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Investigating the risk factors that affect mortality after cemented hemiarthroplasty in advanced age patients
, Özhan Pazarcı
∗Corresponding author: Seyran Kılınç. seyrankilinc@hotmail.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 number of hip fracture surgeries exhibit an increasing trend due to the aging of the world's population and it is expected to become a serious public health problem in the future. This study aimed to investigate the relationship between mortality and morbidity in patients aged 65 years or older who underwent partial hip prosthesis due to hip fracture.
Four-hundred and forty-three patients aged 65 and above who underwent partial hip prosthesis for fractured hips between 2007 and 2014 were retrospectively investigated. The age before surgery, gender, type of fracture, additional diseases, ASA scores of the patients and time to mortality were investigated in addition to the factors that affect mortality.
Of the 443 patients in the study, 167 were males and 276 were females, with an average age of 80.5 ± 7.2 and 81.1 ± 7.0 years, respectively. One hundred and sixty-two (36.57%) of these patients died within the first year. When the patients were investigated according to age groups, there was a significant relationship between mortality after surgery and patients aged 80 years and above. No statistically significant relationship was found between the time to surgery and mortality. When compared in terms of ASA scores, it was concluded mortality in ASA 3 and 4 groups was significantly higher than ASA 1 and 2 groups (p < 0.001). When hospital stay and one-year mortality rates were compared, it was seen that the length of hospital stay of the patients who died in the first year was significantly higher.
In patients who underwent partial hip replacement after hip fracture, there was a significant relationship between mortality, long hospital stay, patients with an ASA score of 3–4, and patients aged 80 years and above, whereas no relationship was detected with time to surgery.
Keywords
Above 65 years
Advanced age
Fractured hip
Geriatric
Hemiarthroplasty
Mortality
Partial hip prosthesis
1 Introduction
The increase in life expectancy and the growth in the elderly population lead to an increase in the incidence of hip fractures.1 In the hip fractures of the elderly, the mortality rate varies between 20 and 30% in the first year.2 In addition, the treatment and the subsequent process in the elderly hip fracture patients bring great costs to the health system of the countries.3 Despite advanced implant technologies, surgical techniques, and anesthesia and rehabilitation techniques, hip fractures in the advanced age still result in high mortality and morbidity.4
The decrease in bone mineral density with age paves the way for fracture formation which causes problems for internal fixation. Due to lack of movement following internal fixation methods, the probability of observing fatal cardiac and pulmonary problems, thromboembolism and bed sores is high. Hemiarthroplasty is also widely used in geriatric patients to allow early return to movement.5 The main purpose of treatment in patients of advanced age with hip fracture is to reduce mortality and provide early mobilization and return to daily activities.6
In this study, we aimed to investigate the relationship between mortality and morbidity and to determine the risk factors in patients above 65 years of age who underwent a hemiarthroplasty due to hip fractures.
2 Materials and methods
The study was started following the approval of the local ethics committee. A total of 443 patients, aged 65 years or older, who were admitted to our clinic and underwent cemented hemiarthroplasty due to hip fractures between 2007 and 2014 were included in the study. Patients under 65 years of age, those who had undergone cementless arthroplasty, and those whose files and follow-up data were not available were excluded.
Patients’ files were retrospectively evaluated and their demographic and clinical data were recorded. Age, gender, date of surgery, time to surgery, type and side of fracture, length of hospital stay, postoperative survival time of the patients and the American Society of Anesthesiologists (ASA) scores were recorded.
According to their age range, the patients were divided into four groups as 65–69 years, 70–74, 75–79 and 80 and above. According to their time of survival, the patients were divided into nine groups as postoperative first day, second week, third month, sixth month, ninth month, twelfth month, over twelfth month and alive. According to the type of the fracture, the patients were divided into two groups: femoral neck fracture and intertrochanteric fracture.
The ASA scores were determined based on the comorbidity factors and were divided into groups 1, 2, 3 and 4. Patients were also divided into two groups, according to whether they were operated on within or after the first 48 hours.
All patients underwent bipolar cemented hemiarthroplasty via a Watson-Jones incision in the supine position using a modular straight cemented stem (TIPSAN A.S., Izmir, Turkey) (Fig. 1).
The SPSS v.22 software was used in statistical analyses. The comparisons between categorical variables were performed using the chi-square test, whereas the normality of the distribution of the continuous variables was tested with the Kolmogorov-Smirnov test. The mean differences between the groups were analyzed using the Kruskal-Wallis and Mann-Whitney U test.
