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Association between fracture type and the risk of bleeding in intertrochanteric femur fractures
∗Corresponding author: Necati Doğan. drnecatidogan@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The current study aimed to determine the association between fracture type and pre-operative hemoglobin level decrease in intertrochanteric fractures. Further, the erythrocyte unit required in replacement therapy until discharge according to fracture type was evaluated.
We retrospectively analyzed 194 patients diagnosed with intertrochanteric femur fracture who received proximal femoral nail implantation. Among them, 122 met the inclusion criteria, and they were divided into group 1 (stable fracture) and group 2 (unstable fracture) according to the Arbeitsgemeinschaft für Osteosynthesefragen classification. Data on age, sex, fracture side, surgical waiting time, pre- and post-operative hemoglobin levels, and total erythrocyte units required were assessed. Then, statistical analysis was performed.
The stable and unstable groups were similar in terms of age, sex, fracture side, and surgical waiting time (p > 0.05). The average erythrocyte units required in replacement therapy were 1.62 (total: 96) in group 2 and 0.91 (total: 57) in group 1. Moreover, group 2 was more likely to require eythrocyte replacement than group 1 (p = 0.001). The average hemoglobin level decreases were 1.70 g/dL in group 1 and 1.95 g/dL in group 2. The pre-operative hemoglobin level decrease had a similar distribution in both groups (p = 0.239).
The pre-operative blood loss volume was similar between unstable and stable intertrochanteric fractures. Moreover, at unstable group, the need for erythrocyte replacement therapy was high in the whole period until discharge.
Abstract
Highlights
•Intertrochanteric fractures were most appropriately classified as stable and unstable.•The erythrocyte replacement amounts of the patients who were followed up were determined exactly from the blood center.•Blood parameter results in service follow-ups were determined regularly.•Additional diseases and the drugs they used were determined from the epicrisis and consultation notes.
Keywords
Erythrocyte replacement
Hemoglobin drop
Intertrochanteric femur fractures
Proximal femoral nail
1 Introduction
Intertrochanteric hip fractures (ITFs) are among the most common types of fractures, and the incidence of intertrochanteric fractures is increasing with the growing elderly population.1 Elderly individuals and those with disabilities commonly sustain fractures that are usually caused by a low-severity injury or simple fall. ITFs are frequently treated with surgery except in patients with significant comorbidities or a low-life expectancy.2,3 Several people with hip fractures receive erythrocyte transfusion, in addition to surgery, due to anemia or bleeding.4
The incidence of anemia in the general population increases with age, thereby reflecting the presence of comorbidities. Anemia may be attributed to postfracture bleeding and intra-operative blood loss.5 People with hip fractures can have massive blood loss after the development of fracture and before surgery. The mean blood loss volumes were 1.5 units in intracapsular fractures and 2 units in extracapsular fractures. Compared with young people, elderly people with hip fractures generally have low resistance and less endurance to cope with hemodynamic changes.6
Generally, erythrocyte transfusion can manage pre-existing anemia, replace blood loss in people with hip fractures, and improve or maintain circulating oxygen-carrying capacity. It is an important part of supportive management in people who underwent hip fracture surgery. Moreover, it improves post-operative functional recovery, mobilization, and quality of life.7
Patients who develop severe anemia may be at risk of mortality and morbidity due to decreased hemoglobin levels. Hence, predicting the volume of peri-operative blood loss and facilitating early reservation and replacement therapy can help prevent morbidities.
Previous studies that investigate the volume of pre-operative blood loss in hip fractures are extremely limited. We hypothesized that the incidence of pre- and peri-operative bleeding is higher in unstable fractures than in stable fractures. The current study aimed to determine the association between fracture type and pre-operative hemoglobin levels in ITFs. Moreover, the erythrocyte replacement unit required until discharge according to fracture type was evaluated.
2 Patients and method
The current retrospective study analyzed 194 patients diagnosed with ITF who visited the emergency orthopedics clinic and received proximal femoral nail (PFN) implantation between June 2020 and February 2022. This research was approved by the local ethics committee of the instiution (KAEK/2021.09.194).
The criteria were developed to standardize the inclusion of patients with peri-operative bleeding.
