Authors: Eveline de Haan, Anna de Ronde, Louis de Jong, Veronique. A. J. I. M. van Rijckevorsel, Gert R. Roukema
Categories: Research, Hip fracture, Uncomplicated, Predictive factors, Clinical outcomes, Hip surgery
Source: BMC Musculoskeletal Disorders
Authors: Eveline de Haan, Anna de Ronde, Louis de Jong, Veronique. A. J. I. M. van Rijckevorsel, Gert R. Roukema
Not all older patients with hip fractures exhibit frailty and a high risk of complications. Identifying low-risk patients allows more cost-effective treatment strategies. This study aims to identify the patients’ characteristics associated with a reduced risk of major complications following acute hip fracture surgery in elderly patients.
A prospective hip fracture database was used to obtain data for this observational cohort study. Complications during hospitalization were categorized as major and minor. Both univariable and multivariable analyses were conducted to determine factors significantly correlated with a hospital stay without major complications in patients of 65 years and older.
In total, 2304 patients were analyzed, of whom 771 (33.5%) had one or more major complications. The following characteristics were associated with an uncomplicated hospital stay after hip fracture surgery; age lower than 75 years, female gender, ASA 1 and 2, no history of atrial fibrillation, nor chronic obstructive pulmonary disease, nor dementia, nor Parkinson, nor myocardial infarction, The Katz Index of Independence in activities of daily living (Katz-ADL) of 6, an albumin above 35 g/L and no use of a walking aid. Patients without major complications had significantly shorter hospital stays and lower rates of 30-day and 1-year mortality.
This study identifies specific characteristics that can help select patients at low risk for major complications after hip fracture surgery. Patients with a low risk of complications may probably not require extensive geriatric care, enabling more efficient allocation of healthcare resources and contributing to cost reduction.
The online version contains supplementary material available at 10.1186/s12891-025-08720-x.
As the global population ages, the incidence of hip fractures is projected to rise [1]. Hip fractures often necessitating surgical intervention even in frail patients with multiple comorbidities, aiming for pain relief and early mobilization [2, 3]. Complications after surgery are inevitable in this population. High incidence rates of delirium (16%–39%), pneumonia (5.9%), surgical site infections (5%) and myocardial infarction (1.9%) have been reported [2–8].
In response to these challenges, specialized Geriatric Fracture Centers (GFC) have been established in many healthcare institutions in the last decades. GFCs aim to enhance care for the frail elderly trauma patients [9]. These departments employ a multidisciplinary approach, integrating the expertise of trauma surgeons a geriatrician to provide comprehensive care, address age-related and geriatric aspects [9]. GFCs focus on assessing delirium risk, managing comorbidities, evaluating pre- and postoperative mobility and assessing nutritional status [9].
With the increasing number of elderly frail patients, selecting appropriate candidates for the limited capacity within GFCs present a challenge. Currently, in most hospitals a high percentage of elderly individuals with hip fracture are admitted to the GFC, however, not all geriatric patients exhibit extensive comorbidities or are at high risk for complications. A subgroup of relatively healthy geriatric trauma patients may not derive substantial benefits from the additional consultation provided by the geriatrician, or the comprehensive care provided by the GFC. This study aims to identify the patients’ characteristics associated with a reduced risk of major complications following acute hip fracture surgery. Not all patients have a high risk of major complications and require extensive geriatric care, By avoiding the unnecessary use of healthcare resources, they can be allocated more effectively.
For this observational cohort study, patients older than 65 years, who underwent proximal hip fracture surgery between 2018 and 2021 were prospectively included in a multicenter database of two level II trauma teaching hospitals in the Netherlands (Fig. 1). Patients with a pathological fracture or patients who received a non-operative/palliative treatment were excluded. Baseline characteristics and clinical outcomes were collected from patient charts. Follow-up after surgery was at least one year. According to antibiotic prophylaxis, 1-2 g cefazolin, was given prior to surgery and the surgery was performed in a laminar flow theater.Fig. 1Flow chart of included patients
Data were collected of risk factors for the development of complications after hip fracture surgery known from literature [1, 10–17]. Data on nutritional status were expressed in BMI and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ) score. The Katz Index of Independence in Activities of Daily Living (Katz-ADL) was scored by a geriatrician to determine the preoperative functional performance of a patient on a scale of 0 (completely dependent) to 6 (completely independent). Information about the living situation before the proximal femur fracture was obtained. To estimate comorbidity, ASA classification, the Nottingham hip fracture score (NHFS) and the Charlson Comorbidity Index (CCI) were used in which patient’s comorbidities and general status were combined [18–20]. To evaluate perioperative clinical outcomes, data regarding the length of hospital stay and mortality rates were collected.
