Determinants of 6-Month Mortality in Super-Old Elderly Patients with Femoral Neck Fractures: The Role of Surgery and Preoperative Status in Japan

Determinants of 6-Month Mortality in Super-Old Elderly Patients with Femoral Neck Fractures: The Role of Surgery and Preoperative Status in Japan | 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 Determinants of 6-Month Mortality in Super-Old Elderly Patients with Femoral Neck Fractures: The Role of Surgery and Preoperative Status in Japan Tetsuro Tani, Makoto Kitade, Ai Takahashi, Seiji Okada, Akihiko Matsumine This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7270580/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction The number of individuals aged > 90 years (super-old elderly) is steadily increasing, along with the incidence of femoral neck fractures. Surgical treatment in patients aged > 85 years is associated with a high risk of complications, and in super-old patients, surgical intervention is particularly challenging because of multiple comorbidities. However, data on mortality without surgery and its associated factors in this age group are lacking. This study aimed to (1) evaluate the 6-month mortality rate following femoral neck fractures in super-old elderly patients and (2) identify factors associated with 6-month mortality following injury. Material and methods This retrospective study included patients aged > 90 years admitted to our hospital with femoral neck fractures between April 2010 and March 2021, with at least 6 months of follow-up. We collected data on demographics, fracture type, preinjury ambulatory function, treatment type (surgical or non-surgical), and admission laboratory data. Patients were grouped by survival status at 6 months after injury, and mortality rates and associated predictive factors were analyzed. Result A total of 76 patients were included in the study (non-surgical group, n = 37; surgical group, n = 39). The cohort included 14 men and 62 women, with a mean age of 91.9 years (range, 90–96 years). The overall 6-month mortality rate was 21.0% (16/76), with higher mortality in the non-surgical group (40.5%) than in the surgical group (2.5%). Significant predictors of 6-month mortality were pre-injury ambulatory function and serum albumin levels at admission. Conclusion In super-old elderly patients with femoral neck fractures, the 6-month mortality rate is approximately 20%, increasing to 40% in the absence of surgical treatment. Poor preinjury ambulatory function and low albumin levels were significant predictors of mortality. These findings highlight the importance of surgical treatment and pre-operative assessments in this population. Femoral neck fracture super-old elderly Nonagenarian mortality rate Introduction Japan currently has the most aged society in the world. According to the Ministry of Health, Labour, and Welfare, nearly 30% of the Japanese population is ≥ 65 years, and more than 2.6 million individuals are aged ≥ 90 years [ 1 ]. Furthermore, projections indicate that among those born after 2020, approximately 30% of men and 50% of women will live to age 90 or beyond [ 2 ]. In response to this demographic shift, the Japan Geriatrics Society classified older adults into three age groups: pre-old (65–74 years), old (75–89 years), and super-old (≥ 90 years) [ 3 ]. Previous studies have reported a decline in cognitive and physical function among the super-old population [ 4 ]. As the population ages, the incidence of femoral neck fractures (FNFs), often due to osteoporosis, continues to rise [ 5 ]. The 1-year mortality rate following FNFs in individuals aged ≥ 65 years has been reported to be around 28% [ 6 ]. FNFs are a significant cause of long-term care in Japan, accounting for approximately 15% of individuals requiring nursing care [ 7 ]. However, data specific to the super-old population remain limited. Surgical treatment is generally recommended within 48 h of injury to prevent complications related to prolonged immobility and reduce the need for long-term care [ 8 ]. Despite these benefits, surgery in the super-old elderly is often challenging due to the presence of multiple comorbidities, which elevate perioperative risk. Although postoperative complications are common in patients aged > 85 years, the influence of surgical treatment on mortality in the super-old population remains unclear [ 9 ]. Moreover, previous studies have rarely included surgery as a risk factor for mortality. Identifying predictors of mortality in this population may help orthopedic surgeons make more informed treatment decisions and improve patient outcomes. The objectives of this study were (1) to evaluate the 6-month mortality rate following FNFs in super-old elderly patients and (2) to identify factors associated with mortality within 6 months of injury. Materials and methods This retrospective study was approved by the Ethics Committee of Fukui University. Among 233 patients admitted with FNFs between April 2010 and March 2021, we identified 86 patients aged ≥ 90 years (super-old elderly). Follow-up data were obtained 6 months after injury. Survival status and ambulatory function of patients who did not visit the outpatient clinic was confirmed through their primary care physicians. Patients were excluded if their follow-up period was < 6 months, if follow-up data could not be obtained, or if they sustained high-energy trauma or had pathological fractures, such as bone metastases or metabolic diseases. Treatment Protocol Surgical treatment was recommended for all the patients. However, non-surgical management was chosen when surgery was deemed high-risk by the anesthesiology department or was refused by the patient or their family. Patients in the non-surgical group were allowed to transfer to a wheelchair and begin range of motion exercises within 1 week of injury before being transferred to different care facilities. Surgical procedures included internal fixation for stable fractures and bipolar hemiarthroplasty for unstable fractures. Fracture types were classified according to the Garden classification [ 10 ]. All patients were encouraged to initiate weight-bearing and rehabilitation as early as possible. The reasons for choosing non-surgical treatment were also recorded. Demographic and Laboratory data Demographic data collected included sex, age at injury, height, and body weight. Clinical variables included the American Society of Anesthesiologists Physical Status (ASA-PS) classification [ 11 ], fracture type according to the Garden classification [ 12 ], and pre-injury ambulatory function [ 13 ], which was categorized as independent ambulation, assisted ambulation, or wheelchair use. Body mass index was calculated as weight/height (kg/m 2 ). Ambulatory function was reassessed at the final follow-up in surviving patients. Laboratory data at admission included white blood cell count, hemoglobin, platelet count, C-reactive protein, serum sodium, potassium, chloride, calcium, blood urea nitrogen, creatinine, total protein, albumin, blood urea nitrogen, aspartate aminotransferase (AST), alanine transaminase (ALT), lactate dehydrogenase, and creatinine kinase. Statistical Analysis The 6-month mortality rate following injury was assessed. Patients were categorized into survival and non-survival groups. Demographic, treatment, and laboratory variables were compared between the two groups. Variables with significant differences in the univariate analysis were further analyzed using multivariate logistic regression to identify independent predictors of mortality. Ambulatory function at the final follow-up was also compared between the surgical and non-surgical groups. All statistical analyses were performed using JMP software. Mann–Whitney U and chi-square tests were used for group comparisons. Statistical significance was set at p < 0.05. