Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery.
Materials and methods
A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year.
Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson’s co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar.
Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.
Older patients who experienced previous trauma are often more venerable to the stressors of the older age . The Holocaust was an organized persecution and murder by the Nazi regime and its collaborators, of approximately six million Jews, among others . Jews were taken into concentration camps where some were murdered upon arrival and others were send to work for 12 h per day under the harsh condition with restricting caloric limitation, and physical punishments . As such, the Holocaust is considered an immense continues stressor. Indeed, the Holocaust survivor (HS) population was found to suffer from higher levels of anxiety, depression and feeling of guilt years after the war, along with impaired social function . They experience neurological deficits, higher chronic pain levels, gastrointestinal symptoms, sleep disturbances, night terrors and low self-esteem . When faced upon medical adverse events and hospitalization, HS apprehend the admission more as a threat and less as a challenge than among age and education matching controls . The hospitalization can inflict intense reactions among survivals and family members . Consequently, they utilize more emotional oriented coping strategies instead of problem-oriented strategies and seek less help in coping . Subsequently, HS report experiencing more distress during hospitalization . In addition, HS were reported to experience more psychological distress when dealing with cancer  and heart surgery .
Fragility hip fractures in elderly populations is a common pathology, with an annual incidence of 280,000 in the USA and a trend for an increase in age-adjusted hip fracture rates . These fractures are related to high post-operative mortality rates and impaired quality of life [10,11,12]. Previous report described a higher incidence of osteoporosis in the HS population, putting them in increased risk for fragility hip fractures . As far as we know, only one study has focused on the immediate rehabilitation of HS following fragility hip fractures, and have found this unique patient population to have worse functional outcomes questionnaires scores .
As the HS population is at increased risk both of sustaining a fragility hip fracture and for worse medical outcomes, this study will focus upon surgical results and in-hospital and 1-year mortality of HS compared with age matching controls. We hypothesized that HS will have a worse immediate outcome following surgery for a fragility hip fracture in terms of length of stay (LOS), complications, readmissions along with a higher 1-year mortality.
Patients and methods
Following approval by the institutional review board, data was retrieved from the medical records of consecutive patients who underwent surgery for the treatment of proximal femoral fractures between January 2011 and June of 2016, in Rabin Medical Center.
Demographic information, co-morbidities, living arrangements and mobility status were collected along with hospitalization aspects such as length of stay (LOS), time to surgery, blood loss, and in-hospital complications. Data regarding re-admissions in the first post-operative year was collected as an indicator for further fragility.
Patients of 80 years and older who underwent surgical treatment of proximal femoral fractures, either closed or open reduction and internal fixation or hemiarthroplasty during the study period were included. Exclusion criteria were an additional coexisting skeletal trauma requiring further surgery and fracture sustained while patients were hospitalized for another cause.
HS were identified according to electronic medical records. As part of each patient medical admission, the nursing stuff is obliged to fill in whether the patient is a HS or not. HS status is self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps, and mass transport [4, 15].
The primary outcome was mortality within the hospital and in the first postoperative year. Secondary outcome measurements included: in-hospital complications, length of stay, blood transfusions, hospital readmissions and readmission etiology.
Continuous variables are presented as mean and standard deviation (SD). Quantitative variables are presented as absolute and relative frequencies. Fisher’s exact tests were used for comparison of proportions. The Student’s t test was applied for normal variables. All reported p values are two-tailed. Statistical significance was defined as p < 0.05.
603 patients 80 years old and older were operated for fragility hip fracture during the study period. For 33 patients, data regarding definition as a HS was missing and they were omitted from the study, leaving 570 patients for analysis, 231 HS and 339 controls. 204 (88.3) of the survivors were from European countries and the remaining 27 (11.7) HS from eastern Africa. The average age the HS were at during the beginning of world war 2 was 12.1 ± 4.8 years.
Patients from both groups were of similar age (for the entire cohort 86.4 ± 4.4 years), Carlson's co-morbidity index score [16, 17], leaving arrangement and pre-fracture mobility. Among HS there were more women (75.8% vs. 67.2% in the control group, p = 0.029). However, a sub-analysis did not find an association within each group or in the entire study population between gender and 1-year survival (p = 0.335 for the entire cohort and 0.396 and 0.687 for the HS and non-HS cohort, respectively) (Table 1).
