|Year : 2019 | Volume
| Issue : 5 | Page : 648-651
Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study
Department of Orthopaedics and Traumatology, Firat University Faculty of Medicine, Elazig, Turkey
|Date of Acceptance||15-Jan-2019|
|Date of Web Publication||15-May-2019|
Dr. M Gurger
Department of Orthopaedics and Traumatology, Firat University, Faculty of Medicine, Elazig
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: This study aimed to evaluate risk factors that impact 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. Patients and Methods: Overall, 109 patients aged ≥65 years with nonpathological hip fractures, treated between 2015 and 2016, were included in this study. Thirty-nine patients (35.8%) were treated with primary arthroplasty, and 70 patients (64.2%) were treated with proximal femoral nail. To determine whether the risk factors affected mortality, Kaplan–Meier and log-rank analyses were conducted, and a Cox regression analysis was conducted to include the factors determined to have an impact on mortality. Results: Twelve patients (11%) died during hospitalization, and 24 patients (22%) died within 1 year after discharge from the hospital. The mortality risk was high for patients who underwent surgery 72 h after fracture, who could not independently perform their daily activities before the operation, had accompanying diseases, had an American Society of Anaesthesiologists score of 3 or 4, and had postoperative complications. There was no statistically significant difference between primary arthroplasty group and proximal femoral nail group with respect to mortality risk. Conclusion: Delayed surgery and postoperative complications may be the most important risk factors increasing 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. These two risk factors can be prevented with proper precautions, and the rate of 1-year survival for these patients can be increased.
Keywords: Aged, hip fractures, mortality, risk factors
|How to cite this article:|
Gurger M. Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study. Niger J Clin Pract 2019;22:648-51
|How to cite this URL:|
Gurger M. Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study. Niger J Clin Pract [serial online] 2019 [cited 2019 May 23];22:648-51. Available from: http://www.njcponline.com/text.asp?2019/22/5/648/258269
| Introduction|| |
Increase in the elderly population has resulted in an increase in the incidence of hip fractures worldwide, which imposes both a social and an economic burden for society. Despite developments in surgical methods and postoperative care, the 1-year mortality rate in the elderly after hip fractures fluctuates between 20% and 30%. In addition, most patients are unable to perform daily life functions on their own after a hip fracture, and their quality of life decreases.
Factors related to senility such as the presence of other diseases, physical weakness, and polypharmacy adversely affect treatment outcomes. Therefore, numerous studies have been conducted to investigate morbidity and fatal risk factors after hip fractures., Certain differences have been observed in these study results. The demographic features of these patients can change over time due to improvements in health services and increasing life expectancy, and these changes may vary by region. This study aimed to evaluate risk factors that impact the 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail (PFN).
| Patients and Methods|| |
Overall, 324 patients hospitalized at our hospital due to hip fracture between January 2015 and January 2016 were retrospectively analyzed after obtaining approval of the local ethics committee. The study design was based on previous studies., Medical charts of patients were reviewed. Of these, 109 patients were included in the study. Patients aged >65 years, who could mobilize independently or with assistance, who had nonpathological femoral neck fracture and intertrochanteric fracture, and who were treated with primary arthroplasty [Figure 1] or PFN [Figure 2] were included in this study. A similar postoperative rehabilitation protocol was implemented for all patients capable of early mobilization and tolerating weight. Factors such as additional diseases, fracture types, surgical methods, discharge status, and postoperative complications were determined via medical chart analysis. Cause of death for patients who died during the first year following surgery were determined by a review of the medical archives. Variables related to mortality, including the age of patients who died in the year following the operation (65–80 or >80 years), gender, other diseases, and number of diseases (0, 1–2, >2), American Society of Anaesthesiologists (ASA) score (1–4), patient mobility prior to the fracture (independent or assisted walking), type of fracture (femoral neck or intertrochanteric), surgical treatment used (arthroplasty or PFN), and number of postoperative complications (0 or ≥1), were recorded.
|Figure 1: (a) Preoperative and (b) postoperative 6-month hip radiographs of a 76-year-old female patient with a partial hip prosthesis operation after left femoral neck fracture|
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|Figure 2: (a) Preoperative and (b) postoperative 12-month hip radiographs of a 65-year-old male patient with a PFN operation after left intertrochanteric femoral fracture|
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Data were analyzed using SPSS 21 (IBM Corp., Armonk, NY, USA). Kaplan–Meier analyses were conducted to determine whether the variables affected mortality, and Cox regression analysis was conducted to include the variables determined to have an impact on mortality in the model. Statistical significance level was set at P = 0.05.
