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Severely Injured Patient in Older Age

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 July 2021) | Viewed by 24575

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Prof. Dr. Paul Alfred Grützner

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Department for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen on the Rhine, Ludwigshafen, Germany
Interests: polytrauma; joint fractures; imaging; orthogeriatrics
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Dear Colleagues,

In everyday clinical practice, we are registering an increasing number of older patients. The geriatric fracture patient is becoming more and more at the forefront due to the demographic development. The Federal Statistical Office anticipates a share of over-67-year-olds of 27.4% in 2060 and thus forecasts a significant increase; the number of polytraumatized geriatric patients will rise in line. The TraumaRegister DGU^® of the German Trauma Society (DGU) provides interesting insights into the age structure and patient outcome. In 2017 in total 26.2% of the patients included were over 70 years old. Geriatric polytraumatized patients show significant differences in injury patterns and treatment strategy compared to younger patients. This is often due to the pre-existing diseases and various drugs that alter the physiology. Hospitals and professional societies are currently dealing with numerous challenges—in particular, considering the 1-year mortality, which is about 25% in fractures close to the hip joint. In other areas (e.g., the treatment of vertebral body fractures, pelvic fractures, or dealing with septic geriatric patients), this patient population also poses great challenges for the treating physicians.

With this Special Issue, we hope that the treatment of patients in older age will be better structured and that the quality of life after a serious accident can be better understood.

Prof. Dr. Paul Alfred Grützner
Guest Editor

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Keywords

polytrauma
TraumaRegister
geriatric patients
quality of life
severely injured
orthogeriatric

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Research

9 pages, 439 KiB

Open AccessArticle

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery

by Alim F. Ramji, Maxwell T. Trudeau, Michael R. Mancini, Matthew R. LeVasseur, Adam D. Lindsay and Augustus D. Mazzocca

J. Clin. Med. 2021, 10(16), 3538; https://doi.org/10.3390/jcm10163538 - 12 Aug 2021

Cited by 4 | Viewed by 2033

Abstract

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation—7 a.m. to 4 p.m.; (2) night operation—4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19–33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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8 pages, 1379 KiB

Open AccessArticle

Influence of Oral Anticoagulation and Antiplatelet Drugs on Outcome of Elderly Severely Injured Patients

by Maximilian Kerschbaum, Siegmund Lang, Leopold Henssler, Antonio Ernstberger, Volker Alt, Christian Pfeifer, Michael Worlicek and Daniel Popp

J. Clin. Med. 2021, 10(8), 1649; https://doi.org/10.3390/jcm10081649 - 13 Apr 2021

Cited by 3 | Viewed by 1776

Abstract

Introduction: Severely injured elderly patients have a poorer prognosis and higher mortality rates after severe trauma compared with younger patients. The aim of this study was to correlate the influence of pre-existing oral anticoagulation (OAC) and antiplatelet drugs (PAI) on the outcome of severely injured elderly patients. Methods: Using a prospective cohort study model over an 11-year period, severely injured elderly patients (≥65 years and ISS ≥ 16) were divided into two groups (no anticoagulation/platelet inhibitors: nAP and OAC/PAI). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, severity of head injuries, and medication-related mortality. Results: In total, 254 out of 301 patients were analyzed (nAP: n = 145; OAC/PAI: n = 109, unknown data: n = 47). The most relevant injury was falling from low heights (<3 m), which led to a significantly higher number of severe injuries in patients with OAC/PAI. Patients with pre-existing OAC/PAI showed a significantly higher overall mortality rate compared to the group without (38.5% vs. 24.8%; p = 0.019). The severity of head injuries in OAC/PAI was also higher on average (AIS 3.7 ± 1.6 vs. 2.8 ± 1.9; p = 0.000). Conclusion: Pre-existing oral anticoagulation and/or platelet aggregation inhibitors are related to a higher mortality rate in elderly polytrauma patients. Low-energy trauma can lead to even more severe head injuries due to pre-existing medication than is already the case in elderly patients without OAC/PAI. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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8 pages, 459 KiB

Open AccessArticle

Comparing the Short-Term Outcome after Polytrauma and Proximal Femur Fracture in Geriatric Patients

by Andreas Gather, Tomoko Tajima-Schneider, Paul A. Grützner and Matthias Münzberg

