patients were enrolled and randomized into two groups: 44 in the PENG group and 45 in the SI-FICB group. The time of block performance was comparable in both groups (p = 0.195). There was a significant decrease in pain scores in the 2 groups, 20 min after the blocks at rest and while positioning for SA. PENG block provided better analgesia than SI-FICB block at positioning (P=0.046) with no significant difference in the ease of positioning (p=0.328). The morphine consumption was comparable in the 2 groups (p = 0.842). There was no significant difference in VAS scores at the 3rd, 6th, 12th, and 24th postoperative hours with p respectively 0.061, 0.767, 0.198, and 0.130. Both PENG and SI-FICB blocks provided adequate perioperative analgesia with the superiority of the PENG block in the sitting position for SA. [ABSTRACT FROM AUTHOR]

Abstract Background Hip fracture is a common but devastating disease with a high mortality rate in the older adult population. C-reactive protein (CRP) is a predictor of the prognosis in many diseases, but its correlations with patient outcomes following hip fracture surgery remain unclear. In this meta-analysis, we investigated the correlation between perioperative CRP level and postoperative mortality in patients undergoing hip fracture surgery. Methods PubMed, Embase, and Scopus were searched for relevant studies published before September 2022. Observational studies investigating the correlation between perioperative CRP level and postoperative mortality in patients with hip fracture were included. The differences in CRP levels between the survivors and nonsurvivors following hip fracture surgery were measured with mean differences (MDs) and 95% confidence intervals (CIs). Results Fourteen prospective and retrospective cohort studies comprising 3986 patients with hip fracture were included in the meta-analysis. Both the preoperative and postoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≥ 6 months (MD: 0.67, 95% CI: 0.37–0.98, P

Abstract Purpose Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population. Methods We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality. Results After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value

Background: Many studies have been conducted to explore the risk factors associated with postoperative delirium (POD) in order to understand its underlying causes and develop prevention strategies, especially for hip fracture surgery. However, the relationship between blood transfusion and POD has been heatedly debated. The purpose of this study was to evaluate the risk factors of POD and the relationship between blood transfusions and the occurrence of POD in hip fracture surgery through big data analysis. Methods: Medical data (including medication history, clinical and laboratory findings, and perioperative variables) were acquired from the clinical data warehouse (CDW) of the five hospitals of Hallym University Medical Center and were compared between patients without POD and with POD. Results: The occurrence of POD was 18.7% (228 of 2398 patients). The risk factors of POD included old age (OR 4.38, 95% CI 2.77–6.91; p < 0.001), American Society of Anesthesiology physical status > 2 (OR 1.84 95% CI 1.4–2.42; p < 0.001), dementia (OR 1.99, 95% CI 1.53–2.6; p < 0.001), steroid (OR 0.53 95% CI 0.34–0.82; p < 0.001), Antihistamine (OR 1.53 95% CI 1.19–1.96; p < 0.001), and postoperative erythrocyte sedimentation rate (mm/h) (OR 0.97 95% CI 0.97–0.98; p < 0.001) in multivariate logistic regression analysis. The postoperative transfusion (OR 2.53, 95% CI 1.88–3.41; p < 0.001) had a significant effect on the incidence of POD. Conclusions: big data analytics using a CDW was a good option to identify the risk factors of POD and to prevent POD in hip fracture surgery. [ABSTRACT FROM AUTHOR]

Aim: The aim of this meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA) in the management of hip fracture surgeries in comparison with placebo. Methods: A systematic search was conducted from August 6, 2021. Eligible studies included randomized clinical trials and prospective studies comparing the use of intravenous TXA in patients treated for hip fractures, in comparison with placebo. Review Manager was used for the meta-analysis. Results: Eighteen prospective studies including 14 RCTs met the eligibility criteria. The results favored the TXA group in the quantity of total blood loss (MD = − 196.91 mL, 95% CI − 247.59, − 146.23, I2 = 92%), intraoperative blood loss (MD = − 26.86 mL, 95% CI − 36.96, − 16.78, I2 = 62%), and rate of blood transfusion (OR 0.35, 95% CI 0.28, 0.42, I2 = 0%). TXA also exhibited higher hemoglobin level at day 1 (MD = 6.77 g/L, 95% CI 4.30, 9.24, I2 = 83%) and day 3 (MD = 7.02 g/L, 95% CI 3.30, 10.74, I2 = 82%) postoperatively. There was no significant difference found in the incidence of thromboembolic events from occurring between the two groups, such as deep vein thrombosis (OR 1.22, 95% CI 0.73, 2.02, I2 = 0%) and pulmonary embolism (OR 0.82, 95% CI 0.33, 2.05, I2 = 0%). Conclusion: Administration of intravenous TXA appears to reduce blood loss, rate of blood transfusions and pose no increased risk of thromboembolic events. Therefore, TXA should be considered by physicians when managing hip fracture patients. [ABSTRACT FROM AUTHOR]

