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Studies on the complications and prediction of mortality after hip fracture surgery
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

An elderly patient who sustains a hip fracture has increased morbidity and mortality. Scandinavia presents the highest incidence annually of hip fractures worldwide. 

Femoral neck fracture (FNF) of the hip accounts for 50% of all hip fractures in geriatric patients. Intertrochanteric and subtrochanteric femoral fracture accounts for the other 50%. Hip fracture patients are plagued with a high 1-year mortality rate ranging from 8% to 36%. Complications of hip fracture surgery after arthroplasty generally include periprosthetic fracture (PPF), periprosthetic joint infection (PJI), and dislocation. 

Treatent regarding FNF has improved in the last decade. Arthroplasties are currently the standard treatment for displaced FNFs in the elderly. The surgical treatment of PPF can be technically demanding, with a high frequency of complications due to deep infection, dislocation and intraoperative fractures. Some prosthetic designs have been reported.

PJIs are associated with prolonged antibiotic treatment, multiple revision surgeries, prolonged hospital stays, late aseptic loosening and poor functional outcome for the patients. A widely accepted treatment of choice for acute deep PJIs comprises debridement, antibiotics and implant retention (DAIR).

There are currently several models for predicting mortality with the aim of identifying and optimizing patients at risk. The Sernbo score was initially developed as a guidance tool for the orthopedic surgeon in decision making in hip fracture surgery.

Study I: This was a prospective cohort study of patients with FNFs treated with hemiarthroplasty or total arthroplasty. The aim of this study was to compare the risk for PPF between the straight, highly, polished, tapered (CPT) stem and the matte anatomic SPII stem. It was found that the CPT stem imposed a higher risk of postoperative PPF.

Study II: This was a retrospective multicenter cohort study of patients with FNFs treated with total or hemiarthroplasty. The aim of this study was to compare the risk for PPF between the straight, highly polished, tapered Exeter stem and the matte anatomic SPII stem. It was found that Exeter stem imposed a higher risk of sustaining a PPF.

Study III: This was a retrospective cohort study of patients treated with a primary hip arthroplasty (hemi- or total hip) for a displaced FNF. The primary aim of this study was to identify the frequency of PJI and to evaluate the success rate of DAIR. The secondary aim was to analyze the risk factors for developing PJI. It was found that DAIR had a high short- term success rate and that the need for repeated bandage changes indicates an increased risk of PJI and should prompt early surgical intervention.

Study IV: This was a retrospective study with the aim of validating the Sernbo score for predicting mortality after hip replacement for a displaced FNF in elderly patients. The Sernbo score (based on age, habitat, walking aids and mental state) can be used to stratify patients into groups with different one-year mortality rates. The score can be calculated using information obtained during routine orthopedic patient assessments.The Sernbo score was found to identify patients at high risk of dying in the first postoperative year.

Study V: This was a retrospective registry study. All patients who sustained a hip fracture and registered in “Rikshöft” (a Swedish database for hip fracture) were included. The aim of this study was to validate the Sernbo score for predicting mortality after hip fracture in elderly patients on a registry-based level. It was found that the Sernbo score can be used to stratify patients into groups with different one-year mortality rates.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2049
Keywords [en]
Hip fracture, femoral neck fracture, treatment, total hip arthroplasty, hemiarthroplasty, internal fixation, outcome, infection, periprosthetic joint infection, mortality
National Category
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-163442ISBN: 978-91-7855-101-9 (print)OAI: oai:DiVA.org:umu-163442DiVA, id: diva2:1352785
Public defence
2019-10-11, Sal B, Tandläkarhögskolan, 9 tr, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2019-09-20 Created: 2019-09-19 Last updated: 2019-09-19Bibliographically approved
List of papers
1. Substantially higher prevalence of postoperative periprosthetic fractures in octogenarians with hip fractures operated with a cemented, polished tapered stem rather than an anatomic stem A prospective cohort study involving 979 hips
Open this publication in new window or tab >>Substantially higher prevalence of postoperative periprosthetic fractures in octogenarians with hip fractures operated with a cemented, polished tapered stem rather than an anatomic stem A prospective cohort study involving 979 hips
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2016 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 87, no 3, p. 257-261Article in journal (Refereed) Published
Abstract [en]