J. Clin. Med. 2021, 10(6), 1287; https://doi.org/10.3390/jcm10061287 - 20 Mar 2021

Viewed by 1931

Abstract

Because of demographic change, geriatric patients are becoming a major challenge for traumatology. Multiple trauma patients and patients with proximal femoral fractures are important groups of patients in geriatric traumatology. This retrospective study compares two patient groups with different severities of injuries, and analyzes their patient characteristics and short-term outcomes, focusing on functionality upon discharge. The investigation aims to present the characterizing features of both patient groups, and to identify the potential risk factors for early functionality after trauma. The patient collective comprises two patient groups: a polytrauma group with 91 patients, and a femoral fracture group with 132 patients. Under the control of potential influencing factors, the present study showed no significant influence of belonging to either of the patient groups (multiple trauma or proximal femoral fracture) on the mobility status at discharge. Age, known dementia, pre-clinical intubation, and the lowest Hb value were identified as significant influencing factors. Despite their old age and vulnerability, the majority of geriatric patients survive accidents. Further prospective investigations concerning the maintenance or restoration of functionality after an accident are therefore desirable. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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11 pages, 534 KiB

Open AccessArticle

More Adverse Events after Osteosyntheses Compared to Arthroplasty in Geriatric Proximal Humeral Fractures Involving Anatomical Neck

by Felix Porschke, Julia Bockmeyer, Philip-Christian Nolte, Stefan Studier-Fischer, Thorsten Guehring and Marc Schnetzke

J. Clin. Med. 2021, 10(5), 979; https://doi.org/10.3390/jcm10050979 - 2 Mar 2021

Cited by 10 | Viewed by 2047

Abstract

The purpose of this study was to compare adverse events and clinical outcomes of geriatric proximal humerus fractures (PHF) involving the anatomical neck (type C according to AO classification) treated with open reduction and internal fixation (ORIF) using locking plate vs. arthroplasty. In this retrospective cohort study, geriatric patients (>64 years) who underwent operative treatment using ORIF or arthroplasty for type C PHFs were included. Complications, revisions and clinical outcomes using Constant Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) Score were assessed and compared between groups. At a mean follow up of 2.7 ± 1.7 years, 59 patients (mean age 75.3 ± 5.5 years) were included. In 31 patients ORIF was performed and 29 patients underwent arthroplasty. Complications and revision surgeries were significantly more frequent after ORIF (32.6% vs. 7.1%, p = 0.023 and 29.0% vs. 7.1%, p = 0.045). In contrast, clinical outcomes showed no significant differences (DASH 39.9 ± 25.7 vs. 39.25 ± 24.5, p = 0.922; CMS 49.7 ± 29.2 vs. 49.4 ± 25.2, p = 0.731). ORIF of type C PHFs in geriatric patients results in significantly more complications and revision surgery when compared to arthroplasty. Therefore, osteosynthesis of geriatric intraarticular fractures of the proximal humerus must be critically evaluated. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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15 pages, 513 KiB

Open AccessArticle

Mortality and Medical Complications of Subtrochanteric Fracture Fixation

by Michalis Panteli, Marilena P. Giannoudi, Christopher J. Lodge, Robert M. West, Ippokratis Pountos and Peter V. Giannoudis

J. Clin. Med. 2021, 10(3), 540; https://doi.org/10.3390/jcm10030540 - 2 Feb 2021

Cited by 12 | Viewed by 3468

Abstract

The aim of this study was to define the incidence and investigate the associations with mortality and medical complications, in patients presenting with subtrochanteric femoral fractures subsequently treated with an intramedullary nail, with a special reference to advancement of age. Materials and Methods: A retrospective review, covering an 8-year period, of all patients admitted to a Level 1 Trauma Centre with the diagnosis of subtrochanteric fractures was conducted. Normality was assessed for the data variables to determine the further use of parametric or non-parametric tests. Logistic regression analysis was then performed to identify the most important associations for each event. A p-value < 0.05 was considered significant. Results: A total of 519 patients were included in our study (age at time of injury: 73.26 ± 19.47 years; 318 female). The average length of hospital stay was 21.4 ± 19.45 days. Mortality was 5.4% and 17.3% for 30 days and one year, respectively. Risk factors for one-year mortality included: Low albumin on admission (Odds ratio (OR) 4.82; 95% Confidence interval (95%CI) 2.08–11.19), dementia (OR 3.99; 95%CI 2.27–7.01), presence of pneumonia during hospital stay (OR 3.18; 95%CI 1.76–5.77) and Charlson comorbidity score (CCS) > 6 (OR 2.94; 95%CI 1.62–5.35). Regarding the medical complications following the operative management of subtrochanteric fractures, the overall incidence of hospital acquired pneumonia (HAP) was 18.3%. Patients with increasing CCS (CCS 6–8: OR 1.69; 95%CI 1.00–2.84/CCS > 8: OR 2.02; 95%CI 1.03–3.95), presence of asthma/chronic obstructive pulmonary disease (COPD) (OR 2.29; 95%CI 1.37–3.82), intensive care unit (ICU)/high dependency unit (HDU) stay (OR 3.25; 95%CI 1.77–5.96) and a length of stay of more than 21 days (OR 8.82; 95%CI 1.18–65.80) were at increased risk of this outcome. The incidence of post-operative delirium was found to be 10.2%. This was associated with pre-existing dementia (OR 4.03; 95%CI 0.34–4.16), urinary tract infection (UTI) (OR 3.85; 95%CI 1.96–7.56), need for an increased level of care (OR 3.16; 95%CI 1.38–7.25), pneumonia (OR 2.29; 95%CI 1.14–4.62) and post-operative deterioration of renal function (OR 2.21; 95%CI 1.18–4.15). The incidence of venous thromboembolism (VTE) was 3.7% (pulmonary embolism (PE): 8 patients; deep venous thrombosis (DVT): 11 patients), whilst the incidence of myocardial infarction (MI)/cerebrovascular accidents (CVA) was 4.0%. No evidence of the so called “weekend effect” was identified on both morbidity and mortality. Regression analysis of these complications did not reveal any significant associations. Conclusions: Our study has opened the field for the investigation of medical complications within the subtrochanteric fracture population. Early identification of the associations of these complications could help prognostication for those who are at risk of a poor outcome. Furthermore, these could be potential “warning shots” for clinicians to act early to manage and in some cases prevent these devastating complications that could potentially lead to an increased risk of mortality. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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8 pages, 1486 KiB

