High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for intertrochanteric fractures in elderly patients

Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors

BACKGROUND

Global prevalence of osteoporosis and fragility fractures is increasing due to the aging population. Proximal femoral fractures are among the most common orthopedic conditions in elderly that significantly cause health deterioration and mortality. Here, we aimed to evaluate the mortality rates and risk factors, besides the functional outcomes after these injuries.

METHODS

In a retrospective cohort study, all patients admitted with a femoral neck or intertrochanteric fracture between 2016 and the end of 2018 were enrolled in this study. Medical records were reviewed to include patients over 60 years of age who had a proximal femoral fracture and had a complete medical record and radiographs. Exclusion criteria included patients with pathological fractures, cancer under active treatment, follow-up loss, and patient access loss. Demographic and clinical features of patients alongside the details of fracture and patient management were recorded and analyzed. In-hospital and post-discharge mortalities due to included types of fractures at one and 12 months were the primary outcome. Modified Harris Hip Scores (mHHS) was the measure of functional outcome.

RESULTS

A total of 788 patients including 412 females (52.3%) and 376 males (47.7%) with a mean age of 76.05 ± 10.01 years were included in this study. Among patients, 573 (72.7%) had an intertrochanteric fracture, while 215 (27.3%) had a femoral neck fracture, and 97.1% of all received surgical treatment. With a mean follow-up of 33.31 months, overall mortality rate was 33.1%, and 5.7% one-month and 20.2% 12-months rates. Analysis of 1-month mortality showed a significant mortality difference in patients operated after 48 h of fracture (p = 0.01) and in patients with American Society of Anesthesiologists (ASA) scores of 3-4 compared to ASA scores of 1-2 (p = 0.001). One-year mortality data showed that the mortality rate in femoral neck fractures was lower compared to other types of fracture. Surgical delay of > 48 h, ASA scores of 3-4, and treatment by proximal femoral plate were associated with shorter survival. The overall mean mHHS score was 53.80 ± 20.78.

CONCLUSION

We found several risk factors of mortality, including age ≥ 80 years, a > 48-hour delay to surgery, and pre-operative ASA scores of 3-4 in patients with proximal femoral fracture. Furthermore, the use of a proximal femoral plate was a significant risk factor for mortality and lower mHHS scores.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus bipolar hemiarthroplasty for the treatment of elderly unstable comminuted intertrochanteric fractures

BACKGROUND

Although proximal femoral nail anti-rotation (PFNA) and bipolar hemiarthroplasty (BHA) are selected by most of the orthopaedic surgeons for elderly intertrochanteric fractures (ITFs) patients, there is still no consensus on the superiority of PFNA and BPH for the elderly with unstable comminuted ITFs. The study aims to compare the curative effects of PFNA and cementless BHA on unstable comminuted ITFs in the elderly.

METHODS

From January 2012 to December 2016, we retrospectively reviewed 62 ITFs patients up to the inclusion and exclusion criteria in the study. Depending on the type of surgery, the patients were divided into two groups: Group BHA (n= 30) and Group PFNA (n = 32). The ITFs were classified according to Evans-Jensen. Hospitalization time, operation time, bleeding loss, weight bearing duration, Harris hip scores, 10-m walking speed, gait and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference between the groups in hospital stay (P > 0.05). The BHA group trended to have a shorter operation time and a larger volume of blood loss (P < 0.01).The weight bearing duration was shorter in the BHA group than the PFNA group (P < 0.05).The Harris hip score was higher, the 10-m walking speed was faster and the gait was better in group BHA than group PFNA at three months postoperatively (P < 0.05), but there was no significant difference between the two groups at 6 and 12 months postoperatively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).

CONCLUSION

The BHA allows an earlier return to weight-bearing activity, but ultimately has the same effective treatments as the PFNA for the elderly with unstable comminuted ITFs.

