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Introduction

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Ces passerelles Lire la suite. Iles du Ponant TV. However, most available epidemiological data are retrospective or predate current perioperative strategies for care of hip fracture patients, notably in terms of new thromboprophylaxis practices [ 3 , 6 - 19 ]. Moreover, data obtained in recent randomized clinical trials in selected patients may not reflect routine practice [ 20 - 23 ]. We therefore performed an observational study on a cohort of consecutive patients undergoing hip fracture surgery. The ESCORTE Evénements cliniques dans les Suites d'une intervention Chirurgicale Orthopédique à Risque Thrombotique Elevé study was a multicenter centers , observational, prospective study of a cohort of consecutive patients undergoing surgery for hip fracture in France.

Before entering the study, all participating patients were informed of the aim and modalities of the study, and provided consent. The study was conducted in accordance with the ethical principles stated in the Declaration of Helsinki, as well as local regulations. They were all scheduled to undergo surgery for fracture of the upper portion of the femur hip surgery. Patients with multiple fractures, fracture of the pelvis, or a pathological fracture were excluded. Each center performed all medical or surgical procedures according to its usual practice.

A clinical research assistant reviewed data against source documents at all centers that reported VTE. Deep vein thrombosis DVT was confirmed by ultrasonography or venography. Minor bleeding was any clinically overt bleeding not classified as major bleeding.

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In France, centers are registered as orthopedic surgery sites. All these centers were contacted. Analyses were performed for all patients in whom data on surgery and endpoints were available. Stepwise modeling was performed to screen potential variables for inclusion in the final model. Potential variables for these analyses were selected on the basis of their clinical plausibility. Among these, patients did not meet the inclusion or exclusion criteria and 33 patients had data that were unusable, leaving Over half the patients Low molecular weight heparins LMWH were used perioperatively in Among living patients treated with LMWH Patients were discharged after a median duration of The adjudication committee confirmed 75 of the reported DVT adjudicated actuarial rate of 1.

Among the 76 reported PE, 16 were adjudicated as definite actuarial rate of 0. Among 24 reported fatal PE, three were adjudicated as definite actuarial rate of 0.

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The remaining events were not confirmed for the following reasons: Thus, the actuarial rate and incidence density of adjudicated symptomatic VTE were 1. Based on the results of the univariate analyses, the following characteristics were tested prospectively as potential independent predictive factors of symptomatic VTE: Twelve cases 0. The main causes of death, as indicated by local investigators, were cardiac diseases patients; Local investigators felt that PE was directly involved in the death of 39 3. In contrast, the risk of death was similar in those patients who received general anesthesia only and those who received spinal anesthesia only.

Finally, neither the type of fracture nor the type of surgery affected the risk of death. Based on the results of the univariate analyses, the following characteristics were tested prospectively as potential independent predictive factors of death: In recent thromboprophylaxis trials performed in similar patients, this rate was between 1.

And finally, in epidemiological studies in patients undergoing total hip or knee replacement surgery, this rate ranged between 1. Our adjudicated rate of 1. Similarly, our adjudicated rate of 0. The low incidence of VTE was achieved with a low rate of bleeding events, i.

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Although these rates are in the lower range of those previously reported, they confirm that postoperative mortality remains high after hip fracture surgery. In ESCORTE, as in previous studies [ 12 , 14 , 20 ], cardiovascular diseases were the most frequent cause of death after hip fracture surgery. Indeed, in the most recent studies, time between hospital admission and surgery did not alter the prognosis [ 15 , 19 ]. We confirmed that increased risk of death was associated with advanced age [ 1 , 9 , 11 ], male gender [ 1 , 3 , 17 ], a poor preoperative ASA Physical Status [ 9 - 11 ], and the occurrence of postoperative complications [ 1 ].

There is no consensus as to which anesthetic technique is best for hip fracture patients.

In contrast to previous results [ 4 , 29 ], we found that the incidence of VTE was similar with general and spinal anesthesia. However, the risk of death was significantly reduced in patients given combined general anesthesia and peripheral nerve block compared with those who received general only or spinal only anesthesia. The beneficial effect of the combined use of general peripheral nerve block may be because this approach results in a reduction of the quantity of general analgesic used to control pain and a reduction in reported pain levels [ 30 ], allowing for earlier functional recovery.

Compared with conventional analgesia, epidural analgesia was also found to reduce the incidence of adverse cardiac outcomes in hip fracture surgery patients [ 31 ]. We believe that our data provide a valid picture of the routine management of hip fracture surgery patients. ESCORTE included a large number of diverse patients managed by a number of different surgeons according to their usual practice.

According to the rate of deaths The demographic features of the included subjects, the type of hip fractures, and the comorbidities observed are consistent with those generally reported in these patients [ 1 ]. Furthermore, prospective and consecutive data collection avoided the inherent inaccuracies of chart review used in retrospective studies.

However, an autopsy was not performed in all patients who died and so a number of fatal PE may have been missed in such patients [ 32 ]; it is possible therefore that the rate of VTE represents an underestimate of the true rate. We used multivariate analysis to analyze risk factors for VTE and mortality while controlling for potential confounding variables. However, it is uncertain whether similar results would be obtained in countries using other types of anticoagulants — such as vitamin K antagonists that are commonly used in the USA — or with new antithrombotic agents [ 5 , 21 , 23 , 25 ].

This prospective study ESCORTE , one of the largest cohort studies, showed that hip fracture patients belong to a vulnerable group of old people with comorbid diseases and a high risk of postoperative morbidity and mortality, dominated by vascular complications. The authors gratefully acknowledge Prof. Daniel I. Sessler and Prof. Harry Büller for the reviewing of the manuscript. This study was supported by a grant from Laboratoires Aventis, Paris, France. The sponsor performed data collection and the final statistical analysis.