Recovery of walking ability in patients with exceptional longevity after hip fracture: Predictors and short-and long-term survival in relation to recovery of walking

Recovery of walking ability in patients with exceptional longevity after hip fracture: Predictors and short-and long-term survival in relation to recovery of walking | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Recovery of walking ability in patients with exceptional longevity after hip fracture: Predictors and short-and long-term survival in relation to recovery of walking Montserrat Barceló, Patricia Valentina Marquez, Ignasi Gich, Jordi Casademont, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8405637/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background There are very few studies on walking recovery and its predictors in extremely older patients after a hip fracture. Relationship between walking recovery and survival has not been studied in this age group either. The objective of our study is to assess walking recovery and its predictors in extremely older patients at 6 months after discharge, and whether there was a relationship with short and long-term survival. Methods Restrospective review including all patients older than 95 years admitted with a fragility hip fracture between December 2009 and September 2015 in a tertiary university hospital in Barcelona. Walking ability was measured by the functional ambulation classification (FAC) prior to admission and at 6 months after discharge. Short- and long-term survival were recorded. Results One hundred and fifty-two patients were included. Before the fracture, 78.3% of patients were independent in ambulation, whereas this percentage dropped to 36.8% afterward. This means that 46.9% of those who previously walked independently regained their ability to do so. Better previous FAC (p < 0.001, OR 3.658), not having delirium during admission (p = 0.010, OR 3.45), and being able to carry out full weight-bearing (p = 0.026, OR 12.705) were the variables associated with better walking recovery. Area under the ROC curve was 0.819 (p 3 had better survival. Conclusion Walking recovery predictors in patients with exceptional longevity were: having better previous FAC, being able to carry out full weight-bearing, and not having delirium. Patients able to walk without help during the first six months after discharge had a better survival. mortality hip fracture centenarians Figures Figure 1 Figure 2 1. Introduction The number of people with extreme longevity represents a small proportion of the population, but is increasing rapidly in Western countries. A study published in 2017 described the increase in the European Union as twice as fast as previously observed, with the number of centenarians doubling in 5 years [ 1 ]. These patients are at high risk of suffering fragility fractures; the incidence of hip fractures in centenarians in our setting is about 4%, which is seven times higher than hip fractures in younger age groups [ 2 ]. Hip fractures have a high impact on older adults in terms of functional loss [ 3 , 4 ]. Numerous studies have evaluated outcomes after hip fracture, and although the results vary widely, it is generally reported that a significant percentage of patients do not regain their ability to walk. For example, a study by Gonzalez Marcos [ 5 ] found that 45% of individuals over the age of 65 were unable to recover their walking ability. Predictors of walking recovery in patients with hip fractures were identified as younger age, ability to walk independently before the fracture and absence of cognitive impairment [ 6 , 7 , 8 ]. There are very few studies on walking recovery in extremely old patients after a hip fracture. Most of these included small numbers of patients and the percentage of patients who regained mobility was low, in some cases less than 25% [ 9 , 10 ]. However, other studies describe a better walking recovery of around 50% or more [ 11 , 12 , 13 ], although functional loss is higher than in other age groups: 74% of octogenarians and 65% of nonagenarians regained unassisted walking [ 11 ]. Furthermore, in younger patients with a mean age of less than 80 years, those who were able to ambulate after discharge had better one-year and 10-year survival [ 14 , 15 ]. No studies have explored the relationship between walking ability and survival in the exceptional longevity age group. We hypothesize that walking recovery in patients with exceptional longevity may be as high as 50%, as previously reported, and that predictors of recovery will be similar to those observed in younger individuals. We would also predict that patients who achieve better walking recovery will also show better survival. 2. Methods 2.1 Setting The study was conducted in the orthopedic surgery ward of the Hospital de la Santa Creu i Sant Pau, a tertiary university hospital in Barcelona serving a population of approximately 425,000 people with a high proportion of older adults. 2.2 Subjects All patients older than 95 years discharged from the orthopedic surgery ward with a diagnosis of fragility hip fracture between December 2009 and September 2015 were retrospectively reviewed. Survival was determined to the present time or date of death of the patient. This study is a continuation of a previous study in patients with exceptional longevity [ 16 ] and was approved by the institutional ethics committee (code IIBSP-FEM-2023-36). It was conducted in accordance with the ethical principles of the Declaration of Helsinki for medical research involving human subjects. During hospitalization, a multidisciplinary approach was followed with the participation of a physician from the Geriatric Unit. Bed rest was imposed for 24 hours after surgery, and physiotherapy was started 24–48 h after surgery, if the patient was clinically stable. 2.3 Data collection The following data were retrospectively collected: age, sex, comorbidities measured by the Charlson index [ 17 ], dementia, depression, pre-fracture and post-discharge ambulation according to the Functional Ambulation Classification (FAC) [ 18 ], place of residence, number of medications prior to admission, and hemoglobin and albumin levels on admission. Length of hospital stay, delay to surgery, type of fracture (prosthesis or not), assessment of surgical risk based on the ASA (American Society of Anesthesiologists) risk score, type of surgery, type of anesthesia, medical and traumatological complications during admission, full weight-bearing capacity after surgery and final discharge destination were also recorded. The post-discharge FAC measured the maximum level of walking recovery achieved by the patient six months after hip fracture. Patients in whom walking ability was not recorded and those who died within one month of discharge were excluded. The FAC classification has been used in other studies [ 6 , 11 , 19 ] and provides a useful measure of the patient’s walking ability. The scale was dichotomized with a cut-off of FAC < 3 and ≥ 3 to differentiate between patients who required physical assistance from another person and those who did not. FAC was measured at six months because it has been described as peak recovery time [ 20 ]. Full or non-full weight-bearing was indicated by the trauma surgeon; partial weight-bearing was considered non-full weight-bearing. If full weight-bearing was not allowed, it was usually for 2–4 weeks after surgery, although this varied. Short- and long-term survival were recorded. The date of death was obtained from the patient’s medical records and the Ministry of Health’s National Death Index website ( https://www.mscbs.gob.es/estadEstudios/estadisticas/estadisticas/estMinisterio/IND_TipoDifusion.htm ), after authorization. 