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP

BackgroundMachine learning (ML) has been widely utilized for constructing high-performance prediction models. This study aimed to develop a preoperative machine learning-based prediction model to identify functional recovery one year after hip fracture surgery.MethodsWe collected data from 176 elderly hip fracture patients admitted to the Department of Orthopaedics and Oncology at Shenzhen Second People's Hospital between May 2019 and December 2019, who met the inclusion criteria. Patient's functional recovery was monitored for one year after surgery. We selected 26 factors, comprising 12 preoperative indicators, 8 surgical indicators, and 6 postoperative indicators. Eventually, 77 patients were included based on the exclusion criteria. Random allocation divided them into the training set (70%) and test set (30%) for internal validation. The Lasso method was employed to screen prognostic variables. We conducted comparisons among various common machine learning classifiers to determine the best prediction model. Prediction performance was evaluated using the area under the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis. To identify the importance of the predictor variables, we performed the recursive feature elimination (RFE) algorithm based on Shapley Additive Explanations (SHAP) values.ResultsThe AUCs for the testing dataset were as follows: logistic regression (Logit) model = 0.934, k-nearest neighbors (KNN) model = 0.930, support vector machine (SVM) model = 0.910, Gaussian naive Bayes (GNB) model = 0.926, decision tree (DT) model = 0.730, random forest (RF) model = 0.957, and Extreme Gradient Boosting (XGB) model = 0.902. Among the seven ML-based models tested, the RF model demonstrated the best prediction performance, incorporating four features: postoperative rehabilitation compliance, marital status, age-adjusted Charlson comorbidity score (aCCI), and clinical frailty scale (CFS).ConclusionWe developed a prediction model for the functional recovery following hip fracture surgery in elderly patients after one year, based on the Random Forest (RF) algorithm. This model exhibited superior prediction performance (ROC) compared to other models. The software application is available for use. External validation in a larger patient cohort or diverse hospital settings is necessary to assess the clinical utility of this tool.

Purpose: Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population. Methods: We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality. Results: After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications. Conclusions: Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context. [ABSTRACT FROM AUTHOR]

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.

A 90-year-old woman with severe aortic stenosis experienced hospital readmission for chronic heart failure exacerbations many times and was admitted to our hospital for undergoing transcatheter aortic valve implantation. Thereafter, she fell in the ward and fractured her femoral trochanter, requiring early hip fracture surgery. We proposed that we should perform simultaneous transcatheter aortic valve implantation and hip fracture surgery to cardiologist and orthopedist from anesthetic and perioperative management perspective. We considered that it was difficult to maintain cardiovascular function without cardiac intervention during hip fracture surgery and starting rehabilitation as early as possible was important. General anesthesia was induced without any complications, and the tracheal tube was removed after the successive surgeries. On postoperative day 1, bedside rehabilitation was started, and on postoperative day 3, she was transferred from the intensive care unit to the general ward. On postoperative day 32, she was transferred to another hospital. Anesthesiologist should play an important role for decision making in not only intraoperative but perioperative management for critical case, we should communicate with other departments. The successful perioperative management of simultaneous transcatheter aortic valve implantation and hip fracture surgery enabled to start rehabilitation early and prevented further patient hospitalization. [ABSTRACT FROM AUTHOR]