| Results|| |
The mean age of the patients was 79.3 years (±7.8). Fifty-five patients (50.5%) were women, and 54 (49.5%) were men. All fractures were caused by simple falls. Most of the patients underwent surgery within the first 3 days after fracture (74.3%). The most frequent co-occurring diseases were hypertension (45%), diabetes (16%), cardiac diseases (14%), and respiratory diseases (13%). At least one complication developed in 41.6% of patients during their follow-up at the hospital. The most common minor complications were delirium (12.8%), decubitus ulcers (8.3%), anemia (4.6%), and electrolyte disturbance (3.7%). The most common major complications were acute kidney failure (2.8%), acute respiratory distress syndrome (ARDS) (1.8%), deep surgical site infection (1.8%), deep vein thrombosis (DVT) (1.8%), and pulmonary embolism (1.8%). Twelve patients (11%) included in this study died during follow-up at the hospital. Twenty-four patients (22%) died during the first year after discharge from the hospital. The 1-year mortality rate was 35.1% for men and 30.9% for women. The mortality rate for the 65–80 age group was 28.1%, whereas it was 36.5% for the >80 age group. When the Cox regression analysis was conducted following the Kaplan–Meier and log-rank analyses, the mortality rate was found to be high in patients who underwent surgery 72 h after the fracture, could not independently perform their daily activities, had other diseases, had an ASA score of 3 or 4, and developed a postoperative complication at the hospital [Table 1].
|Table 1: Determination of factors that have an impact on mortality using Cox regression analysis|
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| Discussion|| |
High mortality rates following hip fractures have been reported in previous studies.,,, A 1-year mortality rate of 27% was reported by Cenzer et al.,, 23.2% by Folbert et al., 25.2% by Geiger et al. 25.2%, and 30.8% by Jiang et al. A study with 606 patients in Brazil confirmed that 130 of the patients (21.5%) died in the first year, and a great majority of these deaths occurred in the first 3 months. Bass et al. reported a mortality rate of 8.9% in the first month, 15.6% in the first 3 months, 21.8% in the first 6 months, and 29.9% within 12 months after fracture. In our study, the 1-year mortality rate was 33%, and 11% of patients died during follow-up at the hospital.
Although the risk of hip fracture is higher in women, mortality due to hip fracture is higher in men. The increase in mortality risk related to age and male gender is discussed in detail in the literature., In one study, Forsen et al. examined the effect of age and gender on short- and long-term mortality after hip fracture and found that male patients had a higher mortality rate. Kenzora et al. found that gender did not have an impact on 1-year mortality. Beringer et al. found that women fared better than men at returning to their previous living situation. In our study, no statistically significant correlation was found between 1-year mortality and gender (P = 0.678).
Age of the patient is an important risk factor in mortality after hip fracture., The incidence of hip fracture increases with age, and the fracture probability doubles every 10 years after the age of 50. With 1.7 million hip fractures worldwide in 1990, Cooper et al. calculated that the number of hip fractures will be 6.3 million by 2050. Alternatively, Pioli et al. could not find any correlation between age and mortality, which is consistent with our findings (P = 0.249).
The literature suggests that lower mortality and postoperative complication rates are obtained when treatment is provided within the first 24–72 h of fracture. There is consensus that an early surgery is beneficial, and it is recommended that surgery should be performed as early as possible. However, how early surgery reduces mortality remains unclear. Most of our patients (74.3%) underwent surgery within the first 72 h. Patients who undergo surgery 72 h after a fracture have 4.40 times higher mortality risk than those who undergo surgery within 24 h. The literature also suggests that poor mobility before surgery is strongly correlated with an increased mortality rate after the surgery. Our study also demonstrates a statistically significant correlation between mobilization status before surgery and mortality rates (P < 0.001).
Aharonoff et al. found that patients with ASA scores of 3 and 4 had higher mortality rates in the first year. An increased ASA score was one of the independent reasons for higher mortality rates. Our study demonstrated that the 1-year mortality risk particularly increases remarkably in patients with an ASA score of 3 (P = 0.044) or 4 (P = 0.007).
Previous studies have shown that mortality risk increases in patients with hip fracture if they also have other diseases such as pulmonary system-related diseases and malignancies. Our study demonstrated that 1-year survival significantly decreases in patients who have extraosseous malignancies before surgery (P = 0.021).
Roche et al. found that one-fifth of patients developed postoperative complications, and the majority of these complications were pulmonary infection and cardiac failure. The same study found that 65% of patients with cardiac failure and 43% of those with pulmonary infection died within the first 30 days following surgery. In addition, it was found that 92% of patients with cardiac failure died in the first year following surgery. In our study, we demonstrated that the most common postoperative major complications were acute kidney failure (2.8%), ARDS (1.8%), deep surgical site inflection (1.8%), DVT (1.8%), and pulmonary embolism (1.8%). There is a statistically significant correlation between postoperative major complications and mortality (P < 0.001).
| Conclusion|| |
Factors that may impact mortality, such as age and gender of the patient, activity level before surgery and co-occurring diseases, are not modifiable factors. However, early surgery and postoperative complications are factors that can be addressed. Therefore, the best strategy to decrease mortality in these patients is to ensure that surgery is performed as soon as possible and that complications that may develop after the operation are prevented and effectively treated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]