Background and purpose - Recent studies have demonstrated a high incidence of postoperative periprosthetic femoral fracture (PPF) in elderly patients treated with 2 commonly used cemented, polished tapered stems. We compared the prevalence and incidence rate of PPF in a consecutive cohort of octagenerians with femoral neck fractures (FNFs) treated with either a collarless, polished tapered (CPT) stem or an anatomic matte stem (Lubinus SP2). Patients and methods - In a multicenter, prospective cohort study, we included 979 hips in patients aged 80 years and above (72% females, median age 86 (80-102) years) with a femoral neck fracture as indication for surgery. 69% of the patients were classified as ASA class 3 or 4. Hip-related complications and repeat surgery were assessed at a median follow-up of 20 (0-24) months postoperatively. Results - 22 hips (2.2%) sustained a PPF at a median of 7 (0-22) months postoperatively; 14 (64%) were Vancouver B2 fractures. 7 of the 22 surgically treated fractures required revision surgery, mainly due to deep infection. The cumulative incidence of PPFs was 3.8% in the CPT group, as compared with 0.2% in the SP2 group (p < 0.001). The risk ratio (RR) was 16 (95% CI: 2-120) using the SP2 group as denominator. Interpretation - The CPT stem was associated with a higher risk of PPF than the SP2 stem. We suggest that the tapered CPT stem should not be used for the treatment of femoral neck fractures in patients over 80 years.

National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-123054 (URN)10.3109/17453674.2016.1162898 (DOI)000377098700009 ()27045318 (PubMedID)
Available from: 2016-08-15 Created: 2016-06-27 Last updated: 2019-09-19Bibliographically approved
2. Increased risk for postoperative periprosthetic fracture in hip fracture patients with the Exeter stem than the anatomic SP2 Lubinus stem
Open this publication in new window or tab >>Increased risk for postoperative periprosthetic fracture in hip fracture patients with the Exeter stem than the anatomic SP2 Lubinus stem
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The purpose of this study was to compare the cumulative incidence of postoperative periprosthetic fracture (PPF) in a cohort of femoral neck fracture (FNF) patients treated with two commonly used cemented stems: either a collarless, polished, tapered Exeter stem or the anatomic Lubinus SP2 stem.

Methods: In this retrospective multicenter cohort study of a consecutive series of patients, we included 2527 patients 60 years and above with an FNF who were treated with either hemiarthroplasty or total hip arthroplasty using either a polished tapered Exeter stem or an anatomic Lubinus SP2 stem. The incidence of PPF was assessed at a minimum of 2 years postoperatively.

Results: The incidence of PPF was assessed at a median follow-up of 47 months postoperatively. Forty patients (1.6%) sustained a PPF at a median of 27 months (range, 0-96 months) postoperatively. Two of the operatively treated fractures were Vancouver A (5%), 7 were Vancouver B1 (18%), 11 were Vancouver B2 (27%), 7 were Vancouver B3 (18%), and 13 were Vancouver C (32%). The cumulative incidence of PPF was 2.3% in the Exeter group compared with 0.7% in the SP2 group (p<0.001). The HR was 5.5 (95% CI, 2.4-12.8, p≤0.01), using the SP2 group as the denominator. Six of 40 (15%) patients needed revision surgery after initial treatment of the PPF.Conclusions: The Exeter stem was associated with a higher risk for PPF than the Lubinus SP2 stem. We suggest that the tapered Exeter stem should be used with caution in the treatment of FNF.

National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-163440 (URN)
Available from: 2019-09-19 Created: 2019-09-19 Last updated: 2019-09-19
3. Early periprosthetic joint infection and debridement, antibiotics and implant retention in arthroplasty for femoral neck fracture
Open this publication in new window or tab >>Early periprosthetic joint infection and debridement, antibiotics and implant retention in arthroplasty for femoral neck fracture
2017 (English)In: HIP International, ISSN 1120-7000, E-ISSN 1724-6067, Vol. 27, no 4, p. 349-353Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Periprosthetic joint infection (PJI) is a severe complication of hip arthroplasty for femoral neck fractures (FNF). Debridement, antibiotics and implant retention (DAIR) is recommended in early PJI in association with stable implants. Few studies have evaluated the outcome of DAIR in this fragile population.The purpose of this study was to analyse risk factors for PJI and the short-term outcome of DAIR in FNF patients treated with a hip arthroplasty.

METHODS: A consecutive series of 736 patients (median age 81 years, 490 women, 246 men) had been treated with either a total hip arthroplasty or a hemi hip arthroplasty for a displaced FNF at our institution. 33 (4.5%) of the hips developed an early (&lt;6 weeks post operatively) PJI and 28 (3.8%) of these patients were treated according to the DAIR-protocol. Regression analyses were performed to assess risk factors for developing a PJI.