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression analysis. Results A total of 76 patients were included in the study, comprising of 14 men and 62 women, with a mean age of 91.9 years (range, 90–96 years). Of these, 37 patients were treated non-surgically and 39 underwent surgical treatment. The 6-month mortality rate was 40.5% (15/37) in the non-surgical group and 2.5% (1/39) in the surgical group (Table 1 ). Table 1 Demographics and clinical characteristics of the study participants, with comparison between the survival and non-survival groups. Factor Total (n = 76) Survival group (n = 60) Non-Survival group (n = 16) p-value Age (years) 91.9 92.4 91.9 0.83 Sex (case) Men 14 9 5 0.16 Women 62 51 11 Body mass index (kg/m 2 ) 19.5 (14.7–29.4) 19.6 (14.7–26.5) 19.4 (15.3–29.4) 0.33 Treatment (case) Surgical treatment 39 38 1 < 0.001* Non-surgical treatment 37 22 15 Ambulatory function (case) Independent ambulation 28 24 4 < 0.001* Assisted ambulation 41 35 6 Wheelchair mobility 7 1 6 American Society of Anesthesiologists-Physical Status (case) Ⅰ 0 0 0 0.20 Ⅱ 24 20 4 Ⅲ 32 27 5 Ⅳ 20 13 7 Garden Classification (case) 1 5 4 1 0.28 2 8 4 4 3 23 17 6 4 40 35 5 Data are presented as numbers for categorical variables and as median (range) for continuous variables. Wilcoxon’s rank-sum test was used for continuous variables and the chi-square test was used for categorical variables. *Significant differences between the survival and non-survival groups. Regarding ambulatory function, 28 patients had independent ambulation, while 41 used assistive devices or a wheelchair. In the survival group, 24 patients were independently ambulatory, 35 were assisted ambulatory, and 1 was wheelchair mobile. In the non-survival group, four patients were independently ambulatory, six were assisted ambulatory, and six were wheelchair mobile (Table 1 ). Among the surgical patients, 5 underwent internal fixation and 34 underwent bipolar hip arthroplasty (Supplementary Table 1). The reasons for not undergoing surgery included patient or family refusal in 13 cases and high surgical risk in 24 cases, as determined by the anesthesiology department. Specific reasons among high-risk cases included cardiac disease (n = 5), pulmonary disease (n = 8), neurological disease (n = 10), and infectious disease (n = 1; Supplementary Table 2). At the final follow-up, ambulatory function in the surgical group included independent ambulation in 4 patients, assisted ambulation in 19 patients, and wheelchair use in 16 patients. In contrast, all patients in the non-surgical group required a wheelchair (Table 2 ). Table 2 Ambulatory function at final follow-up. Final follow-up Ambulatory function Surgical groups (case) Non-surgical group (case) p-value Independent ambulation 4 0 < 0.001* Assisted ambulation 19 0 Wheelchair mobility 16 37 *Significant differences between the surgical and non-surgical groups. When comparing the survival and non-survival groups at 6 months after injury, significant differences were observed in treatment type, pre-injury ambulatory function, and levels of albumin and AST (Tables 1 and 3 ). Logistic regression analysis showed that non-surgical treatment (OR: 9.24, 95% CI: 0.82–104.5), pre-injury wheelchair use (OR: 28.7, 95% CI: 1.04–787.70), albumin level (OR: 0.14, 95% CI: 0.02–0.99), and AST level (OR: 0.89, 95% CI: 0.76–1.04) were associated with 6-month mortality (Table 4 ). These findings indicate that poorer preinjury ambulatory function and hypoalbuminemia were significantly associated with 6-month mortality in super-old elderly patients with FNFs. Surgical intervention was not associated with increased mortality. Table 3 Laboratory data at the time of hospitalization and comparison between the survival and non-survival groups. Factor Total Survival group Non-Survival group p-value White blood cell count (×10³/µL) 8.4 (2.7–17.9) 8.2 (2.7–15.7) 8.9 (4.8–17.9) 0.33 Hemoglobin (g/dL) 11.2 (7.3–15.1) 11.2 (7.3–15.1) 11.3 (8.2–14.3) 0.65 Platelet count (×10⁴/µL) 213.4 (80.0–438.0) 214.8 (80.0–438.0) 208.0 (119.0–327.0) 0.78 C-reactive protein (mg/dL) 2.4 (0.01–17.4) 2.1 (0.01–16.2) 3.3 (0.03–17.4) 0.83 Serum Sodium (mEq/L) 139.2 (129–151) 139.1 (129–145) 139.6 (130–151) 0.30 Serum Potassium (mEq/L) 4.0 (2.3–6.2) 4.1 (2.3–6.2) 3.9 (2.6–5.6) 0.29 Serum chloride (mEq/L) 102.9 (88–115) 102.6 (88–112) 104.4 (95–115) 0.30 Serum calcium (mEq/L) 8.69 (7.7–9.7) 8.71 (7.7–9.7) 8.6 (7.9–9.2) 0.47 Blood urea nitrogen (mg/dL) 23.6 (9–93) 23.1 (9–93) 25.3 (15–53) 0.28 Creatinine (mg/dL) 0.8 (0.3–2.6) 0.8 (0.4–2.6) 1.1 (0.3–2.4) 0.20 Total protein (g/dL) 6.5 (4.8–8.5) 6.6 (4.8–8.5) 6.2 (4.9–7.7) 0.05 Albumin (g/dL) 3.3 (1.9–3.8) 3.4 (2.1–4.5) 2.8 (1.9–3.8) 0.003* Aspartate aminotransferase (U/L) 29.8 (14–263) 32.0 (14–263) 21.2 (14–32) 0.03* Alanine transaminase (U/L) 20.2 (6–236) 21.9 (6–236) 13.2 (7–23) 0.10 Lactate dehydrogenase (U/L) 256.3 (99–479) 256.8 (172–479) 253.9 (99–384) 0.80 Creatinine kinase (U/L) 176.6 (99–479) 188.6 (28–1811) 124.1 (37–227) 0.80 Data are presented as median (range) for continuous variables. Wilcoxon’s rank-sum test was used for continuous variables and the chi-square test was used for categorical variables. *Significant differences between the survival and non-survival groups. Table 4 Results of multivariate analysis: logistic regression analysis of factors associated with 6-month mortality. Parameter Standard error p-value OR (95%CI) Treatment 0.6 0.07 9.2 (0.8–104.5) Surgical treatment - - 1 Non-surgical treatment 0.6 0.07 9.2 (0.8–104.5) Ambulatory function Trend p = 0.10 Independent ambulation - - 1 Assisted ambulation 0.948 0.21 0.30 (0.04–1.9) Wheelchair mobility 1.689 0.04 28.7 (1.04–787.70) Albumin 0.989 0.04 0.14 (0.02–0.99) Aspartate aminotransferase 0.081 0.10 0.89 (0.76–1.04) OR, odds ratio; CI, confidence interval. Discussion This study investigated 6-month mortality following FNFs in patients aged ≥ 90 years (super-old elderly), a population for whom mortality outcomes have not been well studied. Our study found that the 6-month mortality rate was 21% (16/76) overall, with rates of 40.5% (15/37) and 2.5% (1/39) in the non-surgical and surgical groups, respectively. Preinjury ambulatory function, serum albumin levels, and surgical intervention were associated with mortality outcomes. These findings suggest that, even among super-old patients, appropriate surgical management and good nutritional status may have a critical impact on survival. Previous studies have reported 1-year mortality rates of 48.6–84.4% after non-surgical treatment for proximal femoral fractures in patients ≥ 60 years [ 8 , 14 ]. In super-old populations, 6-month mortality in non-surgical cases has been reported to be approximately 40% [ 15 ], consistent with our findings. Notably, the 2.5% 6-month mortality rate in our surgical group is substantially lower than the 34% reported in previous studies [ 14 , 16 ]. These results suggest that advanced age alone should not be viewed as a contraindication to surgery. Although surgical treatment did not emerge as an independent predictor of mortality in multivariate analysis, it was not associated with increased risk either. Instead, factors such as nutritional status and preinjury ambulatory function had stronger associations with mortality outcomes, indicating the importance of overall patient condition in treatment decisions. Some reports have indicated that elective surgery is associated with fewer complications than emergency surgeries [ 17 , 18 ]. Therefore, optimizing patient condition prior to surgery may be beneficial in this age group. Further studies are warranted to investigate the relationship between preoperative nutritional intervention and mortality in this age group. AST and ALT are commonly used indicators of liver function [ 19 ]. ALT is considered a liver-specific indicator, while AST is also present in cardiac and skeletal muscles. In our study, AST levels were significantly higher in the non-survivor group than in the survivor group, likely reflecting muscle injury resulting from the fracture rather than liver dysfunction [ 20 ]. Severe muscle injuries may be associated with increased mortality in this population. Although this difference was considered to be related to fracture type, there was no significant difference in the Garden classification. AST was not a significant predictor in the multivariate analysis; however, the potential prognostic value of AST in hip fracture patients warrants further investigation in larger cohorts. Low serum albumin has been associated with increased postoperative mortality in elderly patients undergoing surgery for hip fractures [ 21 – 23 ]. However, to the best of our knowledge, no previous study has included both surgical and non-surgical cases in a single analysis. In the present study, hypoalbuminemia was found to be associated with 6-month mortality across both treatment groups, suggesting that low albumin may contribute to an increased mortality risk when surgery is performed in this population. Perioperative nutritional intervention or stabilization of general condition should be considered before proceeding with surgical treatment in such patients. This study also found significant differences in ambulatory function between the survival and non-survival groups. Ambulatory function is a component of activities of daily living (ADL), and previous reports have demonstrated associations between poor ADL and low serum albumin levels in elderly Japanese populations [ 24 , 25 ]. Thus, the observed association in our study may also reflect the influence of albumin levels. Previous research has linked preoperative ADL decline with a higher risk of postoperative complications [ 18 ], consistent with our findings. At final follow-up, all patients in the non-operative group were wheelchair-bound, emphasizing the importance of surgical intervention for all patients from the perspective of ADL. Therefore, this study highlights that in this age group, not only surgical intervention but also optimization of perioperative nutritional status remains crucial for improving outcomes. Limitations This study had some limitations. First, there was selection bias between the surgical and non-surgical treatment groups. The nutritional status of the non-surgical group was significantly worse than that of the surgical group, which may have influenced the results. However, because there was no significant difference in the ASA-PS score, which reflects surgical risk, the influence of selection bias is likely limited. Since the nutritional status was poor before surgery and albumin levels were significantly elevated in the multivariate analysis, it is possible albumin had a greater effect on mortality than surgical intervention itself. Further studies are needed to confirm this hypothesis. Second, this was a single-center study conducted at a university hospital. In Japan, university hospitals typically receive patients with poorer overall condition than other medical institutions, potentially leading to a higher proportion of non-surgical cases. Our study may have included a greater number of patients with poorer baseline health, potentially affecting the results. As a result, our findings may reflect a more critically ill demographic. However, since the purpose of this study was to investigate the factors related to mortality in super-old elderly patients with poor health, we believe limitation has little influence on the validity of our findings. Further studies addressing these limitations should be performed to validate our findings. Conclusions In super-old elderly patients with FNFs, the 6-month mortality rate was 20%. Although the mortality rate in the non-surgical group was 40.5%, mortality was more strongly associated with ambulatory function and albumin levels rather than with surgical intervention. In this patient population, surgical intervention should be considered to preserve ambulatory function and potentially improve survival outcomes. However, careful preoperative assessment and optimization of nutritional status are essential in managing this patient population. Abbreviations FNFs Femoral Neck Fractures ASA-PS American Society of Anesthesiologists Physical Status ADL Activities of Daily Living AST Aspartate Aminotransferase ALT Alanine Transaminase OR Odds Ratio CI Confidence Interval CRP C-Reactive Protein LDH Lactate Dehydrogenase CK Creatinine Kinase BMI Body Mass Index Declarations Author Contribution Study design: TT. Data acquisition: TT, MK. Data analysis and interpretation: TT and AT. Writing of the manuscript: TT, Editing the manuscript: All.All authors have read and approved the final manuscript. References Ministry of Health LaW (2022) Vital Statistics. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei22/dl/15_all.pdf Ministry of Health LaW (2022) Life Tables. https://www.mhlw.go.jp/toukei/saikin/hw/life/life22/dl/life22-03.pdf Ouchi Y, Rakugi H, Arai H, Akishita M, Ito H, Toba K, Kai I (2017) Redefining the elderly as aged 75 years and older: Proposal from the Joint Committee of Japan Gerontological Society and the Japan Geriatrics Society. Geriatr Gerontol Int 17(7):1045–1047. https://doi.org/10.1111/ggi.13118 Bullain SS, Corrada MM, Shah BA, Mozaffar FH, Panzenboeck M, Kawas CH (2013) Poor physical performance and dementia in the oldest old: the 90 + study. JAMA Neurol 70(1):107–113. https://doi.org/10.1001/jamaneurol.2013.583 Shoji A, Gao Z, Arai K, Yoshimura N (2022) 30-year trends of hip and vertebral fracture incidence in Japan: a systematic review and meta-analysis. J Bone Min Metab 40(2):327–336. https://doi.org/10.1007/s00774-021-01288-1 Walter N, Szymski D, Kurtz S, Alt V, Lowenberg DW, Lau E, Rupp M (2023) Factors associated with mortality after proximal femoral fracture. J Orthop Traumatol 24(1):31. https://doi.org/10.1186/s10195-023-00715-5 Ministry of Health LaW (2022) Comprehensive Survey of Living Conditions. https://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa22/index.html Chlebeck JD, Birch CE, Blankstein M, Kristiansen T, Bartlett CS, Schottel PC (2019) Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study. J Orthop Trauma 33(7):346–350. https://doi.org/10.1097/bot.0000000000001460 Ogawa T, Schermann H, Kobayashi H, Fushimi K, Okawa A, Jinno T (2021) Age and clinical outcomes after hip fracture surgery: do octogenarian, nonagenarian and centenarian classifications matter? Age Ageing 50(6):1952–1960. https://doi.org/10.1093/ageing/afab137 Garden RS (1964) STABILITY AND UNION IN SUBCAPITAL FRACTURES OF THE FEMUR. J Bone Joint Surg Br 46:630–647 Owens WD, Felts JA, Spitznagel EL Jr. (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49(4):239–243. https://doi.org/10.1097/00000542-197810000-00003 Garden RS, IN FRACTURES OF THE FEMORAL NECK (1961) LOW-ANGLE FIXATION. J Bone Joint Surg Br Volume 43–B(4):647–663. https://doi.org/10.1302/0301-620x.43b4.647 Iosifidis M, Iliopoulos E, Panagiotou A, Apostolidis K, Traios S, Giantsis G (2016) Walking ability before and after a hip fracture in elderly predict greater long-term survivorship. J Orthop Sci 21(1):48–52. https://doi.org/10.1016/j.jos.2015.09.009 De Virgilio-Salgado LG, Olivella G, Ruberté H, Abreu RJ, Otero-López A, Reyes-Martínez P, Ramírez N, Otero-López F (2021) Effect of Nonsurgical Versus Surgical Management on Geriatric Hip Fracture Mortality of Hispanic-American Male Veterans. Geriatr Orthop Surg Rehabil 12:21514593211044621. https://doi.org/10.1177/21514593211044621 Ovidiu A, Stefan GT, Dragos P, Bogdan V, Dana AI (2017) SURVIVAL OF NONAGENARIAN PATIENTS WITH HIP FRACTURES: A COHORT STUDY. Acta Ortop Bras 25(4):132–136. https://doi.org/10.1590/1413-785220172504167561 Ng JPH, Tan TL, Pillai A, Ho SWL (2023) Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients. Arch Orthop Trauma Surg 143(6):3145–3154. https://doi.org/10.1007/s00402-022-04550-x Siam B, Cooper L, Orgad R, Esepkina O, Kashtan H (2022) Outcomes of surgery in patients 90 years of age and older: A retrospective cohort study. Surgery 171(5):1365–1372. https://doi.org/10.1016/j.surg.2021.09.030 Sudlow A, Tuffaha H, Stearns AT, Shaikh IA (2018) Outcomes of surgery in patients aged ≥ 90 years in the general surgical setting. Ann R Coll Surg Engl 100(3):172–177. https://doi.org/10.1308/rcsann.2017.0203 Kim WR, Flamm SL, Di Bisceglie AM, Bodenheimer HC (2008) Serum activity of alanine aminotransferase (ALT) as an indicator of health and disease. Hepatology 47(4):1363–1370. https://doi.org/10.1002/hep.22109 Han JH, Kwak JY, Lee SS, Kim HG, Jeon H, Cha RR (2022) Markedly Elevated Aspartate Aminotransferase from Non-Hepatic Causes. J Clin Med 12(1). https://doi.org/10.3390/jcm12010310 Bohl DD, Shen MR, Hannon CP, Fillingham YA, Darrith B, Della Valle CJ (2017) Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. J Bone Joint Surg Am 99(24):2110–2118. https://doi.org/10.2106/jbjs.16.01620 Borge SJ, Lauritzen JB, Jørgensen HL (2022) Hypoalbuminemia is associated with 30-day mortality in hip fracture patients independently of Body Mass Index. Scand J Clin Lab Invest 82(7–8):571–575. https://doi.org/10.1080/00365513.2022.2150982 Chen Y, Wu X, Chen J, Xu W, Liang X, Huang W, Liao J (2020) Nutritional condition analysis of the older adult patients with femoral neck fracture. Clin Nutr 39(4):1174–1178. https://doi.org/10.1016/j.clnu.2019.04.034 Kitamura K, Nakamura K, Nishiwaki T, Ueno K, Nakazawa A, Hasegawa M (2012) Determination of whether the association between serum albumin and activities of daily living in frail elderly people is causal. Environ Health Prev Med 17(2):164–168. https://doi.org/10.1007/s12199-011-0233-y Okamura T, Hayakawa T, Hozawa A, Kadowaki T, Murakami Y, Kita Y, Abbott RD, Okayama A, Ueshima H (2008) Lower levels of serum albumin and total cholesterol associated with decline in activities of daily living and excess mortality in a 12-year cohort study of elderly Japanese. J Am Geriatr Soc 56(3):529–535. https://doi.org/10.1111/j.1532-5415.2007.01549.x Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx SupplementaryTable2.docx Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 13 Sep, 2025 Reviews received at journal 11 Sep, 2025 Reviews received