2.1 Exclusion criteria
Patients with multitrauma, pathological, non-intertrochanteric, and 31 A3-type fractures based on the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, and bleeding and chronic kidney diseases; those treated with anticoagulants (Corasprin, Plavix, Xarelto, Coumadin, and Tranexamic acid); those who received implantation other than PFN; those who underwent open reduction; and those aged under 65 years were excluded from the study.
2.2 Inclusion criteria
Patients who experienced a simple fall, those with isolated injury and 31 A1-and A2-type fractures, those not receiving anticoagulants, those aged over 65 years of age, and those who received PFN implantation were included in the analysis.
The participants were divided into group 1 (AO 31 A1-type fractures, stable, n = 63) and group 2 (AO 31 A2-type fractures, unstable, n = 59).8
2.3 Peri-operative clinical approach
Routine blood parameters were assessed upon admission to the emergency room. Urine output was monitored with a Foley catheter. Patients with insufficient fluid consumption received replacement therapy with 1000 cc of saline daily. Pre-operative anesthesia was included in the preparation process, and surgeries were performed without delay. All patients received low-molecular-weight heparin subcutaneously. Closed reduction and PFN application were performed on all patients with the standard method, and the nail diameter was 10 mm. Blood control samples were routinely collected in the first hour of arrival in the post-operative service. Blood control was performed once a day until discharge.
The hemoglobin level was maintained at >10 g/dL before surgery and at >8 g/dL during discharge.9
2.4 Data collection
Data on age, sex, fracture side, and surgical waiting time were evaluated.
The first table was created to determine the need for total erythrocyte replacement. Data on the units of red blood cells used from hospitalization to discharge were obtained from the blood center.
The second table was established to assess the pre-operative hemoglobin level decrease. The difference between the hemoglobin level upon hospital admission and the initial post-operative hemoglobin level was calculated. To standardize the difference and to obtain a high-level evidence, a new table was created by removing patients who underwent pre- and intra-operative erythrocyte replacement from the first table. Since PFN implantation is closed method and the surgical time was short, the intra-operative blood loss volume was low (mean: 120 cc).10 Therefore, the study was planned by accepting the perop blood loss as ineffective.
2.5 Statistical analyses
The Statistical Package for the Social Sciences software version 26 (IBM Inc., Chicago, IL, the USA) was used in statistical analysis. Explanatory statistics (mean, standard deviation, median, frequency, ratio, and range) and data distribution were evaluated with the Shapiro–Wilk test. The Student's t-test was normally used to compare data distribution between two groups. A p value of <0.05 was considered statistically significant.
3 Results
The mean ages were 77.45 (65–95) years in group 1 and 81.57 (65–105) years in group 2. Both groups had a similar distribution in terms of age, sex, fracture side, and surgical waiting time (p > 0.05) (Table 1).
| Group 1 n = 63 | Group 2 n = 59 | p value | ||
| Age | Mean ± SDa | 77.45 ± 9.8 | 81.57 ± 9.9 | 0.123 |
| Min-Max (Median) | 65–95 (78.5) | 65–105 (82) | ||
| Sex | M:22 F:41 | M:16 F:43 | 0.112 | |
| Fracture side | R:34 L:29 | R:30 L:29 | 0.466 | |
| Fracture type | AO 31 A11: 29AO 31 A12: 22AO 31 A13: 12 | AO 31 A21: 11AO 31 A22: 30AO 31 A23: 18 | – | |
| Time to surgery (days) | Mean ± SD | 6.16 ± 2.42 | 6.86 ± 2.74 | 0.068 |
| Min-Max (Median) | 2-10 (6) | 2-10 (7) | ||
| Pre-operative hospitalization hemogram | Mean ± SD | 11.75 ± 2.13 g/dL | 10.8 ± 1.67 g/dL | 0.001 a |
| Min-Max (Median) | 7.3–15.8 (12) | 8.2–15.1 (10.3) | ||
| Pre- and intra-operative erythrocyte replacement | 17/63 patients | 18/59 patients | 0.101 | |
| Initial post-operative hemogram | Mean ± SD | 10.48 ± 2.07 g/dL | 9.29 ± 1.02 g/dL | 0.001 a |
| Min-Max (Median) | 6-15 (10.6) | 7.4–11.1 (9.5) | ||
| Total erythrocyte replacement units (1 unit =450 cc) | Total | 57 units | 96 units | 0.001 a |
| Average | 0.91 unit | 1.62 unit |
While the mean pre-operative hospitalization hemogram was 11.75 ± 2.13 g/dL in group 1, it was 10.8 ± 1.67 g/dL in group 2. The pre-operative hospitalization hemogram value of group 2 was found to be significantly more lower than group 1 (p = 0.001). When we looked at the initial post-operative hemogram, the mean was 10.48 ± 2.07 g/dL in group 1, while it was 9.29 ± 1.02 g/dL in group 2. We found that it was significantly more lower in the group 2 in the initial post-operative hemogram (p = 0.001) (Table 1).