2.4 Statistical analysis For categorical variables, absolute numbers, relative frequencies or proportions were calculated and compared using Fisher’s exact test. Continuous variables were presented as means and standard deviations (SD), and compared using Student’s t-test. Spearman's correlation was used to measure correlation between FAC score before and after the hip fracture. To determine independent variables, multivariate logistic regression was performed with statistically significant variables in the univariate analysis; the odds Ratio and 95% confidence interval were calculated. The area under the ROC curve (AUC) was calculated for our final model. The Hosmer-Lemeshow test was used to determine goodness-of-fit. A Kaplan-Meier curve for post-discharge survival was calculated. Statistical analysis was performed with IBM SPSS Statistics for Windows. Version 29.0 (IBM Corp. Armonk. NY, USA). Statistical significance was set at p ≤ 0.05 in all cases 3. Results Between December 2009 and September 2015, one hundred and seventy-five patients older than 95 years were discharged after a hip fracture. Fifteen (8.6%) patients were excluded because they died within one month of discharge, and 8 (4.6%) patients because their walking ability had not been recorded. The remaining 152 patients were included in the analysis. One patient (0.6%) could not be located after the second year. One patient was still alive at the time of the study, 10 years later. Table 1 shows differences between pre-fracture and maximum ambulation ability six months after discharge, measured by FAC score. The mean pre-fracture FAC was 3.12 (SD 1.36), mean post-discharge FAC was 1.67 (SD 1.64). Before the fracture, 78.3% of patients were classified as independent in ambulation (FAC ≥ 3) whereas this percentage had decreased to 36.8% at 6 months after discharge. Consequently 46.9% of those who were previously able to walk independently recovered their ability to walk without assistance. A positive correlation was found between pre-fracture and post hip-fracture FAC scores, with rho = 0.492 (p < 0.001). The baseline characteristics and in-hospital results comparison of exceptional longevity patients classified as FAC < 3 and FAC ≥ 3 are shown in Tables 2 and 3 . Multivariate logistic regression results showed that a better pre-fracture FAC score (p < 0.001, OR 3.658. 95% CI 2.141–6.25), absence of delirium while hospitalized (p = 0.010, OR 3.45. 95% CI 1.342–8.873) and full weight-bearing capacity (p = 0.026, OR 12.705. 95% CI 1.362-118.475) were predictors of walking recovery. The area under the ROC curve for walking recovery was 0.819 (p < 0.001, 95% CI 0.754–0.885) Fig. 1 . The Hosmer-Lemeshow test showed that the model was well calibrated (p = 0.758). Replication of the model with the addition of age and sex yielded very similar results and identified the same predictors. Mean survival after discharge was 2.24 years (SD 1.185). Figure 2 compares the cumulative survival of patients who required assistance to ambulate six months after discharge and those who did not. This difference was maintained for approximately four years, after which it leveled off. Table 1 FAC * score for pre-fracture ambulation and maximum walking ability six months after discharge. Patients = 152 FAC * score before hip fracture Post-discharge FAC * score FAC * 0 n (%) 13 (8.6) 60 (39.5) FAC * 1 n (%) 10 (6.6) 19 (12.5) FAC * 2 n (%) 10 (6.6) 17 (11.2) FAC * 3 n (%) 47 (30.9) 28 (18.4) FAC * 4 n (%) 57 (37.5) 23 (15.1) FAC * 5 n (%) 15 (9.9) 5 (3.3) Dichotomized FAC FAC * < 3 n (%) 33 (21.7) 96 (63.2) FAC * ≥ 3 n (%) 119 (78.3) 56 (36.8) * Functional ambulation classification Table 2 Comparison of patients older than 95 years who needed physical assistance from another person and those who did not six months after discharge: Baseline characteristics Patients = 152 Total n = 152 FAC * score < 3 n = 96 FAC * score ≥ 3 n = 56 p value Age, in years (SD) 97.23 (2.38) 97.50 (2.55) 96.77 (1.98) 0.051 Female sex n (%) 134 (88.2) 87 (90.6) 47 (83.9) 0.165 Charlson index (SD) 1.11 (1.1) 1.26 (1.1) 0.86 (1.06) 0.029 Pre-fracture FAC * score ≥ 3 n (%) 119 (78.3) 63 (65.6) 56 (100) < 0.001 Dementia n (%) 47 (30.9) 39 (40.6) 8 (14.3) < 0.001 Depression n (%) 25 (16.4) 20 (20.8) 5 (8.9) 0.043 Place of residence: n at home (%) 89 (58.6) 47 (49) 42 (75) 0.001 Number of drugs (SD) 5 (2.92) 5.58 (2.91) 4 (2.68) < 0.001 Intracapsular fracture n (%) 68 (44.7) 42 (43.8) 26 (46.4) 0.439 Hemoglobin at admission in g/L (SD) 119.59 (14.96) 118.22 (15.27) 122.02 (14.22) 0.133 Albumin at admission in g/L (SD) 28.24 (3.23) 28.39 (3.1) 27.99 (3.46) 0.485 Table 3 Comparison of patients older than 95 years who needed physical assistance from another person and those who did not six months after discharge: In-hospital test results Patients = 152 Total n = 152 FAC * score < 3 n = 96 FAC * score ≥ 3 n = 56 p value Length of hospital stay, in days (SD) 12.69 (8.42) 13.56 (10.05) 11.20 (4.04) 0.043 Delay to surgery, in days (SD) 3.60 (2.44) 3.81 (2.63) 3.23 (2.05) 0.133 Prosthesis n (%) 54 (35.5) 32 (33.3) 22 (39.3) 0.285 Spinal anesthesia n (%) 148 (97.4) 92 (95.8) 56 (100) 0.155 Transfusion n (%) 92 (60.5) 61 (63.5) 31 (55.4) 0.205 Delirium n (%) 42 (27.6) 32 (33.3) 10 (17.9) 0.029 Patients with medical complications n (%) 71 (46.7) 51 (53.1) 20 (35.7) 0.028 Patients with traumatological complications n (%) 2 (1.3) 1 (1) 1 (1.8) 0.603 Physiotherapy: full weight-bearing n (%) 139 (91.4) 84 (87.5) 55 (98.2) 0.018 Skin or respiratory isolation n (%) 2 (1.3) 2 (2.1) 0 (0) 0.397 Discharge to a center n (%) 64 (42.1) 35 (36.5) 29 (51.8) 0.047 4. Discussion This study shows that almost half of patients aged over 95 years with previous independent ambulation were able to walk unassisted 6 months after the hip fracture. The main predictors of walking recovery were better previous walking ability (measured by FAC) and full weight-bearing capacity after surgery, while delirium during hospitalization was associated with poor functional recovery. It should be noted that despite the very advanced age of patients in our study (mean age 97 years) and the fact that almost one third had dementia, the vast majority (78.3%) had an autonomous gait before the fracture. The few studies conducted on patients with exceptional longevity show very uneven results in relation to walking recovery. In a 2004 study, Oliver et al. reported that 22% of patients regained their pre-fracture walking ability [ 9 ]. The worst results were found by Sarasa-Roca et al., with only 2 of 14 patients (12%) who were previously ambulatory recovering their ability to walk [ 10 ]. Shabat et al. reported that 4 of 11 patients (36%) regained the ability to walk and achieved ambulation [ 21 ]. All three studies were conducted on small numbers of patients. In addition, Holt et al. found in their prospective study of 50 patients aged 95 years and over who underwent surgery for hip fracture that 44% regained their walking ability at 1 year; 96% of these patients were able to walk without assistance before the hip fracture and 40% after hip fracture [ 11 ]. A more recent study including 253 centenarians based on data from the Spanish National Hip Fracture Registry showed similar results to ours for walking recovery at one month, with almost 50% of patients regaining independent