at journal 09 Sep, 2025 Reviewers agreed at journal 12 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers invited by journal 09 Aug, 2025 Editor assigned by journal 06 Aug, 2025 Submission checks completed at journal 06 Aug, 2025 First submitted to journal 01 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7270580","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499155168,"identity":"00f4f635-ce1f-4499-ad12-b9c007c53517","order_by":0,"name":"Tetsuro Tani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYJCCA0DMw8/e//DBBwaGBKggG07lPCAtQD08kj1nmA1nEKsFbI3BjBw2YR6EFtzAnv3swcMfau7IGDDkHmO2bbPL42dvYPzwgYEvD6ctPHkJBw4ce8ZjznAu7XFuW3KxZM8BZskZDGzFuB2WY3DgANthHsvGBnPj3DbmxA03EtiYeRjYEhtwaeF/A9Ty7zCPwWEGM2nLtnoitEgAbTnYBtRyjMdMmrHtMBFabgBtOdt3GBjIbMmGPeeOJ87sOdgsOcMAt1/Y+3OMP1R8O2zPL//44IMfZdWJ/ezNBz98qDiGM8RQASM4AhmBTjI4lkCcFoY/cFYNsVpGwSgYBaNg+AMAdL9cjRcZKsoAAAAASUVORK5CYII=","orcid":"","institution":"Osaka University Graduate School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Tetsuro","middleName":"","lastName":"Tani","suffix":""},{"id":499155169,"identity":"27ae600a-1bec-42fa-a702-303ad1b39d03","order_by":1,"name":"Makoto Kitade","email":"","orcid":"","institution":"University of Fukui","correspondingAuthor":false,"prefix":"","firstName":"Makoto","middleName":"","lastName":"Kitade","suffix":""},{"id":499155170,"identity":"0be7a6ad-fc32-4831-a562-9779c9f7c32a","order_by":2,"name":"Ai Takahashi","email":"","orcid":"","institution":"University of Fukui","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"","lastName":"Takahashi","suffix":""},{"id":499155171,"identity":"bf4243cc-c495-484a-91ed-cecf7f6ca0dd","order_by":3,"name":"Seiji Okada","email":"","orcid":"","institution":"Osaka University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Seiji","middleName":"","lastName":"Okada","suffix":""},{"id":499155172,"identity":"c766e897-5cd4-44d7-b91d-a80ce6a100d0","order_by":4,"name":"Akihiko Matsumine","email":"","orcid":"","institution":"University of Fukui","correspondingAuthor":false,"prefix":"","firstName":"Akihiko","middleName":"","lastName":"Matsumine","suffix":""}],"badges":[],"createdAt":"2025-08-01 11:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7270580/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7270580/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-025-06095-1","type":"published","date":"2025-10-24T16:16:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94490332,"identity":"ab04f80e-7fae-400d-a482-3ae1c89f2029","added_by":"auto","created_at":"2025-10-27 17:09:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":694856,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7270580/v1/99507b3b-42fa-45d9-a2e4-91d0749dc803.pdf"},{"id":89093934,"identity":"7bd79e32-0aa1-4028-9ddb-585b4d911e59","added_by":"auto","created_at":"2025-08-14 15:09:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14822,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7270580/v1/920e097fa587e6df6dd82a4e.docx"},{"id":89092778,"identity":"3a1e6e98-1bab-434e-bf53-ea821e7253f2","added_by":"auto","created_at":"2025-08-14 15:01:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15704,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7270580/v1/069dfd133d786a889cc4c0c6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determinants of 6-Month Mortality in Super-Old Elderly Patients with Femoral Neck Fractures: The Role of Surgery and Preoperative Status in Japan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eJapan currently has the most aged society in the world. According to the Ministry of Health, Labour, and Welfare, nearly 30% of the Japanese population is \u0026ge;\u0026thinsp;65 years, and more than 2.6\u0026nbsp;million individuals are aged\u0026thinsp;\u0026ge;\u0026thinsp;90 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Furthermore, projections indicate that among those born after 2020, approximately 30% of men and 50% of women will live to age 90 or beyond [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In response to this demographic shift, the Japan Geriatrics Society classified older adults into three age groups: pre-old (65\u0026ndash;74 years), old (75\u0026ndash;89 years), and super-old (\u0026ge;\u0026thinsp;90 years) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Previous studies have reported a decline in cognitive and physical function among the super-old population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs the population ages, the incidence of femoral neck fractures (FNFs), often due to osteoporosis, continues to rise [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The 1-year mortality rate following FNFs in individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years has been reported to be around 28% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. FNFs are a significant cause of long-term care in Japan, accounting for approximately 15% of individuals requiring nursing care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, data specific to the super-old population remain limited.\u003c/p\u003e\u003cp\u003eSurgical treatment is generally recommended within 48 h of injury to prevent complications related to prolonged immobility and reduce the need for long-term care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite these benefits, surgery in the super-old elderly is often challenging due to the presence of multiple comorbidities, which elevate perioperative risk. Although postoperative complications are common in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;85 years, the influence of surgical treatment on mortality in the super-old population remains unclear [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, previous studies have rarely included surgery as a risk factor for mortality. Identifying predictors of mortality in this population may help orthopedic surgeons make more informed treatment decisions and improve patient outcomes.\u003c/p\u003e\u003cp\u003eThe objectives of this study were (1) to evaluate the 6-month mortality rate following FNFs in super-old elderly patients and (2) to identify factors associated with mortality within 6 months of injury.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e This retrospective study was approved by the Ethics Committee of Fukui University. Among 233 patients admitted with FNFs between April 2010 and March 2021, we identified 86 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;90 years (super-old elderly). Follow-up data were obtained 6 months after injury. Survival status and ambulatory function of patients who did not visit the outpatient clinic was confirmed through their primary care physicians. Patients were excluded if their follow-up period was \u0026lt;\u0026thinsp;6 months, if follow-up data could not be obtained, or if they sustained high-energy trauma or had pathological fractures, such as bone metastases or metabolic diseases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment Protocol\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSurgical treatment was recommended for all the patients. However, non-surgical management was chosen when surgery was deemed high-risk by the anesthesiology department or was refused by the patient or their family. Patients in the non-surgical group were allowed to transfer to a wheelchair and begin range of motion exercises within 1 week of injury before being transferred to different care facilities. Surgical procedures included internal fixation for stable fractures and bipolar hemiarthroplasty for unstable fractures. Fracture types were classified according to the Garden classification [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. All patients were encouraged to initiate weight-bearing and rehabilitation as early as possible. The reasons for choosing non-surgical treatment were also recorded.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDemographic and Laboratory data\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDemographic data collected included sex, age at injury, height, and body weight. Clinical variables included the American Society of Anesthesiologists Physical Status (ASA-PS) classification [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], fracture type according to the Garden classification [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and pre-injury ambulatory function [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which was categorized as independent ambulation, assisted ambulation, or wheelchair use. Body mass index was calculated as weight/height (kg/m\u003csup\u003e2\u003c/sup\u003e). Ambulatory function was reassessed at the final follow-up in surviving patients.