Keywords
mortality - proximal femur - Parker's mobility score - replacement surgeries - elderly
In-hospital mortality in proximal femur fracture increases on preoperative mobility
status delay in surgery and in prosthetic replacements.
A Proximal femur fractures is a broad term involving the neck of femur, pertrochantric,
and subtrochanteric region fractures.[1] The 90 to 95% of proximal femur fractures are femoral neck fractures and pertrochanteric
fractures and remaining 5 to 10% are subtrochanteric fractures.[2]
[3] Out of all fractures 14% fractures are proximal femur fractures and it accounts
for nearly 72% of total value for the treatment of fractures. Lifetime risk of hip
fracture was 23.3% for men and 11.2% for women.[4] The increase in incidence of hip fractures with increasing the age is a result of
an age-related decrease of bone mass in the proximal femur, as well as of the age-related
increase in the incidence of falls. In patients over 65 years of age, fractures of
the hip were associated with approximately double the mortality of the general population.
For hip fractures Standardized Mortality Rate is 2.0 for women and 3.0 for men.[5] In India, Hip fracture crude incidence above the age of 50 years was 129 per 100,000.[6] There are various studies pertaining to the early mortality of proximal femur fractures
all over the world and none from subcontinent. The aim of this study was to analyze
the in-hospital mortality following proximal femur fracture in elderly Indian population.
Subjects and Methods
The study was done in Sri Ramachandra Medical Centre, a tertiary care referral center
in Chennai, South India. Patients' records were retrospectively evaluated for a period
of 3 years from January 1, 2015 to January 1, 2018. The hospital database has all
the necessary documents like diagnosis, comorbidities, surgical intervention, deep
vein thrombosis prophylaxis, time in hospital from admission to discharge, or death.
This database was linked to individual records of mortality. The inclusion criteria
were patients both male and female aged above 65 years admitted with the diagnosis
of neck of femur or intertrochanteric or subtrochanteric fractures. Ageing, an inevitable
process is commonly measured by chronological age and, as a convention, a person aged
65 years or more is often referred to as “elderly.”[7]
[8]. The modality of fracture fixation was either bipolar hemiarthroplasty or total
hip arthroplasty or dynamic hip screw fixation or proximal femur plate or dynamic
condylar screw or proximal femur nail. The patients who died during preoperative hospital
stay were also included. The exclusion criteria were patients having any associated
fracture or previous hip fracture history or diagnosed primary or secondary malignancies.
Approval obtained from Sri Ramachandra Medical College institutional ethics committee.
Each patient's number of comorbidities was taken from the patient's records of the
previous 2 years. Only the comorbidities like diabetes mellitus, obesity, dementia,
Parkinson's disease, hypertension, cerebrovascular diseases, vascular diseases, chronic
nephropathy, chronic diseases, rheumatoid arthritis, and osteoporosis were considered.
For all the patients included the Charlson's comorbidity index calculated and those
having more than 5 were excluded.[9] To investigate whether there was a difference in mortality between the most common
interventions, four groups were included in the analysis. They were conservative group
(preoperative death), intramedullary group, extramedullary group, and replacement
group. In intramedullary group, patients who underwent proximal femur nail, cervicotrochantric
nails were included. In extramedullary group, proximal femur plating, dynamic condylar
screw, and dynamic hip screw were included. In replacement group, the hemiarthroplasty,
bipolar and total hip arthroplasty patients were included. All the patients, who underwent
surgery, were mobilized from 2nd postoperative day either partial or full weight bearing.
The preinjury mobility statuses of all patients were calculated using Parker's mobility
score. Patients were divided as low, medium, and high. The Parker's mobility score
is an assessment tool that ranks pre fracture mobility on a scale of 0 to 9. A person
with a score of 9 is independent in mobility at home and in the community, whereas
someone with a score of 0 is completely dependent for ambulation.[10] To evaluate any surgical delay two groups were formed. First group contains patients
who were operated within 48 hours of injury, while the second group had patients operated
after 48 hours of injury. After double verification of data by two separate data analyzers',
we had 283 patients who fulfilled the inclusion criteria. After eliminating cases
based on exclusion criteria we had 270 patients for evaluation. Out of which 151 were
females and 119 were males. We used one-way analysis of variance (ANOVA) F-test for statistical analysis of in hospital mortality with preinjury status of the
patients and Student's independent t-test for statistical correlation of mortality with various methods of treatment given,
sex of the patients, age of the patients, and surgical timing.
Results
We had a total of 24 mortalities with 15 males and 9 females. The in-hospital mortality
following proximal femur fracture in elderly population was 10.03%. Twenty patients
had mortality when surgery was done for more than 48 hours ([Table 1]). [Table 2] highlights that 14 patients had in-hospital mortality when they underwent replacement
surgeries for proximal femur fracture. We had 14 patients aged above 70 years died
in hospital during the study period. Sixteen of the in-hospital mortality patients
had low Parker's mobility score ([Table 3]).
