The effect of CKD on intertrochanteric fracture treated with proximal femoral nail anti-rotation: A 7-year study

Ong-art Phruetthiphat; Suppakit Paiboonrungroj; Yodhathai Satravaha; Attaporn Lawanprasert

doi:10.1016/j.jor.2022.06.003

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32 (); 151-155

doi:

10.1016/j.jor.2022.06.003

The effect of CKD on intertrochanteric fracture treated with proximal femoral nail anti-rotation: A 7-year study

Ong-art Phruetthiphat^a,, Suppakit Paiboonrungroj^a, Yodhathai Satravaha^b, Attaporn Lawanprasert^a

a Department of Orthopaedics, Phramongkutklao Hospital, Bangkok, Thailand

b Department of Orthodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand

∗Corresponding author: Ong-art Phruetthiphat. ongart-phr1@hotmail.com

Received: 2022-2-28, Accepted: 2022-6-2, Published: 2022-6-8

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Intertrochanteric fracture is one of the most burdensome osteoporotic fractures in the elderly. Chronic kidney disease is associated with sarcopenia, especially in its advanced stages and, thus may impact functional status. Combining an intertrochanteric fracture with advanced CKD may diminish results after surgical fixation. This study aims to distinguish whether CKD affects the result of intertrochanteric fracture fixation in terms of mechanical and functional outcomes.

A retrospective study reviews all intertrochanteric fractures treated with PFNA fixation from 2012 to 2018. 445 patients were classified into 5 stages of CKD and divided by eGFR = 90 ml/min/1.73 m² into CKD and non-CKD group and by eGFR = 30 ml/min/1.73 m² into advanced CKD and non-advanced CKD group. The primary outcome was one year Harris Hip Score (HHS). Secondary outcomes were medical complications, surgical complications, and a 1-year mortality rate.

Harris Hip Scores (HHS) were not different between non-CKD and CKD groups (eGFR <90 mL/min/1.73 m²). However, there was a difference between non-advanced CKD and advanced CKD groups (eGFR <30 mL/min/1.73 m²) (p < 0.001). Medical complications were not different, except for sepsis in CKD stage 5 compared with stage 1 (p = 0.023). Even though AO/OTA types were more severe in the advanced CKD group, surgical complications and 1-year mortality were not different.

Advanced stage CKD treated with PFNA fixation is associated with lower functional outcomes at one year. Sepsis is more prone to occur after surgery in CKD stage 5.

Level III; Retrospective cohort study.

Keywords

Intertrochanteric fracture

Pertrochanteric fracture

Chronic kidney disease

Functional outcome

Harris hip score (HHS)

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1 Introduction

As the world's populations gradually transition to an aging society, osteoporotic hip fractures have become more prevalent. The number of hip fractures is drastically increasing, projected to be around 4.5–6.26 million by 2050.¹^,² There is a correlation between the fragility of hip fractures to high mortality, with around 11.5–39.5% 1-year mortality,³ loss in disability-adjusted life years, high resources, and financial burden on the healthcare system.^4–7 Operative treatment is the gold standard option, associated with better anatomic outcomes, shorter hospital stays, and a higher likelihood of returning to their independence.⁸ Intramedullary Nails have become well-known as implants for intertrochanteric fractures^9–12 and Proximal Femur Nail Anti-rotation (PFNA II) has become a hospital's standard. However, there is some chance of PFNA fixation failure. Previous studies reported that the quality of fracture reduction, the position of the blade, and TAD were associated with the outcome following PFNA fixation.^13–16 Baumgaertner et al. demonstrated the correlation between TAD and mechanical failure in dynamic hip screws (DHS).^13–15 In contrast, Bojan A.J. et al. found that screw cut-out after Gamma nail fixation for proximal femoral fractures was associated with unstable fracture, non-anatomical reduction, and non-optimal screw position.¹⁶