\u003c/p\u003e\u003cp\u003eLaboratory data at admission included white blood cell count, hemoglobin, platelet count, C-reactive protein, serum sodium, potassium, chloride, calcium, blood urea nitrogen, creatinine, total protein, albumin, blood urea nitrogen, aspartate aminotransferase (AST), alanine transaminase (ALT), lactate dehydrogenase, and creatinine kinase.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe 6-month mortality rate following injury was assessed. Patients were categorized into survival and non-survival groups. Demographic, treatment, and laboratory variables were compared between the two groups. Variables with significant differences in the univariate analysis were further analyzed using multivariate logistic regression to identify independent predictors of mortality.\u003c/p\u003e\u003cp\u003eAmbulatory function at the final follow-up was also compared between the surgical and non-surgical groups.\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed using JMP software. Mann\u0026ndash;Whitney U and chi-square tests were used for group comparisons. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression analysis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 76 patients were included in the study, comprising of 14 men and 62 women, with a mean age of 91.9 years (range, 90\u0026ndash;96 years). Of these, 37 patients were treated non-surgically and 39 underwent surgical treatment. The 6-month mortality rate was 40.5% (15/37) in the non-surgical group and 2.5% (1/39) in the surgical group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eDemographics and clinical characteristics of the study participants, with comparison between the survival and non-survival groups.\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=\"left\" 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\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurvival group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon-Survival group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16)\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 (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.5 (14.7\u0026ndash;29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.6 (14.7\u0026ndash;26.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.4 (15.3\u0026ndash;29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment (case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-surgical treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmbulatory function (case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndependent ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssisted ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheelchair mobility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmerican Society of Anesthesiologists-Physical Status (case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅠ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅢ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅣ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGarden Classification (case)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are presented as numbers for categorical variables and as median (range) for continuous variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eWilcoxon\u0026rsquo;s rank-sum test was used for continuous variables and the chi-square test was used for categorical variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Significant differences between the survival and non-survival groups.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding ambulatory function, 28 patients had independent ambulation, while 41 used assistive devices or a wheelchair. In the survival group, 24 patients were independently ambulatory, 35 were assisted ambulatory, and 1 was wheelchair mobile. In the non-survival group, four patients were independently ambulatory, six were assisted ambulatory, and six were wheelchair mobile (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong the surgical patients, 5 underwent internal fixation and 34 underwent bipolar hip arthroplasty (Supplementary Table\u0026nbsp;1). The reasons for not undergoing surgery included patient or family refusal in 13 cases and high surgical risk in 24 cases, as determined by the anesthesiology department. Specific reasons among high-risk cases included cardiac disease (n\u0026thinsp;=\u0026thinsp;5), pulmonary disease (n\u0026thinsp;=\u0026thinsp;8), neurological disease (n\u0026thinsp;=\u0026thinsp;10), and infectious disease (n\u0026thinsp;=\u0026thinsp;1; Supplementary Table\u0026nbsp;2).\u003c/p\u003e\u003cp\u003eAt the final follow-up, ambulatory function in the surgical group included independent ambulation in 4 patients, assisted ambulation in 19 patients, and wheelchair use in 16 patients. In contrast, all patients in the non-surgical group required a wheelchair (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eAmbulatory function at final follow-up.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinal follow-up\u003c/p\u003e\u003cp\u003eAmbulatory function\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgical groups\u003c/p\u003e\u003cp\u003e(case)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-surgical group\u003c/p\u003e\u003cp\u003e(case)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\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\u003eIndependent ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssisted ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheelchair mobility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant differences between the surgical and non-surgical groups.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen comparing the survival and non-survival groups at 6 months after injury, significant differences were observed in treatment type, pre-injury ambulatory function, and levels of albumin and AST (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Logistic regression analysis showed that non-surgical treatment (OR: 9.24, 95% CI: 0.82\u0026ndash;104.5), pre-injury wheelchair use (OR: 28.7, 95% CI: 1.04\u0026ndash;787.70), albumin level (OR: 0.14, 95% CI: 0.02\u0026ndash;0.99), and AST level (OR: 0.89, 95% CI: 0.76\u0026ndash;1.04) were associated with 6-month mortality (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These findings indicate that poorer preinjury ambulatory function and hypoalbuminemia were significantly associated with 6-month mortality in super-old elderly patients with FNFs. Surgical intervention was not associated with increased mortality.\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\u003eLaboratory data at the time of hospitalization and comparison between the survival and non-survival groups.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurvival group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon-Survival group\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\u003eWhite blood cell count (\u0026times;10\u0026sup3;/\u0026micro;L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.4 (2.7\u0026ndash;17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.2 (2.7\u0026ndash;15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.9 (4.8\u0026ndash;17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.2 (7.3\u0026ndash;15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.2 (7.3\u0026ndash;15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.3 (8.2\u0026ndash;14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelet count (\u0026times;10⁴/\u0026micro;L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e213.4 (80.0\u0026ndash;438.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e214.8 (80.0\u0026ndash;438.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e208.0 (119.0\u0026ndash;327.