All adverse events and complications occurring during hospitalization were collected. Complications were categorized in major and minor complications (Fig. 2). Major complications were defined as a those requiring pharmacological treatment or intervention that prolonged the hospital stay, while minor complication included any deviations from the normal recovery that did not necessitate such interventions and typically did not extend hospitalization. Complications arising from underlying conditions unrelated to the hip fracture or its surgical treatment were not classified as complication (Fig. 2).Fig. 2Deviation of the complications in this cohort during hospital stay after hip fracture surgery
Categorical variables were presented as frequencies and percentages. Continuous variables were presented as mean (standard deviation, ± SD) in case of a normal distribution or as median (interquartile range, IQR) in case of a non-normal distribution. Univariate logistic regression analyses were performed to evaluate associations between potential prognostic factors and the primary outcome, no major complications. Significant associations identified in univariable analysis and variables reported in the literature were included in the multivariate logistic regression mode to analyzing hospital stays without major complications after hip fracture surgery. Missing data in covariates were completed by multiple imputation with chained equations (m = 100 imputation datasets) [21]. Details of the multiple imputation procedure can be found in supplemental file, Appendix 1. Subsequently, backward elimination was performed until all remaining variables reached a P-value < 0.10. The outcomes of the multivariable analysis were compared with the non imputed, complete set (m = 0, n = 1114). Statistical analyses were performed using Stata version 14.0 (StataCorp, College Station, TX, USA), and all statistical tests were two-sided with a significance level of P < 0.05. Mortality rates were established and displayed using the Kaplan–Meier estimator.
Following multivariable analysis, patient characteristics associated with a high likelihood for no major complications during hospital stay were identified. The patient who met all the identified criteria/patient characteristics related to developing no major complications during hospital stay were selected. Information was assessed about the admission ward (GFC or not) and consultation of a geriatrician of those patients.
The study protocol was approved by the local ethics committee (L2017044, Toetsingscommissie Wetenschappelijk Onderzoek Rotterdam (TWOR), Rotterdam, Trial registration number NL8313, registration date not availible). Because of no change in standard practice of care and the high percentage of cognitive dysfunction, the local ethics committee concluded that patients’ consent to review their medical records was not required. Patient data were collected anonymously, and all protocols were conducted in compliance with the Declaration of Helsinki. No external funding was used for this study. The STROBE guidelines were used to ensure the reporting of this study [22].
In total, 2304 patients older than 65 years were analyzed, of whom 771 (33.5%) had one or more major complications (Table 1). The most common major complications were delirium (n = 413, 17.9%), pneumonia (n = 224, 9.7%), urinary tract infection (n = 198, 8.5%) and heart failure (n = 134, 5.8%).