In addition, a systematic review has demonstrated that an additional cement augmentation is a safe method of fixation to treat the elderly patients with trochanteric fractures, and they gained good functional results without any cement-associated complications.¹⁷

Chronic kidney disease seems not to be a significant factor.¹⁸ Nevertheless, the study compared non-CKD with every stage of CKD grouped. Chronic kidney disease, especially in the more advanced stages, was associated with sarcopenia, resulting in poorer muscle mass, strength, and functions.¹⁹ Thus, it lowers the patient's functional status and predisposes them to a more sedentary lifestyle.¹⁹^,²⁰ Inferior functional status, particularly in the lower extremities, such as gait speed and time up and go (TUAG) are associated with disability, cognitive impairment, falls, and even higher mortality rate in elderly and CKD patients.²¹^,²² Hence, some evidence indicates that more advanced stage CKD patients' constitutions and functions are different from those in the earlier stages. The primary outcome is to compare the patients' functional outcomes with intertrochanteric fractures treated with operative fixation between non-CKD and CKD groups and between non-advanced CKD and progressive CKD groups. The secondary outcome will compare the medical and surgical complications of the non-CKD and CKD groups.

2 Methods

2.1

2.1 Setting and subjects

After Institutional Research Board Approval, this retrospective study collected data at our hospital from patients who sustained intertrochanteric fractures from January 1, 2012 to December 31, 2019. This study recruited patients over 60 years old who sustained intertrochanteric fractures with modified AO/OTA Type 31A1.3, 31A2.2, and 31A2.3 from low energy trauma and underwent PFNA fixation with at least one year follow up after surgical fixations.

The exclusion criteria were those patients 1) with multiple fractures, 2) with high energy trauma, 3) with pathologic fractures, 4) patients referred to other hospitals after the operation, 5) who had incomplete medical records, 6) with Modified AO/OTA type 31A1.1 and 31A1.2 underwent DHS fixation, and 7) with Modified AO/OTA type 31A3.1, 31A3.2, and 31A3.3. Finally, this study recruited 445 patients who underwent PFNA fixation.

2.2

2.2 Measurements

General information was reviewed, including age, gender, body mass index, comorbidity, surgical parameters, functional outcome, complications, and mortality rate. The American Society of Anesthesiologists (ASA) physical status classification and the Charlson Comorbidity Index (CCI)²³ were collected to assess patients' physical condition before performing a surgical fixation. The study categorized patients into non-CKD (chronic kidney disease) and CKD groups.²⁴ The former group (Stage 1; n = 43) was defined as those patients with a glomerular filtration rate (GFR) of at least 90 mL per minute (ml/min), while the other group was GFR less than 90 ml/min (n = 402). Furthermore, dividing into four subgroups by CKD groups (Stage 2–5). CKD stage 2 (n = 179) was GFR between 60 and 89 ml/min, CKD stage 3 (n = 180) was GFR between 30 and 59 ml/min, CKD stage 4 (n = 23) was GFR between 15 and 29 ml/min, and CKD stage 5 (n = 20) was GFR less than 15 ml/min. In addition, another two groups classification of patients is Non-Advanced CKD (Stage 1–3) and Advanced CKD (Stage 4–5) groups. Surgical factors were Tip Apex Distance (TAD) (millimeter, mm),¹³^,¹⁵ operative time (minutes), blood loss (milliliter, ml), and patterns of fractures. In this study, fracture patterns were based on modified AO/OTA classification and they retrospectively classified into modified AO/OTA 31 A1.3, A2.2, and A2.3.