Relationship between Charlson comorbidity index, early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures: a retrospective analysis

The aim of this study was to evaluate how the Charlson Comorbidity Index (CCI) scores contribute to early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures. 60 cases with unilateral intertrochanteric fracture were retrospectively analyzed and divided into Low-CCI group (CCI: 1–4) or high-CCI groups (CCI: 5–6). All the patients’ electronic hospital records were reviewed. The preoperative situations (demographic data, comorbidities and fracture conditions), perioperative situations (wait time, operation time, implant choice, blood loss, transfusion or not) and postoperative situations (complications, first time out of bed, function about 1-/2- week and 2-year mortality) were recorded. 51.67% were in low-CCI group and 48.33% in high-CCI group. The survival rates in low- and high-CCI group were 93.5% and 86.2% respectively. According to the functional results of 1- or 2- week after operation, no significant difference was found (P = 0.955, 0.140). Log-rank analysis showed that the main prognostic factors were blood loss, first time out of bed and complication (P < 0.05). Multivariate analysis confirmed that complication and first time out of bed were significant factor on survival rate (P = 0.029, 0.010). Charlson comorbidity index maybe not the indicator of 2-year mortality in older patients with intertrochanteric fractures. In order to improve the prognosis, more attentions should be paid to reduce the complications and encourage postoperative earlier excise out of bed.

Bipolar Hemiarthroplasty should not be selected as the primary option for intertrochanteric fractures in elderly patients aged 85 years or more

This study aimed to compare the early outcome of proximal femoral nail antirotation (PFNA) and bipolar hemiarthroplasty (BPH) in elderly intertrochanteric fractures (ITFs) patients aged 85 years or more.This is a prospective cohort study, and we analyzed 120 elderly patients aged 85 years or more presented with ITFs who underwent BPH and PFNA between January 2017 and July 2018. 84 patients treated with PFNA were set as Group A, and 36 patients treated with BPH were set as Group B. Data such as gender, age, period of follow-up, fracture classification (according to Evans-Jensen classification), preoperative ASA (American Society of Anesthesiologists) physical status, interval between injury and operation, method of anaesthesia, duration of operation time, blood loss during surgery, time of weight bearing after operation, incidence of complications 2 weeks after operation, mortality rates and Harris Hip Score 12 months after operation were recorded and compared.There are no statistically significant differences when compared general data in patients from group A and B (P > .05). Operation time in Group A is less than Group B (103.33, 40-230 min vs 122.64, 75-180 minute, P < .01). Blood loss during surgery in Group A is less than Group B (70.24, 50-100 mL vs 194.44, 100-500 mL, P < .01). Time of weight bearing after operation in Group A is longer than Group B (50.70, 7-100 days vs 6.67, 4-14 days, P < .01). Incidence of complications 2 weeks after operation in Group A is less than Group B (14.12% vs 36.11%, P < .01). Mortality rates 12 months after operation in Group A is similar with Group B (13.10% vs 19.44%, P > .05). Harris Hip Score 12 months after operation in Group A is similar with Group B (64.64,0-91 points vs 64.41, 0-90 points, P > .05).Although BPH and PFNA have similar functional outcome and mortality rates 12 months after operation, BPH has more postoperative complications in elderly patients aged 85 years or more with ITFs, Bipolar Hemiarthroplasty should not be selected as the primary option for ITFs in elderly patients aged 85 years or more.

Bipolar Hemiarthroplasty should not be selected as the primary option for intertrochanteric fractures in elderly patients

Intertrochanteric fractures (ITFs) in the elderly are still a big challenge for clinical doctors. Although proximal femoral nail antirotation (PFNA) and bipolar hemiarthroplasty (BPH) are selected by most of the orthopaedic surgeons for elderly ITFs patients, there is still no consensus on the superiority of PFNA and BPH for ITFs in elderly. In this study, we hypothesized that BPH should not be selected as the primary option for ITFs in elderly patients, and analyzed clinical data of 202 elderly ITFs patients aged 80 years or more treated with PFNA (Group A) and BPH (Group B) to compare the early outcome of PFNA and BPH for ITFs in elderly patients aged 80 years or more. We found that operation time and blood loss during surgery in group A are less than in Group B. Time of weight bearing after operation in Group A is longer than in Group B. Incidence of complications 2 weeks after operation in Group A is 9.29% less than 25.81% in Group B (χ² = 9.539, p = 0.002). Mortality rates 12 months after operation in Group A is 11.43% similar with 19.35% in Group B (χ² = 2.261, p = 0.133). Harris Hip Score 12 months after operation in Group A is 68.00 ± 29.11 points similar with 65.73 ± 33.29 points in Group B (t = 0.490, p = 0.625). Therefore, for elderly ITFs patients aged 80 years or more, BPH should not be selected as the primary option for ITFs in elderly patients.