Table 1Incidence of complications after hip fracture surgery in patients of 65 years and older during hospitalizationComplications during hospital stayIncidence of the complication (n = 2304)Cumulative incidence of the complicationsn %n %Major complications Acute kidney failure783.4%783.4% Bleeding or hematoma with reoperation2 > 0.1%793.4% Cardiovascular event (ACS, STEMI, NSTEMI)50.2%843.6% Cerebral vascular event130.6%964.2% Deceased783.4%1155.0% Delirium41317.9%50521.9% Embolism fat or pulmonary100.4%50822.0% Exacerbation COPD150.6%51522.4% Heart Failure1345.8%57725.0% Luxation/failure of the implant130.6%58325.3% Opiate intoxication1 > 0.1%58325.3% Pneumonia2249.7%65928.6% Resuscitation30.1%66028.6% Urinary tract infection1988.5%76033.0% Wound infection371.6%77133.5%Minor complications Anemia with transfusion47620.7%101744.1% Anemia without transfusion331.4%103344.8% Atrial fibrillation or flutter542.3%104745.4% Bladder retention25210.9%113449.2% Bleeding or hematoma (without reoperation and/or transfusion)1516.5%117751.0% Deep venous trombosis1 > 0.1%117751.0% Drop foot1 > 0.1%117851.1% Electrolyte disorders1426.1%121252.6% Erysipelas1 > 0.1%121252.6% Extravasation infusion1 > 0.1%121352.6% Falling incident602.6%122853.3% Fever eci/reabsorption1 > 0.1%122853.3% Ileus/obstipation50.2%123053.4% Pressure ulcers1094.7%125454.4% Urinary incontinence1 > 0.1%125454.4% Wound leakage/dehiscence150.6%126054.7%Complications due to other underlying diseases (not counted as complication) Cholecystitis1 > 0.1%-- Bowel ischemia2 > 0.1%-- Covid infection30.1%-- Diverticulitis/Gastro-enteritis90.4%-- Gout1 > 0.1%-- Meningitis1 > 0.1%-- Psychiatric disorders1 > 0.1%-- Stomach ulcer1 > 0.1%-- Subdural hematoma1 > 0.1%-- Vestibular neuritis1 > 0.1%--Overall incidence of major complications77133.5%--Overall incidence of minor complications93740.7%--All patients with major and/or minor complications126054.7%--Abbreviations: ACS Acute coronary syndrome, STEMI ST segment myocardial infarction, NSTEMI non- ST segment myocardial infarction, COPD chronic obstructive pulmonary disease
Table 2 presents the results of the univariable analysis assessing baseline factors associated with a hospital stay with and without major complications. The mean age of the included patients was 82.5 years and 34% of all patients were male (n = 713). Out of the 27 baseline factors evaluated, 20 were found to be statistically significant, and highly associated with a hospital stay free of major complications after univariable analysis (Table 2).
Table 2Univariable analyses of risk and prognostic baseline factors for hospitalization without major complicationsVariable****All patients (2304)****Without major complication (1533)****With major complication (771)****Odds ratioP**-valuen (%)n (%)n (%)(95% CI)Age 65—74 years (reference)427/2304 (19%)334/1533 (22%)93/771 (12%)-- 75–84 years836/2304 (36%)577/1533 (38%)259/771 (34%)0.62 (0.47–0.81)0.001 > 85 years1041/2304 (45%)622/1533 (41%)419/771 (54%)0.41 (0.32–0.54) < 0.001Male Gender**713/2304 (34%)440/1533 (29%)273/771 (36%)0.73 (0.61–0.88)**0.001ASA score** 1 and 2 ((reference)642/2304 (28%)507/1533 (33%)135/771 (18%)-- 3 and 41662/2304 (72%)1026/1533 (67%)636/771 (84%)0.43 (0.35–0.53)** < 0.001CCI** (mean ± SD)5.0 (± 1.6)4.9 (± 1.6)5.4 (± 1.5)0.83 (0.78–0.87)** < 0.001NHFS** (mean ± SD)4.8 (± 1.3)4.7 (± 1.3)5.2 (± 1.3)0.74 (0.69–0.79)** < 0.001** Missing550Medical history Atrial fibrillation437/2304 (19%)249/1533 (16%)188/771 (24%)0.60 (0.49–0.74)** < 0.001** Cardiac valve disease193/2304 (8%)118/1533 (8%)75/771 (10%)0.77 (0.57–1.05)0.098 Cerebrovascular accident/TIA494/2304 (21%)311/1533 (20%)183/771 (24%)0.82 (0.66–1.01)0.057 COPD283/2304 (12%)163/1533 (11%)120/771 (16%)0.65 (0.50–0.83)0.001 Dementia560/2304 (24%)322/1533 (21%)238/771 (31%)0.60 (0.49–0.72)** < 0.001** Diabetes Mellitus434/2304 (19%)287/1533 (19%)147/771 (19%)0.98 (0.78–1.22)0.842 Heart Failure159/2304 (7%)80/1533 (5%)79/771 (10%)0.48 (0.35–0.67)** < 0.001** Malignancy in < 20 years367/2304 (16%)230/1533 (15%)137/771 (18%)0.82 (0.65–1.03)0.087 Myocardial infarction214/2304 (9%)114/1533 (7%)100/771 (13%)0.54 (0.41–0.72)** < 