Table 1
Mortality based on surgical delay
|
Replacement group
|
Intramedullary group
|
Extramedullary group
|
Conservative group
|
|
Surgery within 48 h
|
Surgery after 48 h
|
Surgery within 48 h
|
Surgery after 48 h
|
Surgery within 48 h
|
Surgery after 48 h
|
Death within 48 h
|
Death after 48 h
|
|
No. of mortalities (24)
|
2
|
12
|
1
|
3
|
1
|
1
|
–
|
4
|
|
Total no of patients
|
135
|
75
|
56
|
4
|
Table 2
Correlation of mortality and treatment methods
|
Method of treatment
|
Number of mortality
|
Mean
|
Standard deviation
|
Student's independent t-test
|
|
Replacement
|
14
|
23.42
|
25.60
|
t = 2.12; p = 0.05 significant
|
|
Fixation/conservative
|
10
|
5.90
|
4.97
|
Table 3
Mortality based on preinjury status of patients
|
Parker's score
|
Number of mortality
|
Mean
|
Standard deviation
|
One-way ANOVA F-test
|
|
Low (0–4)
|
16
|
21.62
|
24.54
|
F = 3.91; p = 0.02 significant
|
|
Medium (5–8)
|
6
|
5.16
|
3.06
|
|
High (9)
|
2
|
5.00
|
1.41
|
|
Total
|
24
|
16.1250
|
21.40563
|
|
Abbreviation: ANOVA, analysis of variance.
Discussion
Hip fractures in elderly increases the morbidity and mortality considerably.[11]
[12] In-hospital mortality rates ranges between 1 and 10%.[12]
[13]
[14]
[15]
[16] Mortality in proximal femur fractures was considered high in male sex and in elderly
population. We had 14 patients aged more than 70 years who had in-hospital mortality,
which is not statistically significant ([Table 4]), which disproves the common belief that as age increases mortality increases. [Table 5] proves that there is no correlation between genders when considering in-hospital
mortality in proximal femur fractures. Surgical treatment has been established as
the gold standard; however, the surgical option remains a dilemma as none of the existing
osteosynthesis devices could prove its superiority in previous studies.[17]
[18] Parker and Gurusamy in a systematic review of this subject that included 19 trials,
internal fixation was found to result in lower morbidity in several categories, including
blood loss and risk of deep wound infection.[19] However, patients treated with arthroplasty had significantly lower reoperation
rates. No differences were identified in mortality or regaining previous residential
status. As per Sathiyakumar et al, retrospective analysis of 9,640 patients undergoing
operative repair of a hip fracture open reduction and internal fixation of femoral
neck fractures was associated with the highest percentage of total adverse events
and major adverse events (primarily death). Whereas hemiarthroplasty was associated
with a higher percentage of minor adverse events (e.g., urinary tract infection).[20] The current study on hospital mortality when a patient underwent replacement was
14, which is statistically significant when compared to the other methods of treatment
as evident from [Table 2].
Table 4
Correlation of mortality and age of patients
|
Age
|
Number of mortality
|
Mean
|
Standard deviation
|
Student's independent t-test
|
|
> 70 y
|
14
|
20.00
|
26.68
|
t = 1.05; p = 0.30 not significant
|
|
65–70 y
|
10
|
10.70
|
9.29
|
Table 5
Correlation of mortality and sex of patients
|
Sex
|
Number of mortality
|
Mean
|
Standard deviation
|
Student's independent t-test
|
|
Male
|
15
|
14.93
|
17.28
|
t = 0.34; p = 0.73 not significant
|
|
Female
|
9
|
18.11
|
28.05
|
The patients with lower Parker's mobility score had a statistically significant mortality
rate compared to the patients who had higher score ([Table 3]). The recommended guidelines for the management of proximal femur fracture were
within 2 days.[10] There was literature support for and against the early management of proximal femur
fractures. Some studies have reported no differences in outcomes between early and
late management,[21] while others reported that mortality increases only if surgery is delayed beyond
the 4th day.[22]
[23]
[24]
[25] The present study from [Table 6] clearly states that the in-hospital mortality rate increases significantly when
surgery was delayed more than 48 hours.
Table 6
Correlation of mortality with timing of surgery
|
Surgery time
|
Number of mortality
|
Mean
|
Standard deviation
|
Student's independent t-test
|
|
> 48 h
|
20
|
12.75
|
15.30
|
t = 1.81; p = 0.08 significant
|
|
< 48 h
|
4
|
33.00
|
39.68
|
Limitations
The limitations of the study were retrospective and the study was done in a single
center and involving many surgeons with varied experience which may alter the prognosis.
The term “elderly population” was very tricky as it may vary based on different ethnicity.
Moreover in the study, we didn't analyze the mortalities in different types of replacement
surgeries like hemiarthroplasty, bipolar arthroplasty and total hip replacement that
may affect the outcome. The hospital database from which the patients' details were
obtained was not created exclusively for epidemiological analyses.
Conclusion
Age and sex of the patients do not affect the in-hospital mortality in elderly. In-hospital
mortality in elderly patients having proximal femur fracture increases significantly
if the patient was having low-preoperative mobility status, if surgery was delayed
more than 48 hours and if patient undergoes replacement surgeries.