ambulation [ 12 ]. The best results were reported by Barret-Lee et al. in a study of 60 centenarians, in which 63% of patients returned to their pre-fracture level of independence [ 13 ]. In patients with exceptional longevity, the risk factors for non-functional recovery have not been described. However, in patients older than 65 years who had previously been autonomous, Ouellet et al. reported age, dementia, delirium, number of medications and opiate use as predictors of poor functional outcome at 3 and 6 months [ 22 ]. In a retrospective study of 228 patients with a follow-up rate of 54%, Takahashi et al. found that FAC score before the fracture and at discharge correlated positively with FAC at 6 months. Age and surgical delay worsened prognosis but only in patients with hip neck fractures [ 6 ]. Pioli et al., in a study of 774 patients divided into three groups according to pre-fracture ambulation capacity (mobile outdoors, mobile indoors, and mobile with assistance) found different factors predictive of walking recovery, depending on whether it was assessed at 3, 6 or 12 months; pre-fracture functional status was the only significant predictor in all three groups [ 20 ]. It would seem obvious that patients with a better functional status and better walking ability before the fracture would be the most likely to recover the ability to walk. In conenection with this, some authors have suggested that physical resilience in one domain can help offset an unfavorable status in others, and that circumstances that are not always considered, such as where they live (at home or in an institution) and socio-economic situation, may be more important in some patients than disease burden [ 23 ]. Full weight-bearing capacity is an understudied aspect of functional recovery after hip fracture. Non-full weight-bearing usually lasts only a few days or weeks, but it does occur early in rehabilitation. In a study similar to ours with a longer follow-up period, Ariza-Vega et al. found that full weight-bearing was an independent predictor of 1-year functional outcome, together with the patient’s pre-fracture functional status, cognitive status, health status, age and fracture type [ 24 ]. In a prospective study of 41 pertrochanteric hip fracture patients divided in two groups with similar baseline characteristics, Pfeufer et al. found that restrictions on weight-bearing in older adults contributed to loss of mobility and lower gait speed when measured on the fifth post-operative day [ 25 ]. Nevertheless, in a retrospective study in Switzerland of 219 patients over 70 years of age, the authors found no relationship between full weight-bearing and ability to walk during hospitalization [ 26 ]. Despite the increasing use of measures to prevent delirium, it is still very common in patients admitted for hip fracture. It occurs mainly in patients with previous cognitive impairment, multimorbidity, malnutrition and frailty [ 27 , 28 ]. Advanced age is also a well-known risk factor for delirium, although, again, there are very few studies of extremely older patients admitted with hip fracture. Two studies with small numbers of patients found that about 40% of centenarian patients developed delirium during admission [ 29 ], which is similar to our results, and higher than previously reported for younger patients aged 75 to 83 years (11%) [ 30 ]. Delirium has often been an independent risk factor associated with poor functional recovery after hip fracture in patients in the most frequent age range. Marcantonio et al. reported a decline in ambulation and activities of daily living (ADL) in hospitalized patients with delirium one month after discharge, and after adjusting for other risk factors such as age, comorbidities and cognitive and functional impairment [ 31 ]. A study with a 2-year follow-up comparing patients with and without delirium during hospital admission showed that a greater proportion of the non-delirious group had regained mobility at one year (51% vs 34%) and this pattern was maintained for 24 months after discharge [ 32 ]. Our results in patients with exceptional longevity are consistent with these findings, and with those from other studies describing different forms of cognitive impairment as a risk factor for failure to achieve autonomous walking after hip fracture [ 33 , 34 ]. To our knowledge, there are no previous studies linking delirium and functional recovery in patients with exceptional longevity. In our study, delirium and dementia were both associated with a worse outcome on univariate analysis, but delirium was a better predictor. Delirium probably allowed us to detect those patients with underdiagnosed cognitive impairment, which is common in this very old population. Thus, our final model included full weight-bearing after surgery, pre-fracture walking ability and absence of delirium as predictors of walking recovery with a good diagnostic performance [ 35 ]. If validated in other samples, this could be a useful prognostic model in clinical practice. In a 2021 study of more than 25,000 patients, the authors created a predictive model of gait recovery, in which some variables were the same as ours: weight-bearing capacity, cognitive impairment and pre-fracture ambulation, although their model also included age, ASA score, surgical delay, discharge destination, fracture type and pressure ulcers [ 8 ]. In our smaller sample of patients with exceptional longevity, neither age, surgical delay nor fracture type were associated with worse ambulation outcome. Discharge to a center was not significant in the multivariate analysis, but was associated with autonomous walking recovery in the univariate analysis. This may be because only the patients who have the best chance of regaining the ability to walk are discharged to a rehabilitation center, and also that almost half of the patients who needed assistance in order to walk lived in a nursing home before the fracture. Patients able to ambulate independently (FAC > 3) had better short- and long-term survival. Other studies in younger patients that have examined this relationship have also found better survival in patients who regained function. In a study with a 10-year follow-up, conducted in Greece, in patients with a mean age of 79 years and previously independent, it was shown that early post-hip fracture walking ability predicted better short-term and long-term survival [ 15 ]. In other pathologies requiring hospitalization in older adults, good functional status has been shown to be a protective factor against mortality [ 36 ]. The main limitation of our study is that it was conducted in a single hospital. However, patient inclusion was consecutive, with a higher number of patients than in most studies in this age group. The main strengths are the description of predictors of walking recovery, and the relationship between walking recovery and short- and long-term survival in patients with exceptional longevity. To our knowledge, this is the first time that these factors have been described in this age group. 