0.001** Parkinson117/2304 (5%)61/1533 (4%)56/771 (7%)0.53 (0.36–0.77)0.001 Previous hip fracture surgery233/2304 (10%)158/1533 (10%)75/771 (10%)1.07 (0.80–1.42)0.664Anticoagulation use No anticoagulation use ((reference)1037/2304 (45%)752/1533 (49%)285/771 (37%)-- PAI701/2304 (30%)442/1533 (29%)259/771 (34%)0.65 (0.53–0.79)** < 0.001** VKA/DOAC495/2304 (21%)296/1533 (19%)199/771 (26%)0.56 (0.45–0.71)** < 0.001** Combination71/2304 (3%)43/1533 (3%)28/771 (4%)0.58 (0.35–0.95)0.032****Polypharmacy (> 4 medications)1378/2304 (60%)851/1533 (56%)527/771 (68%)0.58 (0.48–0.69)** < 0.001Immunosuppression92/2304 (4%)67/1533 (4%)25/771 (3%)1.36 (0.85–2.18)0.194Albumin on admission** (g/L) < 25 (g/L)86/1729 (5%)37/1144 (3%)49/585 (8%)0.31 (0.20–0.48)** < 0.001** 26- 35 (g/L)494/1729 (29%)291/1144 (26%)203/585 (35%)0.58 (0.47–0.73)** < 0.001** > 36 (g/L) (reference)1149/1729 (66%)816/1144 (71%)333/585 (57%)--GFR on admission (median (IQR))67 (49–80)69 (51–81)63 (47–78)1.01 (1.00–1.01) < 0.001 Missing550--Hb on admission (median (IQR))7.9 (7.1–8.5)7.9 (7.2–8.6)7.7 (7.0–8.4)1.20 (1.10–1.31)** < 0.001** Missing110--Residential status Home (reference)1565/2304 (68%)1089/1533 (71%)476/771 (62%)-- Semi-independent nursing home195/2304 (8%)117/1533 (8%)78/771 (10%)0.66 (0.48–0.89)0.007 Nursing home and psychiatric ward544/2304 (24%)327/1533 (21%)217/771 (28%)0.66 (0.54–0.81)** < 0.001Walking aids** None (reference)1208/2156 (56%)892/1442 (62%)316/714 (44%)-- Rollator or walking stick883/2156 (41%)515/1442 (36%)368/714 (52%)0.50 (0.41–0.60)** < 0.001** Wheelchair/mobility scooter/No functional mobility65/2156 (3%)35/1442 (2%)30/714 (4%)0.41 (0.25–0.68)0.001****Katz-ADL 0—2 (dependent)689/2304 (30%)402/1533 (26%)287/771 (37%)0.50 (0.41–0.61)** < 0.001** 3—5471/2304 (20%)286/1533 (19%)185/771 (24%)0.55 (0.44–0.69)** < 0.001** 6 (independent) (reference)1144/2304 (50%)845/1533 (55%)299/771 (39%)--SNAQ 0 (reference)1414/2089 (68%)969/1381 (70%)445/708 (63%)-- 1–2329/2089 (16%)209/1381 (15%)120/708 (17%)0.80 (0.62–1.03)0.081 ≥ 3346/2089 (16%)203/1381 (15%)143/708 (20%)0.65 (0.51–0.83)0.001****BMI < 18.5130/1691 (8%)88/1113 (8%)42/578 (7%)1.07 (0.73–1.58)0.714 18.5–30 (reference)1416/1691 (84%)936/1113 (84%)480/578 (83%)-- > 30145/1691 (8%)89/1113 (8%)56/578 (10%)0.82 (0.57–1.16)0.255Abbreviations: NHFS Nottingham hip fracture score, CCI Charlton Comorbidity Index, ASA American Society of Anesthesiology, TIA transient ischemic attack, COPD chronic obstructive pulmonary disease, GFR glomerular filtration rate in ml/min/1.73m^2^, Hb hemoglobin in mmole/L, PAI Platelet aggregation inhibitor, VKA Vitamin K antagonist, DOAC direct oral anticoagulants, SNAQ Short Nutritional Assessment Questionnaire, BMI body mass index, Katz-ADL Katz Index of Independence in Activities of Daily Living
Univariable analyses of risk and prognostic peri-operative factors and mortality are shown in Table 3. Patients with a hospital stay without major complications had a significantly shorter length of hospital stay (6 VS 9 days, OR = 0.85, 95%CI 0.83–0.86, p < 0.001) and significantly less 30-day (4% VS 18%, OR = 0.21, 95%CI 0.16–0.29, p < 0.001) and 1-year mortality (21% VS 41%, OR = 0.39, 95%CI 0.32–0.47, p < 0.001) (Table 3, Fig. 3). Fig. 3Kaplan–Meier curve of mortality in patients with (blue) and without (red) major complications after hip fracture surgery during 1 year follow-up, including 95% CITable 3Univariable analyses of risk and prognostic peri-operative factors and mortality for hospitalization without major complicationsVariable****All patients (2304)Without major complication (1533)**With major complication (771)**Odds ratioP-valuen (%)n (%)n (%)(95% CI)Type fracture Medial collum fracture (reference)1382/2304 (60%)896/1533 (58%)486/771 (63%)-- Pertrochanteric fracture922/2304 (40%)637/1533 (42%)285/771 (37%)1.21 (1.01–1.45)**0.034Time to surgery (median (IQR))19 (13–26)19 (13–25)20 (14–33)0.99 (0.98–0.99)** < 0.001** Missings110Moment of the week Week days (ref.)1666/2304 (72%)1111/1533 (72%)555/771 (72%)-- During weekend638/2304 (28%)422/1533 (28%)216/771 (28%)0.98 (0.80–1.18)0.805Moment of the day Daytime (8.00–18.00) (reference)2013/2304 (87%)1342/1533 (88%)671/771 (87%)-- Night time (18.00–8.00)291/2304 (13%)191/1533 (12%)100/771 (13%)0.96 (0.74–1.24)0.728Anaesthesia Spinal (ref.)2038/2296 (89%)1363/1526 (89%)675/770 (88%)-- General258/2296 (11%)163/1526 (11%)95/770 (12%)0.85 (0.65–1.11)0.236Wound Closure Stitches (reference)1248/2159 (58%)867/1420 (61%)381/739 (52%)-- Agraves911/2159 (42%)553/1420 (39%)358/739 (48%)0.68 (0.57–0.81)** < 0.001Surgery time** < 45 min965/2303 (42%)691/1532 (45%)274/771 (35%)1.49 (1.24–1.78)** < 0.001** 45–90 min (reference)1237/2303 (54%)778/1532 (51%)459/771 (60%)-- > 90 min101/2303 (4%)63/1532 (4%)38/771 (5%)0.98 (0.64–1.49)0.918Hb loss (mmol/l) (mean ± SD)1.38 (± 0.88)1.29 (± 0.85)1.56 (± 0.92)0.71 (0.64–0.79)** < 0.001** Missings382810--Admission ward Trauma/orthopaedic surgery (reference)945/2304 (41%)726/1533 (47%)219/771 (28%)-- Geriatric trauma unit1091/2304 (47%)628/1533 (41%)463/771 (60%)0.41 (0.34–0.50)** < 0.001** Other268/2304 (12%)179/1533 (12%)89/771 (12%)0.61 (0.45–0.82)**0.001Time to ready for discharge (days) (median (IQR))4 (3–6)4 (3–5)5 (4–8)0.75 (0.72–0.78) < 0.001** Missing78078Length of hospital stay (days) (median (IQR))6 (4–10)6 (4–8)9 (6–14)0.85 (0.83–0.86) < 0.001 Missing7907930-day mortality207/2304 (9%)68/1533 (4%)139/771 (18%)0.21 (0.16–0.29)** < 0.001**1-year mortality645/2304 (25%)327/1533 (21%)318/771 (41%)0.39 (0.32–0.47) < 0.001Abbreviations: MI minimal invasive, Hb hemoglobin in mmole/L
The multivariable analysis before backward selection is available in the supplemental file, Appendix 2. Results of the multivariable analysis after backward selection are shown in Table 4. Factors associated with no major complications during hospitalization after hip fracture surgery age lower than 75 years, the gender female, ASA 1 and 2, no history of atrial fibrillation (AF), chronic obstructive pulmonary disease (COPD), dementia, Parkinson or myocardial infarction, a Katz-ADL of 6, serum albumin levels above 35 g/L and no reliance on walking aids. Those outcomes are comparable with the non imputed, complete set (m = 0, n = 1114) (Appendix 3). Table 4Multivariable analysis of patient hospital stay with VS without major complicationsFactorOR95%CIp* – valueAge 65—75 years (reference)--- 76–85 years0.730.55–0.970.032 > 86 years0.550.41–0.73** < 0.001Gender male0.750.61–0.920.004ASA 3 and 40.670.53–0.850.001Atrial fibrillation0.760.60–0.950.017COPD0.710.54–0.930.012Dementia0.770.62–0.960.021Parkinson0.500.34–0.740.001Myocardial infarction0.650.48–0.880.005Katz-ADL** 0—2 (dependent)0.750.59–0.950.016 3—50.760.59–0.970.029 6 (independent) (reference)--Albumin on admission < 25 (g/L)0.380.24–0.59** < 0.001** 26- 35 (g/L)0.690.55–0.860.001 > 36 (g/L) (reference)---Walking aids None (reference)--- Rollator or walking stick0.780.62–0.960.021 Wheelchair/mobility scooter/No functional mobility0.680.40–1.150.148Abbreviations: ASA American Society of Anesthesiology, COPD chronic obstructive pulmonary disease, Katz-ADL Katz Index of Independence in Activities of Daily Living^*^ OR < 1.00 associated with a hospital stay with major complications
A total of 1091 patients (47%) were admitted at the GFC. The involvement of geriatricians varied over the overall study they were engaged in co-treatment for 1284 cases (56%), served as the main practitioner in 684 cases (30%), and provided consultation only in 71 cases (3%). Of all patients 265 patients (11%) had no consultation of a geriatrician.
