Exploration Of The Optimal Timing For Surgery In Elderly Patients With Hip Fractures

Part One Clinical study on factors influencing the timing of surgery and its impact on survival rates in elderly patients with intertrochanteric fracturesObjective:The objective of this study is to analyze the reasons for delayed surgery in patients with intertrochanteric fractures（ITF）and to investigate the impact of delayed surgery on perioperative anemia and survival rate.Methods:A retrospective cohort study was conducted on 1,799 acute ITF patients aged≥65 years who were continuously admitted from July 2013 to January 2018.Patients were divided into three groups:non-surgical group,late surgery group（surgery performed>7 days after fracture）,and early surgery group（surgery performed within 7 days after fracture）based on inclusion and exclusion criteria.Demographic data,injury-related data,surgical-related data,complications,perioperative hemoglobin value,transfusion-related data,and calculated series of hidden blood loss（HBL）during hospitalization were collected and compared among the three groups.All independent variables were compared among three groups.All patients were followed up for a long-term period,and the Log-rank test was used to compare the differences in Kaplan-Meier survival curves between groups.Results:A total of 1,017 patients met the inclusion and exclusion criteria.The proportions of diabetes,coronary heart disease,cerebrovascular disease,arrhythmia,heart failure,pulmonary disease,and respiratory failure were significantly higher in the non-surgical and late surgery groups than in the early surgery group（P<0.05）.The proportion of American Society of Anesthesiologists（ASA）grade≥III was higher in the non-surgical and late surgery groups than in the early surgery group（P<0.001）.The median HBL_maxin the non-surgical,late surgery,and early surgery groups was 584.1 m L,780.8m L,and 649.2 m L,respectively,and the difference was significant（P<0.001）.The use of proximal femoral nail anti-rotation（PFNA）for ITF treatment only resulted in a 11-34%increase in HBL during the perioperative period.Survival analysis showed that the cumulative survival rate of the non-surgical group was significantly lower than that of the surgical group（P<0.001,Log-rank）.Further comparison between the two surgical groups showed that the cumulative survival rate of the early surgery group was higher than that of the late surgery group（P=0.001,Log-rank）.Conclusions:1.Comorbidities and high ASA grades are the main reasons for delayed surgery in elderly patients with ITF.2.HBL is the main component of total blood loss in ITF patients,which is mainly caused by the original fracture itself rather than the surgery.3.Late surgery beyond 7 days after fracture is associated with increased HBL and mortality rate compared to surgery within 7 days.Part Two Analysis of the impact of different surgical timing on the dynamic changes of hidden blood loss in elderly patients with intertrochanteric fracturesObjective:This retrospective cohort study aimed to explore the risk factors for HBL and the influence of different surgical timing on the dynamic changes of HBL in elderly patients with ITF.Methods:A total of 1,799 consecutive acute ITF patients aged≥65 years admitted between July 2013 and January 2018 were included in this study and divided into three groups according to the surgical timing:non-operative group,late surgery group（surgery performed more than 7 days after fracture）,and early surgery group（surgery performed within 7 days after fracture）.Demographic data,injury-related data,surgical-related data,complications,perioperative hemoglobin value,transfusion-related data,and calculated series of HBL data were collected and compared among the three groups.Multivariate linear regression was applied to explore the factors influencing HBL using all independent variables.To study the effect of different surgical timing on the dynamic changes of HBL,all patients were divided into surgical and non-surgical groups,and the surgical group was further divided into subgroups according to the number of days after injury.Results:A total of 1,017 patients met the inclusion and exclusion criteria.Multivariate linear regression analysis of HBL_max in three groups showed that risk factors for HBL included gender（P<0.001）,unstable fractures（P<0.001）,transfusion volume（P<0.001）,and body mass index（BMI,overweight,P=0.027,obesity,P=0.019）.Subgroup analysis according to the number of days after injury showed that patients who underwent surgery within 48 hours after injury had a significant increase in HBL during the first 7 days after surgery compared with HBL caused by injury,with the highest increase of 830 m L,which was more than 2.37 times the original HBL.Patients who underwent surgery on the 3rd-8th day after injury showed no significant statistical difference in HBL compared with HBL caused by injury.For patients with delayed surgery of more than 8 days,HBL increased significantly again from the 3rd day after surgery for 4-5 consecutive days compared with HBL caused by injury.HBL_max occurred on the postoperative 3rd-4th day regardless of the timing of surgery.The dynamic changes in HBL of non-operative group patients reflected the influence of original fractures on HBL,and the results showed that HBL_max occurred on the 7th-8th day after fracture.Conclusions:This series of studies has innovatively found that early surgery（within 48 hours after injury）is a significant risk factor for increased HBL during the perioperative period,and other risk factors include gender,unstable fracture type,transfusion volume,history of hypertension,and surgical time≥60 minutes.The peak of HBL caused by the original fracture appears on the 7th-8th day,while the peak of HBL in surgical patients occurs on the 3rd-4th day after surgery.We advocate for early surgery（within 48 hours after injury）for elderly acute ITF patients with few and stable comorbidities who can generally tolerate it.For frail patients with poor conditions and multiple severe comorbidities,especially those with severe anemia,early surgery within 3-7days after fracture is recommended as the optimal surgical timing.For these