5. Conclusion Almost half of patients with exceptional longevity achieved independent ambulation after a hip fracture. Predictors of walking recovery were previous unassisted walking ability and full weight-bearing capacity after surgery, while delirium was associated with a poor outcome. As expected, patients able to walk without assistance in the first six months after discharge have better short-term and long-term survival. These data may be useful for determining prognosis and deciding which patients would benefit from more intensive rehabilitation. Declarations Acknowledgements This study received no funding Ethicals approval : This study was approved by the institutional ethics committee Fundació Institut de Recerca Hospital de la Santa Creu i Sant Pau (code IIBSP-FEM-2023-36). Given that this is a retrospective study, the ethics committee has determined that obtaining informed consent is not required. Clinical trial number: not applicable Avalability of data and materials : The datasets used during the current study are available from the corresponding author on reasonable request. Competing interest : The autors declare no competint interests. Funding : We did not receive any financial suport for the research. Author contributions: MB, PVM and OT: Conceptualization, methodology design, and manuscript drafting.MB and PVM: Data extraction and literature search. IG statistical analysis: , All authors: critical revision and refinement of the manuscript. All Authors reviewed the manuscript. 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Non-weight-bearing status compromises the functional level up to 1 year after hip fracture surgery. Am J Phys Med Rehabil. 2014;93(8):641–8. 10.1097/PHM.0000000000000075 . Pfeufer D, Zeller A, Mehaffey S, Böcker W, Kammerlander C, Neuerburg C. Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients. Arch Orthop Trauma Surg. 2019;139(9):1253–9. 10.1007/s00402-019-03193-9 . Baer M, Neuhaus V, Pape HC, Ciritsis B. Influence of mobilization and weight bearing on in-hospital outcome in geriatric patients with hip fractures. SICOT J. 2019;5:4. 10.1051/sicotj/2019005 . Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci. 2022;14:1068278. 10.3389/fnagi.2022.1068278 . Koskderelioglu A, Onder O, Gucuyener M, Altay T, Kayali C, Gedizlioglu M. Screening for postoperative delirium in patients with acute hip fracture: Assessment of predictive factors. Geriatr Gerontol Int. 2017 jun;17(6):919–24. 10.1111/ggi.12806 . Konttinen N, Rosenberg PH. Outcome after anaesthesia and emergency surgery in patients over 100 years old. Acta Anaesthesiol Scand. 2006;50(3):283–9. 10.1111/j.1399-6576.2006 . 00953.x. Pelavski Atlas AD, Colomina MJ, De Miguel M, Roigé J. Centenarian versus patients within the most frequent age range for hip fractures: transfusion practice. Ach Orthop Trauma Surg. 2009;129:685–9. 10.1007/s00402-009-0842-8 . Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):618 – 24. 10.1111/j.1532-5415 . 2000.tb04718.x. Dolan MM, Hawkes WG, Zimmerman SI, Morrison RS, Gruber-Baldini AL, Hebel JR, Magaziner J. Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol Biol Sci Med Sci. 2000;55(9):M527–34. 10.1093/gerona/55.9.m527 . Loh YL, Wicks J, Alexander T. The impact of dementia on rehabilitation outcomes following hip fracture. Aging Med (Milton). 2023;6(2):132–43. 10.1002/agm2.12251 . Ariza-Vega P, Lozano-Lozano M, Olmedo-Requena R, Martín-Martín L, Jiménez-Moleón JJ. Influence of Cognitive Impairment on Mobility Recovery of Patients With Hip Fracture. Am J Phys Med Rehabil. 2017;96(2):109–15. 10.1097/PHM.0000000000000550 . Çorbacıoğlu ŞK, Aksel G. Receiver operating characteristic curve analysis in diagnostic accuracy studies: A guide to interpreting the area under the curve value. Turk J Emerg Med. 2023;23(4):195–8. 10.4103/tjem.tjem_182_23 . Torres OH, Muñoz J, Ruiz D, Ris J, Gich I, Coma E, Gurguí M, Vázquez G. Outcome predictors of pneumonia in elderly patients: importance of functional assessment. J Am Geriatr Soc. 2004;52(10):1603–9. 10.1111/j.1532-5415.2004.52492.x . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8405637","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580780783,"identity":"eafcdbcc-1863-4392-ac04-30f8a49710e0","order_by":0,"name":"Montserrat Barceló","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDACCTBpwcDA3kCaFgkGHp4DQDoBKnqAKC0SCURq0Z3d/OzDjwoJOXvJ5w8/F/64I29wgPnh5w94tJjdOWY8s+eMhDGPdI6x9IyEZ4YbDrAZS+CzxexGgjEzY5tEYo90DoM0T8Jhxg0HeBgIaEn/zMz4D6hF8vjj30At9kAtzD/wa8kB2tIA1CLBYAayJRGohQ2/LXfOFDP2HAP65UyOmTVP2rPkmYfZzCzO4NNyu30zw48aGzn29uOPb/PY3LHtO978+EYFHi3oAOgiZhKUQ7WMglEwCkbBKEADAFKHT0htM6h5AAAAAElFTkSuQmCC","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Montserrat","middleName":"","lastName":"Barceló","suffix":""},{"id":580780784,"identity":"75ad7688-2d70-43cb-b0f5-2b6fdd74d0cc","order_by":1,"name":"Patricia Valentina Marquez","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"Valentina","lastName":"Marquez","suffix":""},{"id":580780785,"identity":"d5b173ec-e38a-4cd6-b1f9-e77782f80d6e","order_by":2,"name":"Ignasi Gich","email":"","orcid":"","institution":"Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública","correspondingAuthor":false,"prefix":"","firstName":"Ignasi","middleName":"","lastName":"Gich","suffix":""},{"id":580780786,"identity":"c570fb91-3a9c-4e97-b7f4-64d0ae1019f6","order_by":3,"name":"Jordi Casademont","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Jordi","middleName":"","lastName":"Casademont","suffix":""},{"id":580780787,"identity":"bf4dfa79-82c2-4e4d-ae7d-911b7afa5373","order_by":4,"name":"Olga Herminia Torres","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Olga","middleName":"Herminia","lastName":"Torres","suffix":""}],"badges":[],"createdAt":"2025-12-19 14:08:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8405637/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8405637/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101268944,"identity":"d52b6603-c95e-4cbf-a9e4-a88be44d8be2","added_by":"auto","created_at":"2026-01-28 01:26:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19923,"visible":true,"origin":"","legend":"\u003cp\u003eArea under the ROC curve for walking recovery\u003c/p\u003e\n\u003cp\u003eAUC 0.819 (0.754 – 0.885), p \u0026lt; 0.001\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8405637/v1/1a03c2491d389ba27111465a.png"},{"id":101268945,"identity":"852fdc26-e00c-41ab-ac39-5b666e21b63f","added_by":"auto","created_at":"2026-01-28 01:26:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21017,"visible":true,"origin":"","legend":"\u003cp\u003eLong-term cumulative survival according to level of walking ability achieved six months after discharge\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e* Functional ambulation classification\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8405637/v1/d00afc7942437753611aaf63.png"},{"id":103737447,"identity":"89b818d3-5b7a-4ea1-8769-d9612e29fa7f","added_by":"auto","created_at":"2026-03-02 10:12:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":653922,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8405637/v1/048a82b6-6f5c-43b3-9920-eef163f7b5da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Recovery of walking ability in patients with exceptional longevity after hip fracture: Predictors and short-and long-term survival in relation to recovery of walking","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe number of people with extreme longevity represents a small proportion of the population, but is increasing rapidly in Western countries. A study published in 2017 described the increase in the European Union as twice as fast as previously observed, with the number of centenarians doubling in 5 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These patients are at high risk of suffering fragility fractures; the incidence of hip fractures in centenarians in our setting is about 4%, which is seven times higher than hip fractures in younger age groups [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hip fractures have a high impact on older adults in terms of functional loss [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Numerous studies have evaluated outcomes after hip fracture, and although the results vary widely, it is generally reported that a significant percentage of patients do not regain their ability to walk. For example, a study by Gonzalez Marcos [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] found that 45% of individuals over the age of 65 were unable to recover their walking ability. Predictors of walking recovery in patients with hip fractures were identified as younger age, ability to walk independently before the fracture and absence of cognitive impairment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There are very few studies on walking recovery in extremely old patients after a hip fracture. Most of these included small numbers of patients and the percentage of patients who regained mobility was low, in some cases less than 25% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, other studies describe a better walking recovery of around 50% or more [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], although functional loss is higher than in other age groups: 74% of octogenarians and 65% of nonagenarians regained unassisted walking [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, in younger patients with a mean age of less than 80 years, those who were able to ambulate after discharge had better one-year and 10-year survival [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. No studies have explored the relationship between walking ability and survival in the exceptional longevity age group. We hypothesize that walking recovery in patients with exceptional longevity may be as high as 50%, as previously reported, and that predictors of recovery will be similar to those observed in younger individuals. We would also predict that patients who achieve better walking recovery will also show better survival.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted in the orthopedic surgery ward of the Hospital de la Santa Creu i Sant Pau, a tertiary university hospital in Barcelona serving a population of approximately 425,000 people with a high proportion of older adults.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Subjects\u003c/h2\u003e \u003cp\u003eAll patients older than 95 years discharged from the orthopedic surgery ward with a diagnosis of fragility hip fracture between December 2009 and September 2015 were retrospectively reviewed. Survival was determined to the present time or date of death of the patient. This study is a continuation of a previous study in patients with exceptional longevity [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and was approved by the institutional ethics committee (code IIBSP-FEM-2023-36). It was conducted in accordance with the ethical principles of the Declaration of Helsinki for medical research involving human subjects.\u003c/p\u003e \u003cp\u003eDuring hospitalization, a multidisciplinary approach was followed with the participation of a physician from the Geriatric Unit. Bed rest was imposed for 24 hours after surgery, and physiotherapy was started 24\u0026ndash;48 h after surgery, if the patient was clinically stable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eThe following data were retrospectively collected: age, sex, comorbidities measured by the Charlson index [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], dementia, depression, pre-fracture and post-discharge ambulation according to the Functional Ambulation Classification (FAC) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], place of residence, number of medications prior to admission, and hemoglobin and albumin levels on admission. Length of hospital stay, delay to surgery, type of fracture (prosthesis or not), assessment of surgical risk based on the ASA (American Society of Anesthesiologists) risk score, type of surgery, type of anesthesia, medical and traumatological complications during admission, full weight-bearing capacity after surgery and final discharge destination were also recorded. The post-discharge FAC measured the maximum level of walking recovery achieved by the patient six months after hip fracture. Patients in whom walking ability was not recorded and those who died within one month of discharge were excluded. The FAC classification has been used in other studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and provides a useful measure of the patient\u0026rsquo;s walking ability. The scale was dichotomized with a cut-off of FAC\u0026thinsp;\u0026lt;\u0026thinsp;3 and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3 to differentiate between patients who required physical assistance from another person and those who did not. FAC was measured at six months because it has been described as peak recovery time [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Full or non-full weight-bearing was indicated by the trauma surgeon; partial weight-bearing was considered non-full weight-bearing. If full weight-bearing was not allowed, it was usually for 2\u0026ndash;4 weeks after surgery, although this varied. Short- and long-term survival were recorded. The date of death was obtained from the patient\u0026rsquo;s medical records and the Ministry of Health\u0026rsquo;s National Death Index website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mscbs.gob.es/estadEstudios/estadisticas/estadisticas/estMinisterio/IND_TipoDifusion.htm\u003c/span\u003e\u003cspan address=\"https://www.mscbs.gob.es/estadEstudios/estadisticas/estadisticas/estMinisterio/IND_TipoDifusion.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), after authorization.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eFor categorical variables, absolute numbers, relative frequencies or proportions were calculated and compared using Fisher\u0026rsquo;s exact test. Continuous variables were presented as means and standard deviations (SD), and compared using Student\u0026rsquo;s t-test. Spearman's correlation was used to measure correlation between FAC score before and after the hip fracture. To determine independent variables, multivariate logistic regression was performed with statistically significant variables in the univariate analysis; the odds Ratio and 95% confidence interval were calculated. The area under the ROC curve (AUC) was calculated for our final model. The Hosmer-Lemeshow test was used to determine goodness-of-fit. A Kaplan-Meier curve for post-discharge survival was calculated. Statistical analysis was performed with IBM SPSS Statistics for Windows. Version 29.0 (IBM Corp. Armonk. NY, USA). Statistical significance was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05 in all cases\u003c/p\u003e"},{"header":"3. Results","content":" \u003cp\u003eBetween December 2009 and September 2015, one hundred and seventy-five patients older than 95 years were discharged after a hip fracture. Fifteen (8.6%) patients were excluded because they died within one month of discharge, and 8 (4.6%) patients because their walking ability had not been recorded. The remaining 152 patients were included in the analysis. One patient (0.6%) could not be located after the second year. One patient was still alive at the time of the study, 10 years later. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows differences between pre-fracture and maximum ambulation ability six months after discharge, measured by FAC score. The mean pre-fracture FAC was 3.12 (SD 1.36), mean post-discharge FAC was 1.67 (SD 1.64). Before the fracture, 78.3% of patients were classified as independent in ambulation (FAC\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3) whereas this percentage had decreased to 36.8% at 6 months after discharge. Consequently 46.9% of those who were previously able to walk independently recovered their ability to walk without assistance. A positive correlation was found between pre-fracture and post hip-fracture FAC scores, with rho\u0026thinsp;=\u0026thinsp;0.492 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The baseline characteristics and in-hospital results comparison of exceptional longevity patients classified as FAC\u0026thinsp;\u0026lt;\u0026thinsp;3 and FAC\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3 are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Multivariate logistic regression results showed that a better pre-fracture FAC score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR 3.658. 95% CI 2.141\u0026ndash;6.25), absence of delirium while hospitalized (p\u0026thinsp;=\u0026thinsp;0.010, OR 3.45. 95% CI 1.342\u0026ndash;8.873) and full weight-bearing capacity (p\u0026thinsp;=\u0026thinsp;0.026, OR 12.705. 95% CI 1.362-118.475) were predictors of walking recovery. The area under the ROC curve for walking recovery was 0.819 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI 0.754\u0026ndash;0.885) Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The Hosmer-Lemeshow test showed that the model was well calibrated (p\u0026thinsp;=\u0026thinsp;0.758). Replication of the model with the addition of age and sex yielded very similar results and identified the same predictors. Mean survival after discharge was 2.24 years (SD 1.185). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e compares the cumulative survival of patients who required assistance to ambulate six months after discharge and those who did not. This difference was maintained for approximately four years, after which it leveled off.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score for pre-fracture ambulation and maximum walking ability six months after discharge.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score before hip fracture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-discharge FAC\u003cem\u003e*\u003c/em\u003e score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 0 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (39.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 1 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 2 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (11.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 3 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 4 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e 5 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDichotomized FAC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e \u0026lt; 3 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (63.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e 3 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003e* Functional ambulation classification\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients older than 95 years who needed physical assistance from another person and those who did not six months after discharge: Baseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score\u0026thinsp;\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;96\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, in years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97.23 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.50 (2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.77 (1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134 (88.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson index (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.11 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.26 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-fracture FAC\u003cem\u003e*\u003c/em\u003e score\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3 \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDementia \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of residence: \u003cem\u003en\u003c/em\u003e at home (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (58.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of drugs (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.58 (2.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracapsular fracture \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.439\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin at admission in g/L (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119.59 (14.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118.22 (15.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122.02 (14.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin at admission in g/L (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.24 (3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.39 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.99 (3.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.485\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients older than 95 years who needed physical assistance from another person and those who did not six months after discharge: In-hospital test results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score\u0026thinsp;\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;96\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFAC\u003cem\u003e*\u003c/em\u003e score\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay, in days (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.69 (8.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.56 (10.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.20 (4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelay to surgery, in days (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.60 (2.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.81 (2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.23 (2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProsthesis \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal anesthesia \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148 (97.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with medical complications \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with traumatological complications \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapy: full weight-bearing \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e139 (91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (98.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin or respiratory isolation \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge to a center \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (51.