Background: Hypotension often occurs during hip surgery in elderly adults with conventional posterior lumbosacral plexus block. Purpose: We conducted a randomised controlled trial to determine if simple iliopsoas space block can lower the incidence of intraoperative hypotension (IOH) and provide sufficient perioperative pain relief during hip fracture surgery in elderly adults. Methods: Patients undergoing surgery for elderly hip fracture were randomised to receive either an anterior iliopsoas space block with a lateral femoral cutaneous nerve block or a posterior lumbosacral plexus block. The primary outcome was a composite measure of IOH incidence comprising frequency, absolute and relative hypotension durations. Results: Compared to the posterior group, the iliopsoas space block group had a decreased median frequency of IOH [1.09 (0–2. 14) vs. 3 (1.6–4.8), p = 0.001, respectively] along with lower absolute [5 (0–10) min] and relative [minutes below systolic blood pressure of 100 mmHg in % of total anaesthesia time, 6.67 (0–7.65)] duration of IOH compared to the posterior group [35 (10–45) min, p = 0.008; 37.6 (12.99–66.18), p = 0.004, respectively]. The median pain levels in the post-anaesthesia care unit and median intraoperative sufentanil usage were comparable between the iliopsoas space group [2 (1–3); 8 (6–10) μg] and posterior group [1 (0–3); 5 (5–8) μg]. Thermal imaging revealed that the limb injected with the iliopsoas space block had a higher skin temperature than the unblocked limb in the sacral plexus innervated region. Conclusion: A single iliopsoas space block lowers the IOH incidence and provides comparable perioperative analgesia to conventional lumbosacral plexus block. [ABSTRACT FROM AUTHOR]

Background:Postoperative pain management promotes early ambulation and well-being, shortening hospital stays. PENG block is used to manage hip surgery patients' postoperative discomfort. This study compared PENG with FICB for post-op pain management. Total fentanyl consumption in 24 hrs, VAS pain score at 2,6,10,14,18,24 hrs postoperatively, Quadriceps femoris muscle strength at 2,6,10,14,18,24 hrs postoperatively. Material and Methods:A randomized prospective comparative study was performed at Kamineni Academy of Medical Sciences and Research Centre Lb Nagar, Hyderabad, Telangana, India. in 40 patients aged >18 years and ASA 1& 2 groups, scheduled to undergo hip surgeries.patients were randomly allocated into two groups into P group who received PENG block and F group who received FICB. 30 ml of 0.25% Bupivacaine and 4 mg of Dexamethasone was given for both the groups in the nerve block. Outcomes measured were total fentanyl consumption in 24 hours, VAS score @ 2,6,10,14,18,24 hours postoperatively and quadriceps muscle muscle strength @2,6,10,14,18,24, hours postoperatively. Results:There was significant difference in VAS scores and motor power which indicated the potency of sensory blockade and motor sparing seen with PENG block. Also, total fentanyl consumption in 24 hours was less in group P.Conclusion:Findings of this study suggest that PENG Block is superior postoperative analgesic modality to FICB in hip surgeries. [ABSTRACT FROM AUTHOR]