frail patients,interdisciplinary collaboration is necessary to optimize their comprehensive preoperative condition within the"48-hour window"actively,comprehensively,and promptly to cope with the"second strike"caused by surgery.In summary,through this series of studies,we have proposed a new research direction to address the hotly debated issue of"the optimal timing of surgery for elderly hip fractures"from the perspective of the timing of surgery’s impact on HBL during the perioperative period,providing data support and reference for orthopedic surgeons,anesthesiologists,and scholars.Part Three Clinical study on the impact of early surgery（within48 hours）versus delayed surgery（3-7 days）on adverse outcomes in elderly patients with intertrochanteric fracturesObjective:Early surgery after an acute ITF has been widely accepted,yet conflicting conclusions in previous studies make this issue remains controversial.We aimed to compare the incidence of mortality and perioperative complications among older patients with ITF who received early or delayed surgery.Methods:This retrospective cohort study included 2,323 patients who met the inclusion and exclusion criteria from a continuous cohort of 3,035 ITF patients admitted from October 2015 to November 2019.The patients were divided into an early surgery group（within 2 days after fracture）and a delayed surgery group（3-7 days after fracture）based on the timing of surgery.All patients’demographic data,injury-related data,surgery-related data,hospital outcomes,perioperative complications,and patient survival status during follow-up were collected and compared between the two groups.Propensity score matching（PSM）was used to compare postoperative outcomes between the two groups at a 1:4 ratio.All patients were followed up for at least two years,and Log-rank tests were used to compare differences in Kaplan-Meier survival curves between the groups.Results:After adjusting for potential confounding factors using PSM,there were no significant differences（P>0.05）in surgical duration,intraoperative blood loss,transfusion rate,mortality,and major perioperative complication rates（including severe complications,circulatory system complications,respiratory system complications,and neurological system complications）between patients who underwent early or delayed surgery.The delayed surgery group had a longer hospital stay（mean 14.4 days vs.11.5 days,P<0.001）,higher total hospitalization costs（mean 42,048 yuan vs.39,305 yuan,P<0.001）,and higher rates of minor complications,including hematological complications（41.2%vs.31.7%,P=0.007）and endocrine/metabolic system complications（66.4%vs.59.3%,P=0.039）,compared to the early surgery group.However,our result indicated patients in the early surgery group were more inclined to receive more blood transfusions（mean 2.8 units vs.2.2 units,P=0.004）.Conclusions:A 3-7 days delay of surgical treatment for elderly patients with an ITF does not represent a poorer outcome compared with early surgery within 2 days regarding mortality and major perioperative complications,although it has an impact on hospital stay,total hospitalization costs,and minor complication rates.Expedite surgery for appropriate patients is unquestionable whereas,for those with poor conditions and multiple serious comorbidities,especially those with severe anemia,a reasonable preoperative delay of 3-7 days seems justifiable over the rigorous implementation of the current guidelines.Part Four Discriminative ability for adverse outcomes after hip fracture surgery:a comparison and optimization of three commonly used comorbidity-based indicesObjective:Preoperative risk assessment can predict adverse outcomes following hip fracture surgery,helping with decision-making and management strategies.Several risk adjustment models based on coded comorbidities such as Charlson Comorbidity Index（CCI）,modified Elixhauser’s Comorbidity Measure（mECM）,and modified Frailty Index 5-Factor（mFI-5）are currently prevalent for orthopedic patients,but there is no consensus regarding which is optimal.The primary purpose was to identify the risk factors of CCI,mECM,and mFI-5,as well as patient characteristics for predicting（1）1-month,3-month,1-year,and 2-year mortality,（2）perioperative complications,and（3）extended length of stay（LOS）following hip fractured surgery.The secondary aim was to compare the best-performing comorbidity index combined with characteristics identified in terms of their discriminative ability for adverse outcomes.Methods:We retrospectively reviewed 3,379 consecutive patients presenting with intertrochanteric fractures at our Level I trauma center from2013 to 2018.After eliminated by exclusion criteria,2,241 patients undergoing hip fracture surgery by PFNA,with age≥65 years,were included.Three main multivariate Logistic regression models were constructed.Cox proportional hazards models were used to calculate hazard ratios for mortality.A base model included age,BMI,surgical delay,anesthesia type,hemoglobin record at admission,and ASA also was constructed and assessed.Results:Base model+mECM outperformed other models for the occurrence of major complications including severe complications,cardiac complications,and pulmonary complications[the area under the receiver operating characteristic curve（AUC）,0.647,95%CI,0.616-0.677;AUC,0.637,95%CI,0.610-0.664;AUC,0.679,95%CI,0.642-0.715,respectively],while base model+CCI provided better prediction of minor complications of neurological complications and hematological complications（AUC,0.659,95%CI,0.609-0.709;AUC,0.658,95%CI,0.635-0.680）.In addition,BMI,surgical delay,anesthesia type,and ASA were found highly relevant to extended LOS.Age-group（with a 10-year interval）was indicated to be mostly associated with all-cause mortality with fully adjusted hazard ratio of 1.35 and95%CI range 1.20-1.51.Conclusions:In comparison with mFI-5 and CCI,mECM so far may be the best comorbidity index combined with the base model for predicting major complications following hip fracture.The base model already achieved good discrimination for all-cause mortality and extended LOS,further addition of risk adjustment indices led to only 1%increase in the amount of variation explained.