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study shows that almost half of patients aged over 95 years with previous independent ambulation were able to walk unassisted 6 months after the hip fracture. The main predictors of walking recovery were better previous walking ability (measured by FAC) and full weight-bearing capacity after surgery, while delirium during hospitalization was associated with poor functional recovery. It should be noted that despite the very advanced age of patients in our study (mean age 97 years) and the fact that almost one third had dementia, the vast majority (78.3%) had an autonomous gait before the fracture. The few studies conducted on patients with exceptional longevity show very uneven results in relation to walking recovery. In a 2004 study, Oliver et al. reported that 22% of patients regained their pre-fracture walking ability [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The worst results were found by Sarasa-Roca et al., with only 2 of 14 patients (12%) who were previously ambulatory recovering their ability to walk [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Shabat et al. reported that 4 of 11 patients (36%) regained the ability to walk and achieved ambulation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. All three studies were conducted on small numbers of patients. In addition, Holt et al. found in their prospective study of 50 patients aged 95 years and over who underwent surgery for hip fracture that 44% regained their walking ability at 1 year; 96% of these patients were able to walk without assistance before the hip fracture and 40% after hip fracture [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A more recent study including 253 centenarians based on data from the Spanish National Hip Fracture Registry showed similar results to ours for walking recovery at one month, with almost 50% of patients regaining independent ambulation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The best results were reported by Barret-Lee et al. in a study of 60 centenarians, in which 63% of patients returned to their pre-fracture level of independence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In patients with exceptional longevity, the risk factors for non-functional recovery have not been described. However, in patients older than 65 years who had previously been autonomous, Ouellet et al. reported age, dementia, delirium, number of medications and opiate use as predictors of poor functional outcome at 3 and 6 months [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In a retrospective study of 228 patients with a follow-up rate of 54%, Takahashi et al. found that FAC score before the fracture and at discharge correlated positively with FAC at 6 months. Age and surgical delay worsened prognosis but only in patients with hip neck fractures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Pioli et al., in a study of 774 patients divided into three groups according to pre-fracture ambulation capacity (mobile outdoors, mobile indoors, and mobile with assistance) found different factors predictive of walking recovery, depending on whether it was assessed at 3, 6 or 12 months; pre-fracture functional status was the only significant predictor in all three groups [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It would seem obvious that patients with a better functional status and better walking ability before the fracture would be the most likely to recover the ability to walk. In conenection with this, some authors have suggested that physical resilience in one domain can help offset an unfavorable status in others, and that circumstances that are not always considered, such as where they live (at home or in an institution) and socio-economic situation, may be more important in some patients than disease burden [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Full weight-bearing capacity is an understudied aspect of functional recovery after hip fracture. Non-full weight-bearing usually lasts only a few days or weeks, but it does occur early in rehabilitation. In a study similar to ours with a longer follow-up period, Ariza-Vega et al. found that full weight-bearing was an independent predictor of 1-year functional outcome, together with the patient\u0026rsquo;s pre-fracture functional status, cognitive status, health status, age and fracture type [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a prospective study of 41 pertrochanteric hip fracture patients divided in two groups with similar baseline characteristics, Pfeufer et al. found that restrictions on weight-bearing in older adults contributed to loss of mobility and lower gait speed when measured on the fifth post-operative day [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Nevertheless, in a retrospective study in Switzerland of 219 patients over 70 years of age, the authors found no relationship between full weight-bearing and ability to walk during hospitalization [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Despite the increasing use of measures to prevent delirium, it is still very common in patients admitted for hip fracture. It occurs mainly in patients with previous cognitive impairment, multimorbidity, malnutrition and frailty [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Advanced age is also a well-known risk factor for delirium, although, again, there are very few studies of extremely older patients admitted with hip fracture. Two studies with small numbers of patients found that about 40% of centenarian patients developed delirium during admission [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which is similar to our results, and higher than previously reported for younger patients aged 75 to 83 years (11%) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Delirium has often been an independent risk factor associated with poor functional recovery after hip fracture in patients in the most frequent age range. Marcantonio et al. reported a decline in ambulation and activities of daily living (ADL) in hospitalized patients with delirium one month after discharge, and after adjusting for other risk factors such as age, comorbidities and cognitive and functional impairment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A study with a 2-year follow-up comparing patients with and without delirium during hospital admission showed that a greater proportion of the non-delirious group had regained mobility at one year (51% vs 34%) and this pattern was maintained for 24 months after discharge [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Our results in patients with exceptional longevity are consistent with these findings, and with those from other studies describing different forms of cognitive impairment as a risk factor for failure to achieve autonomous walking after hip fracture [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. To our knowledge, there are no previous studies linking delirium and functional recovery in patients with exceptional longevity. In our study, delirium and dementia were both associated with a worse outcome on univariate analysis, but delirium was a better predictor. Delirium probably allowed us to detect those patients with underdiagnosed cognitive impairment, which is common in this very old population. Thus, our final model included full weight-bearing after surgery, pre-fracture walking ability and absence of delirium as predictors of walking recovery with a good diagnostic performance [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. If validated in other samples, this could be a useful prognostic model in clinical practice. In a 2021 study of more than 25,000 patients, the authors created a predictive model of gait recovery, in which some variables were the same as ours: weight-bearing capacity, cognitive impairment and pre-fracture ambulation, although their model also included age, ASA score, surgical delay, discharge destination, fracture type and pressure ulcers [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In our smaller sample of patients with exceptional longevity, neither age, surgical delay nor