Purpose: Proximal femoral fractures are common within the elderly population and are associated with a high risk of mortality and reduced quality of life. Hemiarthroplasty or osteosynthesis (extramedullary or intramedullary) is the primary treatment option for these fractures. However, within this fragile patient population many comorbidities, among others dementia, are seen. Therefore, predicting patients with a high mortality risk after surgery may lead to adopting alternative treatment options with less risks. This paper proposes a new model to distinguish patients with high postoperative mortality risk with adequate follow-up time in combination with a wide set of useful and available variables., Methods: Patients treated with hemiarthroplasty or osteosynthesis for proximal femoral fractures were studied, with a follow-up period of 6 months. Patients who died within this follow-up period were compared to survivors, and predicting variables were assessed in logistic regression: The Zuyderland Hip Inference for Survival and Lifetime Expectancy (ZHISLE). The model was validated internally against a held-out dataset. Furthermore, the model performance was compared against the Almelo Hip Fracture Score (AHFS) on the same sample., Results: Out of 2463 patients undergoing surgical treatment for proximal femoral fractures, 415 (16.8%) died within 183 days. Predictors for early mortality included old age, male sex, high heartbeat, KATZ-ADL and GFI scores, C-reactive protein and urea concentrations and low albumin concentration. Our model showed satisfactory predictive and discriminatory power (ROC curve = 0.81). Internal validation was good (ROC in validation dataset = 0.81), and better than the AHFS (ROC = 0.57)., Conclusions: The ZHISLE model demonstrates good predictive power concerning mortality risk for old patients with a proximal femoral fracture. The model could benefit patients by indicating if a conservative, non-invasive policy might be a better option for those patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The rate of force development (RFD) is an indicator of muscle strength. A previous study reported that the RFD of hip abductor muscles was increased by neuromuscular electrical stimulation (NMES) to gluteus medius (GM) during gait in healthy adults. However, the effects for patients following femoral head replacement for hip fracture are unclear. The aim of this case report was to investigate the effects of gait training with sub-motor threshold NMES on RFD of hip abductor muscles in two patients following femoral head replacement for hip fracture compared to gait training without NMES. Two elderly patients following femoral head replacement for hip fracture received both interventions of gait training with sub-motor threshold NMES to GM and without NMES. Intervention phases involved 14 sessions each, for 28 sessions total. The RFD of hip abductor muscles, maximum walking speed, six-minute walk distance (6MWD), Berg Balance Scale, one-leg standing time (OLST), functional independence measure, and Numeric Pain Rating Scale (NPRS) were used as outcome measures. In both patients, RFD, 6MWD, OLST, and NPRS were improved by gait training with NMES compared to without NMES. Our results suggest the potential of NMES as a treatment methodology for these two patients undergoing femoral head replacement for hip fracture. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: To compare preoperative full-body disinfection (FBD) prior to hip fracture surgery with local disinfection (LD) of the surgical site regarding incidence of postoperative surgical-site infection (SSI), both procedures performed with 4% chlorhexidine. Findings: There were 16 (6.8%) cases of SSI in 2018 when FBD was performed and 8 (3.1%) cases in 2019 when LD was performed. FBD (2018) compared to LD (2019) presented an adjusted OR of 2.0 (95% CI 0.8–5.1) in the logistic regression analysis. Message: Results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared significant levels of pain caused by FBD. Purpose: Swedish national guidelines recommend full-body disinfection (FBD) with 4% chlorhexidine before hip fracture surgery to prevent surgical-site infection (SSI) despite little evidence. Our objective was to compare preoperative FBD with local disinfection (LD) of the surgical site regarding SSI incidence. Methods: All patients with hip fracture, operated at a hospital in Sweden, January 1, 2018 to December 31, 2019 were included. Patients in 2018 (n = 237) were prepared with FBD and patients in 2019 (n = 259) with LD. Primary outcome was SSI and secondary outcome was SSI and/or death. We adjusted for potential confounders with logistic regression. The adjusted analysis was performed in two models to enable assessment of variables that lacked either outcome; in the first model, these variables were not adjusted, and the second model was restricted to a sub-population not affected by respective variables. Results: There were 16 (6.8%) cases of SSI in 2018 and 8 (3.1%) cases in 2019. FBD (2018) compared to LD (2019) presented an adjusted OR of 1.9 (95%CI 0.8–4.9, P = 0.16) respectively 2.0 (95%CI 0.8–5.1, P = 0.14) in the two models of the logistic regression. In addition, 40 (16.9%) patients in 2018 and 29 (11.2%) patients in 2019 had the combined outcome of SSI and/or death, adjusted OR 1.6 (95% CI 0.9–2.8, P = 0.08) respectively 1.7 (95% CI 0.9–2.9, P = 0.06). Conclusion: We found a non-significant increased risk of SSI 2018 compared to 2019 after adjustment. Randomized control trials are needed. Nonetheless, results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared substantial pain. [ABSTRACT FROM AUTHOR]

Background: Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderly patients during hip fracture surgery. Patients and Methods: In this retrospective cohort study, records of 584 patients (≥ 65 years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed. Results: The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017). Conclusion: Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery. [ABSTRACT FROM AUTHOR]

Aims: This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery. Methods: This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion: A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920.

Aims: This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods: Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results: Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion: There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720.