2.3

2.3 Intraoperative procedure and postoperative management

Three senior orthopedic traumatologists (O.P., T.J., Y.P.) operated patients with intertrochanteric fractures that underwent surgical fixation with a standard-proximal femoral nail anti-rotation (PFNA II). Preoperative antibiotic (Cefazolin 2 g) was intravenously injected 30 min in all patients before the skin incision. Some patients with a history of allergy to penicillin were prescribed 600 or 900 mg of Dalacin C intravenously. After performing a closed reduction under intraoperative fluoroscopy, a guidewire was marked at the tip of the greater trochanter and, afterward, inserted into the intramedullary canal of the proximal femur. Executed the proximal reaming and measured the diameter of the nail. Applying a 200 mm length of standard PFNA to the medullary canal was substantial. An Insertion of the guidewire to the femoral head was necessary with the precise position measured by fluoroscopic imaging in anteroposterior, and lateral views. The helical blade was applied to the femoral head within 20–30 mm of tip apex distance (TAD)¹³^,¹⁵ and tightened in the next step after a distal screw was finally applied.,¹³^,¹⁵ and tightened in the next step, after a distal screw was finally applied. During the postoperative period, administration of adequate pain control to all patients was necessary. They received the same protocol of postoperative pain control: Celecoxib (200 mg; mg) 1 tablet oral twice a day, Acetaminophen (500 mg) 1 tablet every 6 h, and Eperisone (50 mg) 1 tablet oral threes time a day. Intravenous morphine was applied when a patient had aggravated pain (VAS>3). Weight-bearing was allowed as tolerated, and deep vein thrombosis prophylaxis by mechanical pump and prescription of 81 mg of Aspirin once per day allocated in almost patients. In comparison, 75 mg of Clopidogrel once daily prescribed to those patients with a high risk of VTE (history of deep vein thrombosis, prolonged immobilization, hypercoagulable state) during hospital admission until one month after surgery.

2.4

2.4 Rehabilitation protocol

Postoperative day 0 must be sitting upright, ankle pumping and ankle rotation exercise. Postoperative day 1 included isometric quadriceps exercise on the bed, hip abduction exercise on the bed, straight leg raising, range of knee motion exercise, sitting at bedside, active quadriceps exercise at the bedside, and standing with a walker at the bedside. Postoperative day 2 consisted of standing knee raise, standing hip abduction, standing hip extension, and ambulation with gait aid (4-legged walker) with assistance from the attending doctor. If patients did not meet the ambulatory goal, the rehabilitation team was available for assistance. Postoperative day 3 (discharge day) is defined as improved ambulatory performance until safe for home discharge. If some patients cannot achieve their rehabilitation goal, patients are not allowed to discharge from the hospital.

2.5

2.5 Outcome measurements

All patients in the outpatient department need follow-up at two weeks, six weeks, three months, six months, nine months, and one year, respectively. Plain radiography (anteroposterior (AP) radiograph of both hips and lateral radiographs of affected hip) was taken at a 2-week follow-up and measured by two independent orthopedic surgeons who did not participate in the operative field. The quality of reduction, nail shaft axis (NSA), the displacement between cortices of proximal and distal fragments (gap and step), Tip Apex Distance (TAD) in AP and lateral views (in millimeter, mm),¹³^,¹⁵ and Cleveland zone assessed through PACS software in our institute. Two orthopedic surgeons calculated the average of the measurements.

Harris Hip Score (HHS) evaluated the outcome. It categorized it into two aspects in all patients: pre-fracture condition (pre-injury HHS) via interview and post-surgical condition through clinical examination at one-year follow-up. In conclusion, HHS consists of several domains: for example, pain (44 points), limp (11 points), support (11 points), distance walked (11 points), sitting (5 points), stairs (4 points), putting on socks and shoes (4 points), taking public transport (1 point), absence of deformity (4 points), and range of motion (5 points). Zero-point means the lowest HHS, while one hundred points are the highest HHS.²⁵ Then, four groups divide HHS: excellent (90–100 points), good (80–89), fair (70–79), and poor outcome (<70 points). The one-year postoperative HHS was comparable between non-CKD and CKD groups (Table 3) and between non-advanced CKD and advanced CKD groups (Table 4) .

Surgical complications were assessed, including PFNA blade cut-out, PFNA blade cut through (centrally migrate), varus collapse, hematoma, surgical site infection (SSI), and deep wound infection. Medical complications were congestive heart failure, pneumonia, urinary tract infection, sepsis, venous thromboembolism (deep vein thrombosis, pulmonary embolism), and one-year mortality (Tables 5 and 6).