RESULTS: DAIR eradicated the PJI in 82% (23/28) of patients at a median follow-up of 31 (SD 29.8) months of the infected hips.The logistic regression analysis indicated that 2 or more changes of the primary dressing due to wound bleeding was associated with an increased risk for developing PJI (OR 4.9, 95% 1.5 to 16.1, p = 0.01).

CONCLUSIONS: The short-term success-rate of DAIR was unexpectedly favourable in this fragile patient population; the results being on par with that after PJI in osteoarthritis patients. The need for repeated bandage changes postoperatively indicates an increased risk for PJI and should prompt early surgical intervention.

Keywords
Antibiotics and implant retention (DAIR), Debridement, Femoral neck fracture, Hip Arthroplasty, Periprosthetic joint infection (PJI)
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-131599 (URN)10.5301/hipint.5000467 (DOI)000406433200006 ()28165600 (PubMedID)
Available from: 2017-02-17 Created: 2017-02-17 Last updated: 2019-09-19Bibliographically approved
4. The Sernbo score predicts 1-year mortality after displaced femoral neck fractures treated with a hip arthroplasty
Open this publication in new window or tab >>The Sernbo score predicts 1-year mortality after displaced femoral neck fractures treated with a hip arthroplasty
Show others...
2017 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 88, no 4, p. 402-406Article in journal (Refereed) Published
Abstract [en]

Background and purpose - Displaced femoral neck fractures (FNFs) are associated with high rates of mortality during the first postoperative year. The Sernbo score (based on age, habitat, mobility, and mental state) can be used to stratify patients into groups with different 1-year mortality. We assessed this predictive ability in patients with a displaced FNF treated with a hemiarthroplasty or a total hip arthroplasty. Patients and methods - 292 patients (median age 83 (65-99) years, 68% female) with a displaced FNF were included in this prospective cohort study. To predict 1-year mortality, we used a multivariate logistic regression analysis including comorbidities and perioperative management. A receiver operating characteristic (ROC) analysis was used to evaluate the predictive ability of the Sernbo score, which was subsequently divided in a new manner into a low, intermediate, or high risk of death during the first year. Results - At 1-year follow-up, the overall mortality rate was 24%, and in Sernbo's low-, intermediate-, and high-risk groups it was 5%, 22%, and 51%, respectively. The Sernbo score was the only statistically significant predictor of 1-year mortality: odds ratio for the intermediate-risk group was 4.2 (95% Cl: 1.5-12) and for the high-risk group it was 15 (95% CI: 5-40). The ROC analysis showed a fair predictive ability of the Sernbo score, with an area under the curve (AUC) of 0.79 (95% CI: 0.73-0.83). Using a cutoff of less than 11 points on the score gave a sensitivity of 61% and a specificity of 83%. Interpretation - The Sernbo score identifies patients who are at high risk of dying in the first postoperative year. This scoring system could be used to better tailor perioperative care and treatment in patients with displaced FNF.

Place, publisher, year, edition, pages
Taylor & Francis, 2017
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-134030 (URN)10.1080/17453674.2017.1318628 (DOI)000404588400007 ()28426259 (PubMedID)
Available from: 2017-04-25 Created: 2017-04-25 Last updated: 2019-09-19Bibliographically approved
5. The modified Sernbo score as a predictor of 1-year mortality after hip fracture: A registry study on 55,716 patients
Open this publication in new window or tab >>The modified Sernbo score as a predictor of 1-year mortality after hip fracture: A registry study on 55,716 patients
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Purpose

Patients sustaining a hip fracture have a high mortality rate during the first postoperative year and the Sernbo score may stratify patients into a high, intermediate and low risk of death during this period. We added gender with the aim to improve the original score (i.e. a modified score), and assessed its predictive properties on patients from the National Swedish Hip Fracture Register.

Patients and Methods

55,716 hip fracture patients, 69% women, older than 65 years at surgery (registered between 2010-2015) with complete Sernbo scores and mortality data were studied. Receiver Operating Characteristics analyses (ROC) were used. Validation of Sernbo score.

Results

The over-all 1-year mortality rate was 26% - and 6%, 17% and 42% in the low, intermediate and high risk groups respectively. The ROC analysis indicated a predictive ability of the Modified-Sernbo score, with an AUC of 0.72 (CI 0.71–0.73). ROC analysis of the original Sernbo Score showed an AUC 0.70 (CI 95% 0.70-0.71).

Conclusion

The Modified-Sernbo score identifies patients at high-risk of death during the first year postoperatively, slight improvement when adding sex to the score and validated on national level. This scoring system could be used to tailor peri- and postoperative care and treatment in patients with hip fracture.

National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-163443 (URN)
Available from: 2019-09-19 Created: 2019-09-19 Last updated: 2019-09-19

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