Open AccessArticle

Are There Any Red Flag Injuries in Severely Injured Patients in Older Age?

by Daniel Popp, Borys Frankewycz, Siegmund Lang, Antonio Ernstberger, Volker Alt, Michael Worlicek and Maximilian Kerschbaum

J. Clin. Med. 2021, 10(2), 185; https://doi.org/10.3390/jcm10020185 - 7 Jan 2021

Cited by 2 | Viewed by 1946

Abstract

Introduction: Severely injured elderly patients pose a significant burden to trauma centers and, compared with younger patients, have worse prognoses and higher mortality rates after major trauma. The objective of this study was to identify the etiological mechanisms that are associated with severe trauma in elderly patients and to detect which injuries correlate with high mortality in elderly patients. Methods: Using a prospect cohort study model over an 11-year period, severely injured patients (ISS ≥ 16) were divided into two age groups (Group 1: 18–64; Group 2: 65–99 years). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, distribution of affected body parts (AIS and ISS regions) and injury related mortality. Results: In total, 1008 patient were included (Group 1: n = 771; Group 2: n = 237). The most relevant injury in elderly patients was falling from low heights (<3 m) in contrast to traffic accident in young patients. Severely injured patients in the older age group showed a significantly higher overall mortality rate compared to the younger group (37.6% vs. 11.7%; p = 0.000). In both groups, the 30-day survival for patients without head injuries was significantly better compared to patients with head injuries (92.7% vs. 85.3%; p = 0.017), especially analyzing elderly patients (86.6% vs. 58.6%; p = 0.003). The relative risk of 30-day mortality in patients who suffered a head injury was also higher in the elderly group (OR: Group 1: 4.905; Group 2: 7.132). Conclusion: In contrast to younger patients, falls from low heights (<3 m) are significant risk factors for severe injuries in the geriatric collective. Additionally, elderly patients with an ISS ≥ 16 had a significantly higher mortality rate compared to severe injured younger patients. Head injuries, even minor head traumata, are associated with a significant increase in mortality. These findings will contribute to the development of more age-related therapy strategies in severely injured patients. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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10 pages, 1231 KiB

Open AccessArticle

Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?—A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis

by Kai O. Jensen, Maximilian Lempert, Kai Sprengel, Hans P. Simmen, Carina Pothmann, Mathias Schlögl, Heike A. Bischoff-Ferrari, Christian Hierholzer, Hans C. Pape and Valentin Neuhaus

J. Clin. Med. 2020, 9(11), 3544; https://doi.org/10.3390/jcm9113544 - 3 Nov 2020

Cited by 6 | Viewed by 2003

Abstract

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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14 pages, 567 KiB

Open AccessArticle

Association between Hemiarthroplasty vs. Total Hip Arthroplasty and Major Surgical Complications among Patients with Femoral Neck Fracture

by Takahisa Ogawa, Toshitaka Yoshii, Mutsuko Moriwaki, Shingo Morishita, Yoto Oh, Kazumasa Miyatake, Ara Nazarian, Koichiro Shiba, Atsushi Okawa, Kiyohide Fushimi and Takeo Fujiwara