2.6

2.6 Statistical analysis

STATA (version 14) performed all the statistical analyses. Mean ± standard deviation (S.D.) presented patients' characteristics, median (minimum and maximum), frequency, and percentage. Using the Chi-square or Fisher's exact test to categorize variables was significant in comparing the group. Also, the application of the Student's T-test/Mann-Whitney U test for the continuous variable was appropriate.

3 Results

There was no difference in gender, underlying disease, and CCI between non-CKD and CKD groups, as shown in Table 1. However, CKD patients were significantly associated with older age, lower BMI, and a higher rate of ASA class 3 compared to non-CKD patients. In addition, the CCI in advanced CKD was significantly higher than in non-advanced CKD (5.9 vs. 4.6, p < 0.001), as demonstrated in Table 4.

Table 1 Demography and Comorbidity between Non-Chronic Kidney Disease (Non-CKD) and Chronic Kidney Disease (CKD) patients.

Parameters	Non-CKD (n = 43)	CKD (n = 402)	P-value
Demographic data
Age	74.7 ± 8.2	81.3 ± 8.3	<0.001
Gender			0.332
Female	28 (65.1%)	290 (72.1%)
Male	15 (34.9%)	112 (27.9%)
BMI (kg/m²)	24.5 ± 4.1	22.2 ± 3.7	<0.001
Comorbidity
Type 2 DM	17 (39.5%)	119 (29.6%)	0.179
Hypertension	27 (62.8%)	284 (70.7%)	0.286
Dyslipidemia	20 (46.5%)	181 (45.0%)	0.852
ASA class			0.001
1	1 (2.3%)	8 (2.0%)
2	23 (53.5%)	108 (26.9%)
3	19 (44.2%)	286 (71.1%)
CCI	4.4 ± 1.9	4.7 ± 1.6	0.157
Total Hip BMD (T-score)	−3.0 ± 0.6	−3.0 ± 0.7	0.983
BMI is Body mass index, DM is Diabetic mellitus, CCI is Charlson comorbidity index, BMD is Bone mineral density

Surgical parameters (Modified AO/OTA classification, quality of reduction, Tip apex distance, Cleveland zone, and Nail shaft axis) were not different between non-CKD and CKD groups, as shown in Table 2.

Table 2 Surgical parameters between Non-Chronic Kidney Disease (Non-CKD) and Chronic Kidney Disease (CKD) patients.

Parameters	Non-CKD (n = 43)	CKD (n = 402)	P-value
Modified AO/OTA classification			0.143
31A1.3	14 (32.6%)	179 (44.5%)
31A2.2	23 (53.5%)	153 (38.1%)
31A2.3	6 (13.9%)	70 (17.4%)
Quality of Reduction (n = 441)			0.230
Acceptable/Good	36 (87.8%)	371 (92.8%)
Poor	5 (12.2%)	29 (7.2%)
TAD (millimeters)(mm)			0.366
20–30 mm	31 (72.1%)	264 (65.7%)
<20 mm	9 (20.9%)	121 (30.1%)
>30 mm	3 (7.0%)	17 (4.2%)
Cleveland zone (n = 439)			0.890
5,7,8	31 (75.6%)	297 (74.6%)
1,2,3,4,6	10 (24.4%)	101 (25.4%)
Nail Shaft Axis (NSA)			0.814
−2 to +2	35 (81.4%)	311 (77.4%)
<-2	5 (11.6%)	53 (13.2%)
>2	3 (7.0%)	38 (9.4%)

Table 3 Pre-injury Harris Hip Score (HHS), One-year Functional outcome assessed by Harris Hip Score (HHS) between Non-Chronic Kidney Disease (Non-CKD) and Chronic Kidney Disease (CKD) groups.