The erythrocyte replacement unit required from hospitalization to discharge was calculated. The average erythrocyte replacement units (1 unit = 450 cc) were 1.62 (total: 96) in group 2 and 0.91 (total: 57) in group 1. Moreover, group 2 was more likely to require blood replacement than group 1 (p = 0.001) (Table 1).
Patients who received pre- and intra-operative blood replacement therapy were excluded from the study to accurately determine the volume of pre-operative blood loss. Finally, 87 of 122 patients were included in the study (Table 2). Among them, 46 and 41 patients were classified under groups 1 and 2, respectively. Both groups had a similar distribution in terms of age, sex, fracture side, and surgical waiting time (p > 0.05). Pre-operative bleeding was defined as a significant difference between the hemoglobin value upon hospital admission and the initial post-operative hemoglobin value. The average hemoglobin level decreases were 1.95 g/dL in group 2 and 1.70 g/dL in group 1. Further, group 2 had a higher pre-operative hemoglobin level decrease than group 1. However, the results did not significantly differ (p = 0.239) (Table 2).
| Group 1 n = 46 | Group 2 n = 41 | p value | ||
| Age | Mean ± SD | 75.3 ± 8.22 | 80.04 ± 8.64 | 0.074 |
| Min-Max (Median) | 65–88 (75.5) | 65–96 (81) | ||
| Sex | M:20 F:26 | M:11 F:30 | 0.062 | |
| Fracture side | R:24 L:22 | R:16 L:25 | 0.96 | |
| Fracture type | AO 31 A11: 23AO 31 A12: 17AO 31 A13: 6 | AO 31 A21: 8AO 31 A22: 21AO 31 A23: 12 | – | |
| Time to surgery (days) | Mean ± SD | 6.23 ± 2.60 | 6.39 ± 2.34 | 0.389 |
| Min-Max (Median) | 2-10 (6.5) | 4-10 (5) | ||
| Preoperative-hospitalization hemogram (H) | Mean ± SD | 12.40 ± 1.69 g/dL | 11.50 ± 1.48 g/dL | 0.01 a |
| Min-Max (Median) | 9.5–15.8 (12.3) | 9.1–13.4 (11.4) | ||
| Initial postoperative hemogram (I) | Mean ± SD | 10.74 ± 1.95 g/dL | 9.42 ± 0.95 g/dL | 0.001 a |
| Min-Max (Median) | 7.1–15 (10.65) | 7.7–11.1 (9.5) | ||
| Pre-operative bleeding (H–I) | Mean ± SD | 1.70 ± 1.05 g/dL | 1.95 ± 1.66 g/dL | 0.239 |
| Min-Max (Median) | 0.3–3.9 (1.6) | 0.1–3.7 (1.6) |
As shown in Tables 1 and 2, the pre-operative hospitalization hemogram and initial post-operative hemogram values significantly differed between groups 1 and 2 (p =0.001).
4 Discussion
The current study showed no significant difference in terms of bleeding between stable and unstable ITFs from fracture onset to surgery. In contrast, the unit of erythrocyte replacement used until discharge in unstable fractures is quite high.