3 Results
Of the 443 patients in the study, 167 were males and 276 were females, with an average age of 80.5 ± 7.2 and 81.1 ± 7.0 years, respectively.
As for the postoperative survival time, seven patients died within one day following surgery, 21 within two weeks, 27 within one month, 40 within three months, 28 within six months, 18 within nine months and 21 within twelve months. Thus, 162 (36.57%) of the 443 patients had died within the first year. The one-year mortality rate of the patients aged 80 years and above was significantly higher than that of the 65–69 years group (p = 0.018). The life expectancy of the patients according to their age groups is summarized in Table 1.
| Age range | Time of survival | Deceased | Alive | p | |||||||
| 1st day | 2nd week | 1st month | 3rd month | 6th month | 9th month | 12th month | >12th month | ||||
| 65–69 years (n = 31) | 1 | 1 | 4 | 1 | 2 | 1 | 3 | 4 | 17 (54.84%) | 14 (45.16%) | |
| 70–74 years (n = 53) | 0 | 4 | 3 | 3 | 8 | 1 | 1 | 18 | 38 (71.70%) | 15 (28.30%) | |
| 75–79 years (n = 97) | 2 | 6 | 3 | 10 | 4 | 3 | 7 | 36 | 71 (73.20%) | 26 (26.80%) | |
| ≥80 years (n = 262) | 4 | 10 | 17 | 26 | 14 | 13 | 10 | 102 | 196 (74.81%) | 66 (25.19%) | 0.018 a |
| Total (n = 443) | 7 (1.58%) | 21 (6.32%) | 27 (12.42%) | 40 (%21.44) | 28 (27.77%) | 18 (31.83%) | 21 (36.57%) | 160 (72.69%) | 322 (72.69%) | 121 (27.31%) | |
In terms of time to surgery, the patients were evaluated in two groups, according to whether they were operated on within or after the first 48 hours. The effect of the time that passed between fracture and surgery on one-year mortality did not differ significantly among the groups (p = 0.059) (Table 2).
| Time to surgery | Mortality (<1 year) | Mortality (>1 year) | Deceased | Alive | p |
| <48 h (n = 212) | 69 (32,55%) | 95 (44.81%) | 164 (77,36%) | 48 (22,64%) | 0,059 |
| >48 h (n = 231) | 93 (40.26%) | 65 (28.14%) | 158 (68.40%) | 73 (31.60%) | |
| Total (443) | 162 (36.57%) | 160 (36.12%) | 322 (72.69%) | 121 (27.31%) |
In evaluation of the length of hospital stay and one-year mortality rate, it was found that the length of hospital stay of the patients who died within the first year was significantly higher (p = 0.038) (Table 3).
| Time of survival | p | ||||
| <1 year | >1 year | Deceased | Alive | ||
| Gender | |||||
| Male (n = 167) | 62 (37.13%) | 64 (38.32%) | 126 (75.45%) | 41 (24.55%) | 0.310 |
| Female (n = 276) | 100 (36.23%) | 96 (34.78%) | 196 (71.01%) | 80 (28.99%) | |
| Length of stay (days, mean ± SD) | 13.17 ± 6.9 | 12.99 ± 5.3 | 13.08 ± 6.2 | 11.42 ± 5.5 | 0.038 |
| Diagnosis | |||||
| Femoral neck fracture (n = 226) | 75 (33.19%) | 83 (36.73%) | 158 (69.91%) | 68 (30.09%) | 0.181 |
| Intertrochanteric fracture (n = 217) | 87 (40.09%) | 77 (35.48%) | 164 (75.58%) | 53 (24.42%) | |
| ASA score | |||||
| 1-2 (n = 125) | 37 (29.60%) | 36 (28.80%) | 73 (58.40%) | 52 (41.60%) | <0.001 |
| 3-4 (n = 318) | 125 (39.31%) | 124 (38.99%) | 249 (78.30%) | 69 (21.70%) | |
| Side of fracture | |||||
| Right (n = 232) | 80 (34.48%) | 82 (35.34%) | 162 (69.83%) | 70 (30.17%) | 0.157 |
| Left (n = 211) | 82 (38.86%) | 78 (36.97%) | 160 (75.83%) | 51 (24.17%) | |
The comparison of the ASA scores showed that patients with an ASA score of 3 and 4 had significantly higher mortality compared to those with an ASA score of 1 and 2 (p < 0.001) (Table 3).