Within the study cohort, no patients met all identified criteria for a hospital stay without major complications following hip fracture surgery. 114 patients (5%) met all but 1 of the protective factors found. Of these 114 patients, 3 patients (3%) developed a major complication. Notably, among these 114 patients, 11 were admitted to the GFC with access to intensive high-care facilities. The geriatrician was in co-treatment by 27 of the 114 patients and in consult in 6 of the 147 patients with a low risk of complicated hospital stay.
Not all older patients with hip fractures are frail or at risk of developing complications. Identifying patients at low risk for adverse outcomes allows for efficiency and reduce healthcare costs. The aim of this study is to identify specific patient characteristics associated with a low risk of major complications following acute hip fracture surgery during hospital stay. By focusing on these characteristics, healthcare resources can be directed toward patients who are more likely to require them.
Major complications occurred in 33.5% of the study cohort during hospital stay. The incidence of major complications in the study cohort is comparable with literature (30%) [23–26], suggesting that the study population is representative of typical hip fracture patients. The two most common major complications were delirium and pneumonia, affecting 18% and 10% of the included patients, respectively. These rates are comparable to those found in previous meta-analyses, which reported incidence rates of 17% for delirium and 9% for pneumonia in hip fracture patients [27, 28]. Patients with a hospital stay without major complications had a shorter length of hospital stay (6 (IQR 4–8) days vs. 9 (IQR 6–14) days, OR = 0.85, SD:0.83–0.86, P < 0.001) and significantly less 30-day (4% VS 18%, OR = 0.21, SD:0.16–0.29, P < 0.001) and 1-year mortality (21% VS 41%, OR = 0.39, SD:0.32–0.47, P < 0.001).
Several patient characteristics were identified as associated with an uncomplicated hospital stay following hip fracture surgery. These include age below 75 years, the gender female, ASA 1 and 2, no history of AF, nor COPD, nor dementia, nor Parkinson, nor myocardial infarction, a Katz-ADL of 6, serum albumin levels exceeding 35 g/L independence from walking aids were associated with an uncomplicated hospital stay after hip fracture surgery.
A lower age, the female gender and a lower ASA-score were associated with a hospital stay without complications. These findings align with previous literature. Higher age, the gender male and a higher ASA-score are well-established risk factors for several major complications such as 30-day mortality, delirium, and pneumonia after hip fracture surgery [8, 29–31].
A recent systematic review by Abu-Assi et al. explored the relationship between AF and hip fractures [32]. The authors concluded that AF and hip fractures frequently coexist, with AF associated with increased readmission and mortality rates in hip fracture patients [32]. This study's analysis corroborates these findings, demonstrating that the absence of AF is associated with a hospital stay free from major complications after hip fracture surgery.
COPD and Dementia are well-established risk factors for increased mortality and complications after hip fracture surgery [33, 34], which is in line with the results of this study. In a recent cohort study of Nguyen et al. Parkinson was described as risk factor for higher 30-day complications and mortality [35]. This study further supports these findings, demonstrating that PD is strongly associated with in-hospital major complications after hip fracture surgery.
After multivariable analysis, myocardial infarction remained associated with major complications after hip fracture surgery. However, the history of myocardial infarction is not extensively described in the literature in relation to the outcome of hip fracture surgery.
The Katz-ADL is known as a risk factor for mortality after hip fracture surgery [36]. This study's multivariable analysis confirms that lower Katz-ADL scores (more dependency) remains significantly associated with major complications. Patients with a low Katz-ADL exhibit pre-existing frailty and need for care. Hypothetically, the hip fracture and subsequent surgery could be perceived as the inciting event in a frail patient population, resulting in major complications.