J. Clin. Med. 2020, 9(10), 3203; https://doi.org/10.3390/jcm9103203 - 3 Oct 2020

Cited by 15 | Viewed by 3033

Abstract

Previous studies have shown better clinical outcomes after total hip arthroplasty (THA) compared to hemiarthroplasty (HA) for displaced femoral neck fracture. However, few studies have focused on the surgical risks of the two procedures. Therefore, we investigated the perioperative complications of HA and THA in femoral neck fracture, using a large nationwide inpatient database. A total of 286,269 patients (281,140 patients with HA and 5129 with THA) with a mean age of 81.7 were enrolled and HA and THA patients were matched by a propensity score to adjust for patient and hospital characteristics. Patients in a matched cohort were analyzed to compare complications and mortality. The systemic complication rate was not significantly different after a propensity score matching of 4967 pairs of patients. However, the incidence of both hip dislocation and revision surgery was more frequent in the THA group (Risk difference (RD), 2.74; 95% Confidence interval (CI), 2.21–3.27; p < 0.001; RD, 2.82; 95% CI, 2.27–3.37; p < 0.001, respectively). There was no significant difference in 30 day in-hospital mortality among the two groups. The risk of dislocation and reoperation was higher for THA than for HA in elderly patients with a femoral neck fracture in this retrospective study using a nationwide database. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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9 pages, 595 KiB

Open AccessArticle

Registry-Based Mortality Analysis Reveals a High Proportion of Patient Decrees and Presumed Limitation of Therapy in Severe Geriatric Trauma

by Cora Rebecca Schindler, Mathias Woschek, René Danilo Verboket, Ramona Sturm, Nicolas Söhling, Ingo Marzi and Philipp Störmann

J. Clin. Med. 2020, 9(9), 2686; https://doi.org/10.3390/jcm9092686 - 19 Aug 2020

Cited by 3 | Viewed by 1799

Abstract

Background: The treatment of severely injured patients, especially in older age, is complex, and based on strict guidelines. Methods: We conducted a retrospective study by analyzing our internal registry for mortality risk factors in deceased trauma patients. All patients that were admitted to the trauma bay of our level-1-trauma center from 2014 to 2018, and that died during the in-hospital treatment, were included. The aim of this study was to carry out a quality assurance concerning the initial care of severely injured patients. Results: In the 5-year period, 135 trauma patients died. The median (IQR) age was 69 (38–83) years, 71% were male, and the median (IQR) Injury Severity Score (ISS) was 25 (17–34) points. Overall, 41% of the patients suffered from severe traumatic brain injuries (TBI) (AIS_head ≥ 4 points). For 12.7%, therapy was finally limited owing to an existing patient’s decree; in 64.9% with an uncertain prognosis, a ‘therapia minima’ was established in consensus with the relatives. Conclusion: Although the mortality rate was primarily related to the severity of the injury, a significant number of deaths were not exclusively due to medical reasons, but also to a self-determined limitation of therapy for severely injured geriatric patients. The conscientious documentation concerning the will of the patient is increasingly important in supporting medical decisions. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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13 pages, 934 KiB

Open AccessArticle

Attributable Mortality of Hip Fracture in Older Patients: A Retrospective Observational Study

by Lorène Zerah, David Hajage, Mathieu Raux, Judith Cohen-Bittan, Anthony Mézière, Frédéric Khiami, Yannick Le Manach, Bruno Riou and Jacques Boddaert

J. Clin. Med. 2020, 9(8), 2370; https://doi.org/10.3390/jcm9082370 - 24 Jul 2020

Cited by 15 | Viewed by 3356

Abstract

Hip fracture (HF) in older patients is associated with a high six-month mortality rate. Several clinical conditions may affect outcome, including baseline characteristics, co-existing acute illnesses, perioperative factors, and postoperative complications. Our primary objective was to estimate the respective effect of these four domains on six-month mortality after HF. A retrospective observational study using a monocentric cohort of older patients was conducted. All patients ≥ 70 years old admitted to the emergency department for HF and hospitalized in our perioperative geriatric care unit from June 2009 to September 2018 were included. Among 1015 included patients, five (0.5%) were lost to follow-up, and 1010 were retained in the final analysis (mean age 86 ± 6 years). The six-month mortality rate was 14.8%. The six-month attributable mortality estimates were as follows: baseline characteristics (including age, gender, comorbidities, autonomy, type of fracture): 62.4%; co-existing acute illnesses (including acute events present before surgery that could result from the fracture or cause it): 0% (not significantly associated with six-month mortality); perioperative factors (including blood transfusion and delayed surgery): 12.3%; severe postoperative complications: 11.9%. Baseline characteristics explained less than two-thirds of the six-month mortality after HF. Optimizing patients care by improving management of perioperative factors and thus decreasing postoperative complications, could reduce by a maximum of one quarter of the six-month mortality rate after HF. Full article

(This article belongs to the Special Issue Severely Injured Patient in Older Age)

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