No significant relationship was detected between gender, the side or the type of fracture and mortality.
4 Discussion
The rate of hip fractures exhibits an increasing trend in all future projections, which suggests that hip fracture and related problems will continue to be a serious health problem for the elderly population.7 Various mortality rates due to hip fractures have been reported in the literature.6,8–10 In a controlled mortality study with the same age group, the mortality rate of the patients with hip fractures was reported to be 4 to 5 times higher.11 The mortality rate in Bass et al.’s study was 8.9% in the first month after fracture, 15.6% in the first three months, 21.8% in the first six months and 29.9% in one year9 and 24% in Broos et al.’s study,12 whereas, in our study, it was 12.4% in the first month, 21.4% in the third month, 27.7% in the sixth month and 36.5% in one year. Moreover, seven patients (1.5%) died within the first day. Another study supports the findings of our study, emphasizing that the mortality rate was high in the first three months.13
Studies comparing the mortality between pertrochanteric fractures and intracapsular femoral neck fractures have reported that there was no significant difference between the two groups in terms of mortality.14,15 In our study, we observed that the fracture type had no significant effect on mortality either. However, a study by Karagiannis et al. suggests that the fracture type is effective in long-term mortality and that intertrochanteric type fractures have a poor prognosis.16
The risk of fracture risk and the incidence of hip fractures have been reported to be high in women. However, several studies reported that male patients have a higher mortality rate following hip fractures when compared to their female counterparts.9,17–19 In our study, although the number of female patients was higher than the male patients, no statistically significant relationship was found between the one-year mortality and gender (Table 3).
The incidence of hip fractures increases with age and is known to be a serious public health problem for this group of patients.7 Age is one of the major risk factors affecting mortality after hip fracture.15,18 The literature holds some studies that suggest no significant difference between age groups and mortality in hip fracture patients.6,20 However, in our study, we found a significant difference between the one-year mortality rate in patients above 80 years of age and that of the 65–69 years group (Table 1). The literature supports the findings from our study.15,21
Among the factors that affect mortality, surgical timing is a frequently encountered parameter in the literature. Although different results have been obtained in terms of mortality with surgical timing, early surgical treatment is thought to be more favorable for complications and mortality.22–24 Dolk found no significant difference in terms of mortality between the patients operated immediately and after 48 h after fracture.25 while some authors found no difference in terms of mortality between the patients operated within the first 24 hours.26,27 Similarly, there was no significant difference among the groups in terms of mortality in our study (Table 2). On the other hand, some authors reported that delaying the post-fracture surgery for more than five days was associated with high mortality.28,29
In our study, the one-year mortality rate was found significantly higher in patients with an ASA score of 3 and 4 compared to those with an ASA score of 1 and 2 (Table 3). The literature strongly supports this finding of ours. Several studies evaluated the relationship between the ASA score and mortality and pointed out to the increased mortality risk in patients with an ASA score of 3 and 4 in comparison to the control group.6,15,30,31
The length of hospital stay in advanced age hip fracture patients increases due to comorbidity. On the other hand, some studies have shown that short length of hospital stay decreases mortality.32 In another study, it was concluded that detailed preoperative tests prolong the time to surgery and length of hospital stay, but rarely alters the treatment method.33 In our study, the one-year mortality rate was significantly higher in patients who were hospitalized for a long time. We believe that clearly identifying the factors that may lead to this situation, questioning the geriatric patient approach and establishing structured units in this regard is of great importance. Our findings support the opinion that elderly patients with hip fracture should be hospitalized as short as possible.
The retrospective design of our study was a major limitation. In addition, we failed to evaluate the factors such as anesthesia type, the duration of surgery and the amount of intraoperative bleeding, which may have effected mortality. The lack of postoperative functional evaluation was another limitation. However, the fact that our study was conducted on a homogenous and large series of patients who underwent hemiarthroplasty using the same type cement renders our study an important one.
In conclusion, a properly managed treatment following hip fractures is directly related to survival in the elderly patient group. Determining the risk factors and taking necessary measures is important in reducing the mortality rate. Mortality after hip fracture is increased in patients with an ASA score of 3 and 4 and aged 80 years and above. Prolonged hospitalization after hip fracture is significantly associated with the first-year mortality.
Funding
None.
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