Recent literature has highlighted the relationship between hypoalbuminemia and increased post-operative mortality in hip surgery patients [14, 37, 38]. This study corroborates these findings, demonstrating that patients with hypoalbuminemia were significantly associated with major complications. Notably, albumin levels emerged as a stronger predictor of complications compared to underweight status or SNAQ scores, which were not statistically significant after backward selection. Specifically, serum albumin level lower than 35 g/L were associated with major complications, suggesting that hip fracture patients with albumin levels below this threshold may benefit from geriatrician consultation.
This study found that pre-fracture mobility status was associated with postoperative major complications. Patients who required mobility aids before their fracture were more likely to experience major complications post-surgery. Conversely, those who either had no need for walking aids or used a wheelchair, as well as those with no functional mobility, had a lower chance of major complications.
The study identified 114 patients (5% of the cohort) who met all but one factors associated with an uncomplicated hospital stay following hip fracture surgery. Of these 114 low-risk patients, only 3 ultimately developed major complications, indicating a high negative predictive value for the identified risk factors. This suggests that the selected characteristics are robust indicators of patients likely to have a hospital stay without major complications. However, a part of these 114 low-risk patients received what may be considered"unnecessary"care, including geriatric consultations or cotreatment (n = 33/114) and admission to the GFC (n = 11/114) with its intensive care protocols. This finding highlights a potential area for improving resource allocation and care efficiency.
The results suggest an opportunity to refine care pathways for hip fracture patients. By accurately identifying low-risk patients, hospitals may be able to streamline care, reducing unnecessary consultations and intensive interventions for those unlikely to benefit from them — a process guided by evaluating the negative predictive value (NPV). This approach could potentially decrease healthcare costs and optimize the use of specialized geriatric resources for higher-risk patients who are more likely to benefit from intensive multidisciplinary care.
This study presents a novel approach to hip fracture patient care by identifying characteristics associated with a low risk of major complications during hospital stay after surgery. While extensive research exists on risk factors for complications following hip fracture surgery, this is the first study to assess predictive patient characteristics for a hospital stay without major complications. This research has the potential to inform more personalized care strategies for hip fracture patients. This approach allows for potential optimization of care pathways, enabling healthcare providers to allocate intensive care and interventions more efficiently.
The investigation utilized a large cohort of hip fracture patients with detailed descriptions of baseline and perioperative factors from a prospective hip fracture database. The cohorts are representative of the target population and have limited missing data, which enhances the external validity of the findings.
This observational cohort study has several limitations that warrant consideration. The primary limitation is the frequent admission of patients to the GFC and the common co-treatment by geriatricians, which obscures the specific impact of geriatric interventions on patient outcomes. This confounding factor makes it challenging to isolate the effects of individual care components.
Furthermore, this study is an observational cohort study based on patients’ medical charts, meaning potentially unreported data is not included in our analysis. However, the comprehensive database encompasses all consecutive patients and due to careful status research and follow-up, the amount of missing data is very limited (Appendix 1).
Unfortunately, there is no clear definition of complications after hip fracture surgery. The classification in this study is designed in such a way that it is reproducible, with complications that require additional care falling under the major complications. The definition of complications varies and can therefore not be precisely compared with the literature.
In the further, the risk for major complications in case of absence of 2 and more protective factors should be accessed. Ideally, a prediction model can be designed to weigh the factors against each other and to predict the individual change of a major complication after hip fracture surgery.
This cohort study demonstrates that patients with a high probability of experiencing a hospital stay without major complications following hip fracture surgery can be identified preoperatively through specific patient characteristics. Factors associated with a lower risk of major complications include age lower than 75 years, the gender female, ASA 1 and 2, no history of AF, nor COPD, nor dementia, nor Parkinson, nor myocardial infarction, a Katz-ADL of 6, serum albumin levels below 35 g/L and no use of a rollator or walking aid.
Identification of these low-risk patients presents an opportunity to optimize resource allocation and enhance care efficiency. By recognizing patients less likely to require intensive interventions, healthcare providers can potentially avoid unnecessary admissions to the GFC and reduce geriatric consultations. This proactive approach may facilitate the delivery of more tailored, cost-effective care for hip fracture patients.
Supplementary Material 1.Supplementary Material 2.Supplementary Material 3.