fracture type were associated with worse ambulation outcome. Discharge to a center was not significant in the multivariate analysis, but was associated with autonomous walking recovery in the univariate analysis. This may be because only the patients who have the best chance of regaining the ability to walk are discharged to a rehabilitation center, and also that almost half of the patients who needed assistance in order to walk lived in a nursing home before the fracture. Patients able to ambulate independently (FAC\u0026thinsp;\u0026gt;\u0026thinsp;3) had better short- and long-term survival. Other studies in younger patients that have examined this relationship have also found better survival in patients who regained function. In a study with a 10-year follow-up, conducted in Greece, in patients with a mean age of 79 years and previously independent, it was shown that early post-hip fracture walking ability predicted better short-term and long-term survival [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In other pathologies requiring hospitalization in older adults, good functional status has been shown to be a protective factor against mortality [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The main limitation of our study is that it was conducted in a single hospital. However, patient inclusion was consecutive, with a higher number of patients than in most studies in this age group. The main strengths are the description of predictors of walking recovery, and the relationship between walking recovery and short- and long-term survival in patients with exceptional longevity. To our knowledge, this is the first time that these factors have been described in this age group.\u003c/p\u003e"},{"header":"5. Conclusion","content":" \u003cp\u003eAlmost half of patients with exceptional longevity achieved independent ambulation after a hip fracture. Predictors of walking recovery were previous unassisted walking ability and full weight-bearing capacity after surgery, while delirium was associated with a poor outcome. As expected, patients able to walk without assistance in the first six months after discharge have better short-term and long-term survival. These data may be useful for determining prognosis and deciding which patients would benefit from more intensive rehabilitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThis study received no funding\u003c/p\u003e\u003cp\u003e\u003cu\u003eEthicals approval\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional ethics committee Fundaci\u0026oacute; Institut de Recerca Hospital de la Santa Creu i Sant Pau (code IIBSP-FEM-2023-36). Given that this is a retrospective study, the ethics committee has determined that obtaining informed consent is not required.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvalability of data and materials\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interest\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eThe autors declare no competint interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eWe did not receive any financial suport for the research.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthor contributions:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMB, PVM and OT: Conceptualization, methodology design, and manuscript drafting.MB and PVM: Data extraction and literature search. IG statistical analysis: , All authors: critical revision and refinement of the manuscript. All Authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTeixeira L, Ara\u0026uacute;jo L, Jopp D, Ribeiro O. Centenarians in Europe. Maturitas. 2017;104:90\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.maturitas.2017.08.005\u003c/span\u003e\u003cspan address=\"10.1016/j.maturitas.2017.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Aug 12. PMID: 28923181.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodr\u0026iacute;guez-Molinero A, Yuste A, Banegas JR. 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Turk J Emerg Med. 2023;23(4):195\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/tjem.tjem_182_23\u003c/span\u003e\u003cspan address=\"10.4103/tjem.tjem_182_23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorres OH, Mu\u0026ntilde;oz J, Ruiz D, Ris J, Gich I, Coma E, Gurgu\u0026iacute; M, V\u0026aacute;zquez G. Outcome predictors of pneumonia in elderly patients: importance of functional assessment. J Am Geriatr Soc. 2004;52(10):1603\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1532-5415.2004.52492.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1532-5415.2004.52492.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"mortality, hip fracture, centenarians","lastPublishedDoi":"10.21203/rs.3.rs-8405637/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8405637/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground There are very few studies on walking recovery and its predictors in extremely older patients after a hip fracture. Relationship between walking recovery and survival has not been studied in this age group either. The objective of our study is to assess walking recovery and its predictors in extremely older patients at 6 months after discharge, and whether there was a relationship with short and long-term survival.\u003c/p\u003e \u003cp\u003eMethods Restrospective review including all patients older than 95 years admitted with a fragility hip fracture between December 2009 and September 2015 in a tertiary university hospital in Barcelona. Walking ability was measured by the functional ambulation classification (FAC) prior to admission and at 6 months after discharge. Short- and long-term survival were recorded.\u003c/p\u003e \u003cp\u003eResults One hundred and fifty-two patients were included. Before the fracture, 78.3% of patients were independent in ambulation, whereas this percentage dropped to 36.8% afterward. This means that 46.9% of those who previously walked independently regained their ability to do so. Better previous FAC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR 3.658), not having delirium during admission (p\u0026thinsp;=\u0026thinsp;0.010, OR 3.45), and being able to carry out full weight-bearing (p\u0026thinsp;=\u0026thinsp;0.026, OR 12.705) were the variables associated with better walking recovery. Area under the ROC curve was 0.819 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mean survival after discharge was 2.24 years (SD 1.185). Patients with post-fracture FAC\u0026thinsp;\u0026gt;\u0026thinsp;3 had better survival.\u003c/p\u003e \u003cp\u003eConclusion Walking recovery predictors in patients with exceptional longevity were: having better previous FAC, being able to carry out full weight-bearing, and not having delirium. Patients able to walk without help during the first six months after discharge had a better survival.\u003c/p\u003e","manuscriptTitle":"Recovery of walking ability in patients with exceptional longevity after hip fracture: Predictors and short-and long-term survival in relation to recovery of walking","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 01:26:11","doi":"10.21203/rs.3.rs-8405637/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"acefaaeb-0850-4741-b208-fcb087fced96","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T10:11:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 01:26:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8405637","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8405637","identity":"rs-8405637","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}