Studies on the complications and prediction of mortality after hip fracture surgery

Abstract: 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.