Holocaust survivals did not have lower survival rates either within the hospital or in the post-operative year (odds ratio = 0.964, CI 0.652–1.425, p = 0.853). They were not further delayed to surgery, and 81% of them were operated within the desirable 48 h (compared with 83.5% of controls, p = 0.436) (Table 2). In both groups, the main reason for the surgical delay was cardiovascular morbidity (13.6% and 16.1% for HS and controls respectively), followed by concurrent anticoagulation treatment (13.6% and 14.3% for HS and controls respectively). Both LOS and in-hospital complication rates were similar between groups (Table 2). In both study groups, the vast majority of patients were discharged for further institutionalized rehabilitation (88.6% and 90.1% for HS and controls respectively, p = 226).
In the post-operative year, HS were less likely to be hospitalized than controls with a rate of 0.7 ± 1 hospitalization per HS vs. 0.9 ± 1.5 recurrent hospitalizations per control, p = 0.021. However, the chance to be hospitalized did not differ between groups, as 45.5% of HS were re-admitted compared with 47.7% of controls (p = 0.662), this was also true for the first post-operative month (as 10.9% of HS were re-admitted compared with 13.6% of controls (p = 0.428). The rate of orthopedic complications was also similar for both groups (Table 3).
The current study found that holocaust survivals who lived beyond the octogenarian years did not demonstrate worse outcomes following fragility fracture surgery compared with age and comorbidity matching controls. These finding are somewhat surprising as previous studies from the field of epidemiology , psychology [1, 4], social work , cardiology , oncology , and orthopedic trauma  implied that this unique patient population is in increased risk for injury-related stress and worse patient outcomes.
The extreme condition to which HS were exposed to in early life were found to put them at risk for metabolic syndrome, dyslipidemia, diabetes, hypertension, cardiovascular morbidity, vascular disease, malignancy and peptic diseases in adulthood [18,19,20]. This is also true for the younger population of patients who were born between 1940 and 1945, under Nazi rule . They were also found to be at increased risk for osteopenia and osteoporosis, which was even greater for individuals who were younger than 17 at the end of the war, as the majority of our survivals cohort . As these patients are more exposed to fragility fractures  and to risk factors for complications, we sought to explore whether they would experience worse patient outcomes. Notably, despite previous reports, we did not find HS to present with increased co-morbidities [18,19,20, 23, 24], or reduced mobility . As our patients were a slightly older than previous reports, 86.1 years old on average (compared with an average of 67–82 years old in other cohorts [18,19,20, 25, 26]), this may imply that the fitter patients survived to the elder age.
HS were not found to have increased mortality rates, either within the hospital or in the proceeding year. In a study by Stesssman et al. , who followed the aging process of HS for a period of 7 years, HS did not have increased mortality rates compared with controls. Similar results were demonstrated by Collins et al.  who monitored HS for a period of 10 years.
Neither LOS nor in-hospital complications differed between groups. Kimron and Cohen  suggested hospitalization could inflict greater levels of distress on HS, and can lead to anxiety, depression and nightmares. Still in our cohort, no excess complications were reported among HS, including a similar prevalence of delirium between groups. As both groups presented with similar co-morbidities, most patients were fit to enter the operating room within 48 h. Since complication rates and discharge destination was also similar, so was the LOS.
The rate of readmission in the year following surgery was used as an estimation of further fragility. We found that a similar percentage of HS and controls were hospitalized in the succeeding year, with controls having a higher average of hospitalizations per patient. This concurs with Kagansky et al.  who pointed the unique durability and ability to cope with chronic illness of the survivors and with Collins et al.  and Stessman et al.  who stated that this group is highly resilient.
This study presents several limitations. First due to the retrospective nature and secondly due to the method of patient identification. Patients were self-identified and the nature of their survival and what they endured during the war was not investigated (including time spent in concentration camps). Also, the duration and characteristics of the holocaust differed between Europe and northern Africa, which might lead to an heterogenous group of patients. However, as most patients were from eastern Europe, we believe the heterogeneity is minimal.
Our findings suggest that Holocaust survivor patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.
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Frenkel Rutenberg, T., Vitenberg, M., Daglan, E. et al. Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture. Arch Orthop Trauma Surg 141, 39–44 (2021). https://doi.org/10.1007/s00402-020-03459-7
- Holocaust survivors
- Fragility hip fracture
- osteoporotic fracture