Surgical management of displaced femoral neck fractures in patients with dementia: a comparison in mortality between hemiarthroplasty and pins/screws

Abstract

Introduction Dementia is common in patients with hip fractures and is strongly associated with increased postoperative mortality. The choice of surgical intervention for displaced femoral neck fractures (dFNF) in patients with dementia has been a matter of debate. This study aims to investigate how short- and long-term mortality differs between those who have been operated with hemiarthroplasty or pins/screws. Methods All patients with dementia and dFNF, i.e., Garden III and IV, who underwent primary emergency hip fracture surgery, with either hemiarthroplasty or pins/screws, in Sweden between Jan 1, 2008 and Dec 31, 2017 were eligible for inclusion in the current study. Patients were divided into two groups based on the surgical intervention: hemiarthroplasty and pins/screws. The primary outcome of interest was 30-day postoperative mortality, and the secondary outcome was 1-year postoperative mortality. Poisson and Cox regression analyses were performed both before and after propensity score matching. Results A total of 9394 cases met the inclusion criteria; 84% received hemiarthroplasty and 16% received pins/screws. In the unmatched analysis, the adjusted incidence rate ratio (IRR) for 30-day postoperative mortality was not affected by the chosen surgical method (adj. IRR 0.96, CI 95% 0.83–1.12, p = 0.629). After propensity score matching, similar results were observed with no difference in 30-day postoperative mortality (adj. IRR 0.89, CI 95% 0.74–1.09, p = 0.286). There was a statistically significant decrease in the risk of 1-year postoperative mortality in the hemiarthroplasty group compared to the pins/screws group, both before and after propensity score matching. Conclusion This study could not demonstrate any difference in 30-day mortality in patients with dementia and dFNFs when comparing hemiarthroplasty with pins/screws. Patients that received hemiarthroplasties did, however, have a lower risk of 1-year postoperative mortality.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

“…Other factors that have been demonstrated to affect adverse outcomes after surgery is the surgical method used, where internal fixation has been associated with lower risks compared with arthroplasty when the surgery is performed out-of-hours, while patients with dementia and dislocated cervical hip fractures had better outcomes when they underwent hemiarthroplasty rather than internal fixation. 22 25 However, no difference was seen in the outcomes measured in the current study when analyzing patients who underwent internal fixation, arthroplasty, had an extended surgical duration, or underwent surgery out-of-hours. One potential explanation for our findings could be the relatively short procedure time for hip fracture surgery; as most surgical techniques are relatively simple procedures the overall surgical trauma might result in less physiological strain compared to more complex surgeries with longer surgical durations.…”

“…These comorbidities, along with the acute injury, have a negative impact on the cardiovascular system as well as other organ systems, which may affect the postoperative risk of adverse events 7–9 14. Furthermore, studies have shown that several other factors could increase the risk of postoperative adverse events after hip fracture surgery, such as surgical duration, out-of-hours surgery, and dementia 5 19–22 24 25 31. However, these variables have not been taken into account in the previous studies on this topic 12 13…”

“…Subsequently, subgroup analyses were performed by repeating the regression analyses with specific subgroups of patients who were deemed to potentially be at a higher risk of suffering adverse events as a result of the choice of anesthesiological method used. These subgroups were selected since prior studies have observed an association between them and postoperative outcomes; they consisted of patients who underwent internal fixation or arthroplasty, had an extended surgical duration (surgical duration >100 min), had a reduced surgical fitness (ASA classification ≥3), had an elevated RCRI (RCRI ≥2), had an increased comorbidity burden (CCI ≥7), had a diagnosis of dementia prior to surgery, underwent surgery out-of-hours (17:00-08:00), and geriatric patients (aged ≥65 years) 5 18–22 24 25 31 32. An extended surgical duration was defined as any operation that lasted >100 min, as this was the 90th percentile for all operations in this dataset.…”

“…5 14 18 19 Furthermore, several other risk factors have been associated with an increased risk of adverse postoperative outcomes. [20][21][22][23][24][25] However, the latest meta-analyses have not conducted any subgroup analyses taking into account these different risk factors. Therefore, the aim of the current study was to evaluate the association between mode of anesthesia and postoperative morbidity as well as mortality within a general hip fracture population as well as within specific subgroups.…”

“…Some of the indices commonly used to assess the risk of postoperative events in these patients are the American Society of Anesthesiologists (ASA) classification, the Charlson Comorbidity Index (CCI) and the Revised Cardiac Risk Index (RCRI) 5 14 18 19. Furthermore, several other risk factors have been associated with an increased risk of adverse postoperative outcomes 20–25. However, the latest meta-analyses have not conducted any subgroup analyses taking into account these different risk factors.…”