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-reactive protein (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.4 (0.01\u0026ndash;17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.1 (0.01\u0026ndash;16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.3 (0.03\u0026ndash;17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum Sodium (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e139.2 (129\u0026ndash;151)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e139.1 (129\u0026ndash;145)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e139.6 (130\u0026ndash;151)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum Potassium (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.0 (2.3\u0026ndash;6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.1 (2.3\u0026ndash;6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.9 (2.6\u0026ndash;5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum chloride (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e102.9 (88\u0026ndash;115)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e102.6 (88\u0026ndash;112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e104.4 (95\u0026ndash;115)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum calcium (mEq/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.69 (7.7\u0026ndash;9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.71 (7.7\u0026ndash;9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.6 (7.9\u0026ndash;9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood urea nitrogen (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23.6 (9\u0026ndash;93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23.1 (9\u0026ndash;93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.3 (15\u0026ndash;53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.8 (0.3\u0026ndash;2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.8 (0.4\u0026ndash;2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.1 (0.3\u0026ndash;2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal protein (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.5 (4.8\u0026ndash;8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.6 (4.8\u0026ndash;8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.2 (4.9\u0026ndash;7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.3 (1.9\u0026ndash;3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.4 (2.1\u0026ndash;4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.8 (1.9\u0026ndash;3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAspartate aminotransferase (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.8 (14\u0026ndash;263)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32.0 (14\u0026ndash;263)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.2 (14\u0026ndash;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlanine transaminase (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.2 (6\u0026ndash;236)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21.9 (6\u0026ndash;236)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.2 (7\u0026ndash;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLactate dehydrogenase (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e256.3 (99\u0026ndash;479)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e256.8 (172\u0026ndash;479)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e253.9 (99\u0026ndash;384)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCreatinine kinase (U/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e176.6 (99\u0026ndash;479)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e188.6 (28\u0026ndash;1811)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e124.1 (37\u0026ndash;227)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are presented as median (range) for continuous variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eWilcoxon\u0026rsquo;s rank-sum test was used for continuous variables and the chi-square test was used for categorical variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Significant differences between the survival and non-survival groups.\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=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of multivariate analysis: logistic regression analysis of factors associated with 6-month mortality.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStandard error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR (95%CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.2 (0.8\u0026ndash;104.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-surgical treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.2 (0.8\u0026ndash;104.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmbulatory function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTrend p\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndependent ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssisted ambulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.948\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30 (0.04\u0026ndash;1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWheelchair mobility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.689\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.7 (1.04\u0026ndash;787.70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.989\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.14 (0.02\u0026ndash;0.99)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAspartate aminotransferase\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.89 (0.76\u0026ndash;1.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eOR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated 6-month mortality following FNFs in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;90 years (super-old elderly), a population for whom mortality outcomes have not been well studied. Our study found that the 6-month mortality rate was 21% (16/76) overall, with rates of 40.5% (15/37) and 2.5% (1/39) in the non-surgical and surgical groups, respectively. Preinjury ambulatory function, serum albumin levels, and surgical intervention were associated with mortality outcomes. These findings suggest that, even among super-old patients, appropriate surgical management and good nutritional status may have a critical impact on survival.\u003c/p\u003e\u003cp\u003ePrevious studies have reported 1-year mortality rates of 48.6\u0026ndash;84.4% after non-surgical treatment for proximal femoral fractures in patients\u0026thinsp;\u0026ge;\u0026thinsp;60 years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In super-old populations, 6-month mortality in non-surgical cases has been reported to be approximately 40% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], consistent with our findings. Notably, the 2.5% 6-month mortality rate in our surgical group is substantially lower than the 34% reported in previous studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These results suggest that advanced age alone should not be viewed as a contraindication to surgery. Although surgical treatment did not emerge as an independent predictor of mortality in multivariate analysis, it was not associated with increased risk either. Instead, factors such as nutritional status and preinjury ambulatory function had stronger associations with mortality outcomes, indicating the importance of overall patient condition in treatment decisions. Some reports have indicated that elective surgery is associated with fewer complications than emergency surgeries [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, optimizing patient condition prior to surgery may be beneficial in this age group. Further studies are warranted to investigate the relationship between preoperative nutritional intervention and mortality in this age group.\u003c/p\u003e\u003cp\u003eAST and ALT are commonly used indicators of liver function [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. ALT is considered a liver-specific indicator, while AST is also present in cardiac and skeletal muscles. In our study, AST levels were significantly higher in the non-survivor group than in the survivor group, likely reflecting muscle injury resulting from the fracture rather than liver dysfunction [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Severe muscle injuries may be associated with increased mortality in this population. Although this difference was considered to be related to fracture type, there was no significant difference in the Garden classification. AST was not a significant predictor in the multivariate analysis; however, the potential prognostic value of AST in hip fracture patients warrants further investigation in larger cohorts.\u003c/p\u003e\u003cp\u003eLow serum albumin has been associated with increased postoperative mortality in elderly patients undergoing surgery for hip fractures [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, to the best of our knowledge, no previous study has included both surgical and non-surgical cases in a single analysis. In the present study, hypoalbuminemia was found to be associated with 6-month mortality across both treatment groups, suggesting that low albumin may contribute to an increased mortality risk when surgery is performed in this population. Perioperative nutritional intervention or stabilization of general condition should be considered before proceeding with surgical treatment in such patients.