Parameters	Non-CKD (n = 43)	CKD (n = 402)	P-value
Harris Hip Score (HHS)
Pre-injury HHS	87.6 ± 7.8	88.2 ± 7.3	0.597
One-year postoperative HHS	85.8 ± 9.1	87.3 ± 8.0	0.276
HHS by grading			0.467
Excellent (90–100)	17 (47.2%)	196 (54.1%)
Good (80–89)	10 (27.8%)	109 (30.1%)
Fair (70–79)	8 (22.2%)	46 (12.7%)
Poor (<70)	1 (2.8%)	11 (3.0%)

Pre-injury Harris Hip Scores (HHS) between non-CKD and CKD groups were not different, while Pre-injury HHS in advanced CKD was significantly lower than non-advanced CKD (83.1 vs. 88.7, p = 0.003). One-year postoperative HHS was not different between non-CKD and CKD groups (85.8 vs. 87.3, p = 0.276) (Table 3). However, there was a significant difference between non-advanced CKD and advanced CKD groups (87.8 vs. 82.0, p < 0.001) (Table 4). Medical complications were not different, except for sepsis in CKD stage 5 compared with stage 1 (17.7% vs 0.0%, p = 0.023) as demonstrated in Table 6. Even though modified AO/OTA types (p = 0.023) were more severe and appropriate NSA (p = 0.024) was at a lower rate in the advanced CKD group (Table 4), surgical complications and one-year mortality were not different among any groups (CKD stage 1, 2, 3, 4, and 5 were 16.3%, 12.3%, 9.4%, 0.0%, and 5.0%, respectively with p = 0.232 as shown in Table 6).

Table 4 Demographic Data, Comorbidity, Surgical parameters and Functional outcome between Non-Advanced Chronic Kidney Disease (CKD) and Advanced Chronic Kidney Disease (CKD) groups.

Parameters	Non-Advanced CKD (n = 402)	Advanced CKD (n = 43)	P-value
Demographic Data
Age	80.4 ± 8.5	83.2 ± 8.2	0.039
Gender			0.725
Female	286 (71.1%)	32 (74.4%)
Male	116 (28.9%)	11 (25.6%)
BMI (kg/m2)	22.5 ± 3.9	21.4 ± 2.9	0.069
Comorbidity
Type 2 DM	119 (29.6%)	17 (39.5%)	0.179
Hypertension	273 (67.9)	38 (88.4)	0.005
Dyslipidemia	178 (44.3)	23 (53.5)	0.249
ASA class			0.011
1	9 (2.2)	0 (0.0)
2	126 (31.3)	5 (11.6)
3	267 (66.4)	38 (88.4)
CCI	4.6 ± 1.6	5.9 ± 1.7	<0.001
Total Hip BMD (T-score)	−3.0 ± 0.7	−2.9 ± 1.0	0.609
Modified AO/OTA			0.023
31A1.3	181 (45.0%)	12 (27.9%)
31A2.2	158 (39.3%)	18 (41.9%)
31A2.3	63 (15.7%)	13 (30.2%)
Nail Shaft Axis (NSA)			0.024
−2 to +2	319 (79.4%)	27 (62.8%)
<-2	47 (11.7%)	11 (25.6%)
>2	36 (8.9%)	5 (11.6%)
Harris Hip Score (HHS)
Pre-injury HHS	88.7 ± 6.9	83.1 ± 9.6	0.003
One-year postoperative HHS	87.8 ± 0.4	82.0 ± 1.5	<0.001
HHS by grading			0.467
Excellent (90–100)	200 (56.2%)	13 (31.0%)
Good (80–89)	104 (29.2%)	15 (35.7%)
Fair (70–79)	44 (12.4%)	10 (23.8%)
Poor (<70)	8 (2.3%)	4 (9.5%)

Table 5 Surgical and medical complication between Non-Chronic Kidney Disease (Non-CKD) and Chronic Kidney Disease (CKD) groups.

