Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement.

IMPORTANCE Patients undergoing surgery for a hip fracture have a higher risk of mortality and major complications compared with patients undergoing an elective total hip replacement (THR) operation. The effect of older age and comorbidities associated with hip fracture on this increased perioperative risk is unknown. OBJECTIVE To determine if there was a difference in hospital mortality among patients who underwent hip fracture surgery relative to an elective THR, after adjustment for age, sex, and preoperative comorbidities. DESIGN, SETTING, AND PARTICIPANTS Using the French National Hospital Discharge Database from January 2010 to December 2013, patients older than 45 years undergoing hip surgery at French hospitals were included. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), codes were used to determine patients' comorbidities and complications after surgery. A population matched for age, sex, and preoperative comorbidities of patients who underwent elective THR or hip fracture surgery was created using a multivariable logistic model and a greedy matching algorithm with a 1:1 ratio. EXPOSURE Hip fracture. MAIN OUTCOMES AND MEASURES Postoperative in-hospital mortality. RESULTS A total of 690,995 eligible patients were included from 864 centers in France. Patients undergoing elective THR surgery (n = 371,191) were younger, more commonly men, and had less comorbidity compared with patients undergoing hip fracture surgery. Following hip fracture surgery (n = 319,804), 10,931 patients (3.42%) died before hospital discharge and 669 patients (0.18%) died after elective THR. Multivariable analysis of the matched populations (n = 234,314) demonstrated a higher risk of mortality (1.82% for hip fracture surgery vs 0.31% for elective THR; absolute risk increase, 1.51% [95% CI, 1.46%-1.55%]; relative risk [RR], 5.88 [95% CI, 5.26-6.58]; P < .001) and of major postoperative complications (5.88% for hip fracture surgery vs 2.34% for elective THR; absolute risk increase, 3.54% [95% CI, 3.50%-3.59%]; RR, 2.50 [95% CI, 2.40-2.62]; P < .001) among patients undergoing hip fracture surgery. CONCLUSIONS AND RELEVANCE In a large cohort of French patients, hip fracture surgery compared with elective THR was associated with a higher risk of in-hospital mortality after adjustment for age, sex, and measured comorbidities. Further studies are needed to define the causes for these differences.

[1]  Onyebuchi A Arah,et al.  A systematic review of the effects of residency training on patient outcomes , 2012, BMC Medicine.

[2]  E. K. Alpar,et al.  Elevation of plasma CGRP and SP levels in orthopedic patients with fracture neck of femur , 2000, Neuropeptides.

[3]  C. Esmon.  The interactions between inflammation and coagulation , 2005, British journal of haematology.

[4]  A. Sassoon,et al.  Total hip arthroplasty for femoral neck fracture: comparing in-hospital mortality, complications, and disposition to an elective patient population. , 2013, The Journal of arthroplasty.

[5]  S. Ford.  Outcome differences after elective or emergency hip operations , 2014, Anaesthesia.

[6]  P. Dieppe,et al.  90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis , 2013, The Lancet.

[7]  G. Guyatt,et al.  Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial , 2013, Canadian Medical Association Journal.

[8]  M. Raux,et al.  Perioperative Management of Elderly Patients with Hip Fracture , 2014, Anesthesiology.

[9]  J. Danesh,et al.  Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial , 2000, The Lancet.

[10]  N. Fazzalari,et al.  Increased expression of IL-6 and RANK mRNA in human trabecular bone from fragility fracture of the femoral neck. , 2004, Bone.

[11]  S. Lemeshow,et al.  A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. , 1993, JAMA.

[12]  S. Woolson,et al.  A comparison of the results of total hip and knee arthroplasty performed on a teaching service or a private practice service. , 2007, The Journal of bone and joint surgery. American volume.

[13]  R. Robinson.  The Impact of Resident Teaching on Total Hip Arthroplasty , 2007, Clinical orthopaedics and related research.

[14]  Catherine Quantin,et al.  Medical Informatics, e-Health: Fundamentals and Applications , 2013 .

[15]  P. Landais,et al.  Computerized Medico-Economic Decision Making: An International Comparison , 2014 .

[16]  Howard A Fink,et al.  Hip fracture and increased short-term but not long-term mortality in healthy older women. , 2011, Archives of internal medicine.

[17]  Kevin Mackway-Jones,et al.  The coagulopathy of trauma: a review of mechanisms. , 2008, The Journal of trauma.

[18]  C. Svensen.  Vascular endothelial growth factor (VEGF) in plasma increases after hip surgery. , 2004, Journal of clinical anesthesia.

[19]  Mark Lunt,et al.  Selecting an Appropriate Caliper Can Be Essential for Achieving Good Balance With Propensity Score Matching , 2013, American journal of epidemiology.

[20]  M. Bhandari,et al.  Accelerated versus standard care in hip fracture patients: does speed save lives? , 2014, Journal of comparative effectiveness research.

[21]  Cathleen S. Colón-Emeric,et al.  Meta-analysis: Excess Mortality After Hip Fracture Among Older Women and Men , 2010, Annals of Internal Medicine.

[22]  S. White,et al.  Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset , 2014, Anaesthesia.

[23]  A. W. Undok.  Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery , 2012 .

[24]  J. Magaziner,et al.  Association Between Interleukin‐6 and Lower Extremity Function After Hip Fracture—The Role of Muscle Mass and Strength , 2008, Journal of the American Geriatrics Society.

[25]  A. Weiss,et al.  Cytokines and C-reactive protein production in hip-fracture-operated elderly patients. , 2007, The journals of gerontology. Series A, Biological sciences and medical sciences.

[26]  Jeremy A Rassen,et al.  Metrics for covariate balance in cohort studies of causal effects , 2014, Statistics in medicine.

[27]  J. Desborough.  The stress response to trauma and surgery. , 2000, British journal of anaesthesia.

[28]  A. Hill,et al.  Central nervous system interleukin‐8 production following neck of femur fracture , 2005, ANZ journal of surgery.

[29]  M. Raux,et al.  Postoperative Admission to a Dedicated Geriatric Unit Decreases Mortality in Elderly Patients with Hip Fracture , 2014, PloS one.

[30]  P. Austin.  Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples , 2009, Statistics in medicine.

[31]  G. Guyatt,et al.  Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis , 2010, Canadian Medical Association Journal.

[32]  G. Guyatt,et al.  Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. , 2012, JAMA.