\u003c/p\u003e\u003cp\u003eThis study also found significant differences in ambulatory function between the survival and non-survival groups. Ambulatory function is a component of activities of daily living (ADL), and previous reports have demonstrated associations between poor ADL and low serum albumin levels in elderly Japanese populations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Thus, the observed association in our study may also reflect the influence of albumin levels. Previous research has linked preoperative ADL decline with a higher risk of postoperative complications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], consistent with our findings. At final follow-up, all patients in the non-operative group were wheelchair-bound, emphasizing the importance of surgical intervention for all patients from the perspective of ADL. Therefore, this study highlights that in this age group, not only surgical intervention but also optimization of perioperative nutritional status remains crucial for improving outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study had some limitations. First, there was selection bias between the surgical and non-surgical treatment groups. The nutritional status of the non-surgical group was significantly worse than that of the surgical group, which may have influenced the results. However, because there was no significant difference in the ASA-PS score, which reflects surgical risk, the influence of selection bias is likely limited. Since the nutritional status was poor before surgery and albumin levels were significantly elevated in the multivariate analysis, it is possible albumin had a greater effect on mortality than surgical intervention itself. Further studies are needed to confirm this hypothesis. Second, this was a single-center study conducted at a university hospital. In Japan, university hospitals typically receive patients with poorer overall condition than other medical institutions, potentially leading to a higher proportion of non-surgical cases. Our study may have included a greater number of patients with poorer baseline health, potentially affecting the results. As a result, our findings may reflect a more critically ill demographic. However, since the purpose of this study was to investigate the factors related to mortality in super-old elderly patients with poor health, we believe limitation has little influence on the validity of our findings. Further studies addressing these limitations should be performed to validate our findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn super-old elderly patients with FNFs, the 6-month mortality rate was 20%. Although the mortality rate in the non-surgical group was 40.5%, mortality was more strongly associated with ambulatory function and albumin levels rather than with surgical intervention. In this patient population, surgical intervention should be considered to preserve ambulatory function and potentially improve survival outcomes. However, careful preoperative assessment and optimization of nutritional status are essential in managing this patient population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFNFs\u0026nbsp; \u0026nbsp;Femoral Neck Fractures\u003c/p\u003e\n\u003cp\u003eASA-PS American Society of Anesthesiologists Physical Status\u003c/p\u003e\n\u003cp\u003eADL\u0026nbsp; \u0026nbsp;\u0026nbsp;Activities of Daily Living\u003c/p\u003e\n\u003cp\u003eAST\u0026nbsp; \u0026nbsp; \u0026nbsp;Aspartate Aminotransferase\u003c/p\u003e\n\u003cp\u003eALT\u0026nbsp; \u0026nbsp;\u0026nbsp;Alanine Transaminase\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence Interval\u003c/p\u003e\n\u003cp\u003eCRP\u0026nbsp; \u0026nbsp; \u0026nbsp;C-Reactive Protein\u003c/p\u003e\n\u003cp\u003eLDH\u0026nbsp; \u0026nbsp;\u0026nbsp;Lactate Dehydrogenase\u003c/p\u003e\n\u003cp\u003eCK\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Creatinine Kinase\u003c/p\u003e\n\u003cp\u003eBMI \u0026nbsp; \u0026nbsp; Body Mass Index\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy design: TT. Data acquisition: TT, MK. Data analysis and interpretation: TT and AT. Writing of the manuscript: TT, Editing the manuscript: All.All authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health LaW (2022) Vital Statistics. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei22/dl/15_all.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei22/dl/15_all.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health LaW (2022) Life Tables. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/life/life22/dl/life22-03.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/life/life22/dl/life22-03.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOuchi Y, Rakugi H, Arai H, Akishita M, Ito H, Toba K, Kai I (2017) Redefining the elderly as aged 75 years and older: Proposal from the Joint Committee of Japan Gerontological Society and the Japan Geriatrics Society. Geriatr Gerontol Int 17(7):1045\u0026ndash;1047. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ggi.13118\u003c/span\u003e\u003cspan address=\"10.1111/ggi.13118\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBullain SS, Corrada MM, Shah BA, Mozaffar FH, Panzenboeck M, Kawas CH (2013) Poor physical performance and dementia in the oldest old: the 90\u0026thinsp;+\u0026thinsp;study. JAMA Neurol 70(1):107\u0026ndash;113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamaneurol.2013.583\u003c/span\u003e\u003cspan address=\"10.1001/jamaneurol.2013.583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShoji A, Gao Z, Arai K, Yoshimura N (2022) 30-year trends of hip and vertebral fracture incidence in Japan: a systematic review and meta-analysis. J Bone Min Metab 40(2):327\u0026ndash;336. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00774-021-01288-1\u003c/span\u003e\u003cspan address=\"10.1007/s00774-021-01288-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalter N, Szymski D, Kurtz S, Alt V, Lowenberg DW, Lau E, Rupp M (2023) Factors associated with mortality after proximal femoral fracture. J Orthop Traumatol 24(1):31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10195-023-00715-5\u003c/span\u003e\u003cspan address=\"10.1186/s10195-023-00715-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health LaW (2022) Comprehensive Survey of Living Conditions. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa22/index.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa22/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChlebeck JD, Birch CE, Blankstein M, Kristiansen T, Bartlett CS, Schottel PC (2019) Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study. J Orthop Trauma 33(7):346\u0026ndash;350. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/bot.0000000000001460\u003c/span\u003e\u003cspan address=\"10.1097/bot.0000000000001460\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOgawa T, Schermann H, Kobayashi H, Fushimi K, Okawa A, Jinno T (2021) Age and clinical outcomes after hip fracture surgery: do octogenarian, nonagenarian and centenarian classifications matter? Age Ageing 50(6):1952\u0026ndash;1960. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ageing/afab137\u003c/span\u003e\u003cspan address=\"10.1093/ageing/afab137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarden RS (1964) STABILITY AND UNION IN SUBCAPITAL FRACTURES OF THE FEMUR. J Bone Joint Surg Br 46:630\u0026ndash;647\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOwens WD, Felts JA, Spitznagel EL Jr. (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49(4):239\u0026ndash;243. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00000542-197810000-00003\u003c/span\u003e\u003cspan address=\"10.1097/00000542-197810000-00003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarden RS, IN FRACTURES OF THE FEMORAL NECK (1961) LOW-ANGLE FIXATION. J Bone Joint Surg Br Volume 43\u0026ndash;B(4):647\u0026ndash;663. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1302/0301-620x.43b4.647\u003c/span\u003e\u003cspan address=\"10.1302/0301-620x.43b4.647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIosifidis M, Iliopoulos E, Panagiotou A, Apostolidis K, Traios S, Giantsis G (2016) Walking ability before and after a hip fracture in elderly predict greater long-term survivorship. J Orthop Sci 21(1):48\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jos.2015.09.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jos.2015.09.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Virgilio-Salgado LG, Olivella G, Rubert\u0026eacute; H, Abreu RJ, Otero-L\u0026oacute;pez A, Reyes-Mart\u0026iacute;nez P, Ram\u0026iacute;rez N, Otero-L\u0026oacute;pez F (2021) Effect of Nonsurgical Versus Surgical Management on Geriatric Hip Fracture Mortality of Hispanic-American Male Veterans. Geriatr Orthop Surg Rehabil 12:21514593211044621. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/21514593211044621\u003c/span\u003e\u003cspan address=\"10.1177/21514593211044621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOvidiu A, Stefan GT, Dragos P, Bogdan V, Dana AI (2017) SURVIVAL OF NONAGENARIAN PATIENTS WITH HIP FRACTURES: A COHORT STUDY. Acta Ortop Bras 25(4):132\u0026ndash;136. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1413-785220172504167561\u003c/span\u003e\u003cspan address=\"10.1590/1413-785220172504167561\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNg JPH, Tan TL, Pillai A, Ho SWL (2023) Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients. Arch Orthop Trauma Surg 143(6):3145\u0026ndash;3154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00402-022-04550-x\u003c/span\u003e\u003cspan address=\"10.1007/s00402-022-04550-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiam B, Cooper L, Orgad R, Esepkina O, Kashtan H (2022) Outcomes of surgery in patients 90 years of age and older: A retrospective cohort study. Surgery 171(5):1365\u0026ndash;1372. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.surg.2021.09.030\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2021.09.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSudlow A, Tuffaha H, Stearns AT, Shaikh IA (2018) Outcomes of surgery in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;90 years in the general surgical setting. Ann R Coll Surg Engl 100(3):172\u0026ndash;177. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1308/rcsann.2017.0203\u003c/span\u003e\u003cspan address=\"10.1308/rcsann.2017.0203\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim WR, Flamm SL, Di Bisceglie AM, Bodenheimer HC (2008) Serum activity of alanine aminotransferase (ALT) as an indicator of health and disease. Hepatology 47(4):1363\u0026ndash;1370. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/hep.22109\u003c/span\u003e\u003cspan address=\"10.1002/hep.22109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHan JH, Kwak JY, Lee SS, Kim HG, Jeon H, Cha RR (2022) Markedly Elevated Aspartate Aminotransferase from Non-Hepatic Causes. J Clin Med 12(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm12010310\u003c/span\u003e\u003cspan address=\"10.3390/jcm12010310\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBohl DD, Shen MR, Hannon CP, Fillingham YA, Darrith B, Della Valle CJ (2017) Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. J Bone Joint Surg Am 99(24):2110\u0026ndash;2118. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/jbjs.16.01620\u003c/span\u003e\u003cspan address=\"10.2106/jbjs.16.01620\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorge SJ, Lauritzen JB, J\u0026oslash;rgensen HL (2022) Hypoalbuminemia is associated with 30-day mortality in hip fracture patients independently of Body Mass Index. Scand J Clin Lab Invest 82(7\u0026ndash;8):571\u0026ndash;575. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00365513.2022.2150982\u003c/span\u003e\u003cspan address=\"10.1080/00365513.2022.2150982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Y, Wu X, Chen J, Xu W, Liang X, Huang W, Liao J (2020) Nutritional condition analysis of the older adult patients with femoral neck fracture. Clin Nutr 39(4):1174\u0026ndash;1178. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2019.04.034\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2019.04.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKitamura K, Nakamura K, Nishiwaki T, Ueno K, Nakazawa A, Hasegawa M (2012) Determination of whether the association between serum albumin and activities of daily living in frail elderly people is causal. Environ Health Prev Med 17(2):164\u0026ndash;168. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12199-011-0233-y\u003c/span\u003e\u003cspan address=\"10.1007/s12199-011-0233-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOkamura T, Hayakawa T, Hozawa A, Kadowaki T, Murakami Y, Kita Y, Abbott RD, Okayama A, Ueshima H (2008) Lower levels of serum albumin and total cholesterol associated with decline in activities of daily living and excess mortality in a 12-year cohort study of elderly Japanese. J Am Geriatr Soc 56(3):529\u0026ndash;535. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1532-5415.2007.01549.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1532-5415.2007.01549.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":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Femoral neck fracture, super-old elderly, Nonagenarian, mortality rate","lastPublishedDoi":"10.21203/rs.3.rs-7270580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7270580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003eThe number of individuals aged\u0026thinsp;\u0026gt;\u0026thinsp;90 years (super-old elderly) is steadily increasing, along with the incidence of femoral neck fractures. Surgical treatment in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;85 years is associated with a high risk of complications, and in super-old patients, surgical intervention is particularly challenging because of multiple comorbidities. However, data on mortality without surgery and its associated factors in this age group are lacking. This study aimed to (1) evaluate the 6-month mortality rate following femoral neck fractures in super-old elderly patients and (2) identify factors associated with 6-month mortality following injury.\u003c/p\u003e\u003ch2\u003eMaterial and methods\u003c/h2\u003e\u003cp\u003eThis retrospective study included patients aged\u0026thinsp;\u0026gt;\u0026thinsp;90 years admitted to our hospital with femoral neck fractures between April 2010 and March 2021, with at least 6 months of follow-up. We collected data on demographics, fracture type, preinjury ambulatory function, treatment type (surgical or non-surgical), and admission laboratory data. Patients were grouped by survival status at 6 months after injury, and mortality rates and associated predictive factors were analyzed.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eA total of 76 patients were included in the study (non-surgical group, n\u0026thinsp;=\u0026thinsp;37; surgical group, n\u0026thinsp;=\u0026thinsp;39). The cohort included 14 men and 62 women, with a mean age of 91.9 years (range, 90\u0026ndash;96 years). The overall 6-month mortality rate was 21.0% (16/76), with higher mortality in the non-surgical group (40.5%) than in the surgical group (2.5%). Significant predictors of 6-month mortality were pre-injury ambulatory function and serum albumin levels at admission.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIn super-old elderly patients with femoral neck fractures, the 6-month mortality rate is approximately 20%, increasing to 40% in the absence of surgical treatment. Poor preinjury ambulatory function and low albumin levels were significant predictors of mortality. These findings highlight the importance of surgical treatment and pre-operative assessments in this population.\u003c/p\u003e","manuscriptTitle":"Determinants of 6-Month Mortality in Super-Old Elderly Patients with Femoral Neck Fractures: The Role of Surgery and Preoperative Status in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-14 15:01:09","doi":"10.21203/rs.3.rs-7270580/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-13T10:26:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T02:44:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T16:31:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317772582028811804796588529244118419405","date":"2025-08-12T05:29:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152170108661011922804604505914281574274","date":"2025-08-12T03:35:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-10T02:43:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-06T07:02:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-06T07:02:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-08-01T11:00:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0143cb75-83ab-48aa-8120-1330e7789c1f","owner":[],"postedDate":"August 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:33:52+00:00","versionOfRecord":{"articleIdentity":"rs-7270580","link":"https://doi.org/10.1007/s00402-025-06095-1","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2025-10-24 16:16:56","publishedOnDateReadable":"October 24th, 2025"},"versionCreatedAt":"2025-08-14 15:01:09","video":"","vorDoi":"10.1007/s00402-025-06095-1","vorDoiUrl":"https://doi.org/10.1007/s00402-025-06095-1","workflowStages":[]},"version":"v1","identity":"rs-7270580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7270580","identity":"rs-7270580","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}