Previous studies have shown increased mortality and morbidity among patients who underwent surgery after 24–72 h.11,12 However, the treatment of several diseases was delayed in the COVID-19 pandemic, and the treatment of patients with hip fracture who required intensive care was interrupted. Among patients included in our study, those with comorbidities underwent surgery after the average time due to intensive care occupancy during the COVID-19 pandemic. Meanwhile, the mean waiting times for surgery were 6.23 days in group 1 and 6.39 days in group 2. Chen et al.13 showed that rapid surgical procedures (reducing the surgical waiting time) can reduce the volume of blood loss. In our study, despite the long surgical waiting time, the decrease in hemogram was less than expected. Meanwhile, the mean hemoglobin level decreases during the waiting period before surgery were 1.70 g/dL in group 1 and 1.95 g/dL in group 2. Despite the long waiting period, there was no significant decrease in hemoglobin levels.
The use of antithrombolytic therapy (Corasprin, Plavix, Xarelto, and Coumadin) against heart diseases and peripheral vascular pathologies in among elderly individuals has become common. Such drugs can increase the risk of bleeding after fracture and surgery and causes difficulties in administering regional and general anesthesia.14 A previous study15 has shown that anticoagulant treatment does not cause significant blood loss in the peri-operative period. However, anticoagulant use was excluded from the study in to ensure standardization, similar to a previous publication.16
In the literature, only two publications discussed about pre-operative bleeding. Lin et al.16 excluded patients who are on anticoagulant and erythrocyte replacement therapy and only analyzed those with pre-operative bleeding. Results showed that patients with unstable fractures had a higher risk of pre-operative bleeding than those with stable fractures. By contrast, Luo et al.17 found that compared with patients with stable fractures, those with unstable fractures were more likely to require blood replacement in the pre-operative period. The method used to assess pre-operative bleeding was similar between the current and previous. Unlike in previous studies, we found no statistically significant difference between the two groups (p = 0.239). There was a lack of statistical difference, and this is attributed to the fact that the current study had a larger sample size than previous ones.
We found that the amount of erythrocyte replacement used until discharge was higher in unstable fractures (Group 2) (p<0.001). We also found that the pre-operative hospitalization hemogram of unstable fractures was significantly lower than that of stable fractures (p<0.001). Although the amount of erythrocyte replacement appears to be quite high in unstable fractures, it seems difficult to determine with our current method whether it is due to the type of fracture or the low hospitalization hemogram of the patient. Low hospitalization hemogram value may be a very strong factor affecting the amount of erythrocyte replacement.
Previous studies18–21 assessing the incidence of bleeding in intertrochanteric fractures have also examined blood losses in the peri-operative period, which is similar to our study. Results have shown that fracture type, anesthesia use, anticoagulant treatment, osteoporosis, female sex, hypertension, (surgical waiting time of >2 days, operative time of >60 min), initial admission hemogram, and advanced age are associated with an increased risk of bleeding. The current study showed that the relationship between fracture type and bleeding is low, and a low hospitalization hemogram may predict a high need for erythrocyte replacement.
Some studies have recommended immediate surgery13 or the use of tranexamic acid22 to reduce the risk of bleeding. With PFN implantation, which is widely used nowadays, the average surgical time has decreased to 30 min. Nevertheless, further studies must be conducted to evaluate the effects of transamine and lower blood units on morbidity, mortality, and medical cost in intertrochanteric fractures.
Finally, the current study had several important limitations that must be considered. First, it was retrospective in nature, and clinical follow-up was not performed. Therefore, future studies with larger data on clinical outcomes should be conducted. Second, surgeries were performed by different surgeons with various surgical experience. However, the surgical procedures were similar. Hence, a prospective study must be performed to gather more evidence.
5 Conclusions
The pre-operative blood loss volume was similar between unstable and stable intertrochanteric fractures, and the need for erythrocyte replacement was higher in the whole period until discharge at unstable group. Patients with unstable fractures were more likely to require erythrocyte replacement than those with stable fracture. Hence, healthcare professionals must be ready to manage this type of case. Thus, close hemogram follow-up may be required in the pre- and post-operative periods due to the risk of mortality in patients with comorbidities who are hospitalized due to unstable intertrochanteric hip fractures.
Author's contribution
All authors contributed to conceptualization, data curation and analysis, writing the manuscript, and agree to be accountable for all aspects of the work. All authors have contributed to and approved the final version of the manuscript.
Funding/sponsorship
None.
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