Parameters	Non-CKD (n = 43)	CKD (n = 402)	P-value
Surgical complications (n = 396)
Surgical site infection	0 (0.0%)	2 (0.6%)	1.000
Hematoma	0 (0.0%)	1 (0.3%)	1.000
Deep wound infection	0 (0.0%)	3 (0.8%)	1.000
Mechanical failure
-Blade cut out	1 (2.5%)	7 (2.0%)	0.577
-Blade cut through	1 (2.5%)	3 (0.8%)	0.348
-Varus collapse	0 (0.0%)	3 (0.8%)	1.000
Medical complication (n = 396)
Congestive heart failure	0 (0.0%)	1 (0.3%)	1.000
Pneumonia	1 (2.5%)	5 (1.4%)	0.474
Deep vein thrombosis	0 (0.0%)	3 (0.8%)	1.000
Pulmonary embolism	0 (0.0%)	1 (0.3%)	1.000
Sepsis	8 (2.3%)	4 (9.5%)	0.608
One year mortality	7 (16.3%)	10 (9.9%)	0.195

Table 6 Surgical and medical complication among Chronic Kidney Disease (CKD) subgroups.

Complications	Stage 1	Stage 2	Stage 3	Stage 4	Stage 5
Surgical
Surgical site infection	0 (0.0%)	2 (1.2%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Hematoma	0 (0.0%)	0 (0.0%)	1 (0.6%)	0 (0.0%)	0 (0.0%)
Deep infection	0 (0.0%)	0 (0.0%)	2 (1.3%)	0 (0.0%)	1 (5.9%)
PFNA blade cut-out*	1 (2.5%)	4 (2.4%)	3 (1.9%)	0 (0.0%)	0 (0.0%)
PFNA blade cut through*	1 (2.5%)	0 (0.0%)	2 (1.3%)	0 (0.0%)	1 (5.9%)
Varus collapse	0 (0.0%)	1 (0.6%)	1 (0.6%)	0 (0.0%)	1 (5.9%)
Medical
Congestive heart failure	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)
Pneumonia	1 (2.5%)	0 (0.0%)	4 (2.5%)	1 (7.1%)	0 (0.0%)
Deep vein thrombosis	0 (0.0%)	1 (0.6%)	1 (0.6%)	1 (7.1%)	0 (0.0%)
Pulmonary embolism	0 (0.0%)	0 (0.0%)	1 (0.6%)	0 (0.0%)	0 (0.0%)
Sepsis	0 (0.0%)	4 (2.4%)	3 (1.9%)	0 (0.0%)	3 (17.7%)
Urinary tract infection	3 (7.5%)	4 (2.4%)	8 (5.0%)	2 (14.3%)	1 (5.9%)
One-year mortality (p = 0.232)	6(16.3%)	19(12.3%)	15(9.4%)	0 (0%)	1 (5.0%)

4 Discussion

Osteoporotic hip fracture has been a major problem found in the elderly,¹^,²^,⁴ has high mortality and diminished function outcome.^5–7 Intertrochanteric fracture is one of the most common osteoporotic hip fractures, with operative fixation as treatment of choice.⁸ Post-operative rehabilitation is essential for recovery, starting within 48-h post-operation and continuing until the patient achieves pre-fracture ambulation capabilities.^26–28 This rehabilitation protocol required muscle function to facilitate ambulation. However, sarcopenia, found in the elderly and CKD patients, may delay the process and result in poorer functional outcomes. CKD, also found in this advanced aging group due to decreased GFR, may cause inferior bone and muscle quality.¹⁹^,²⁴ Thus, osteoporotic patients with an additional CKD may have a higher incidence of hip fracture^29–32 and other undesirable outcomes.

Our study showed that more advanced stages of chronic kidney disease significantly affect the postoperative functional status, fracture pattern, and the nail-shaft-axis.³³ In addition, the incidence of sepsis in CKD stage 5 increased. There was no previous study pointing out the difference in post-operative functional status, more severe fracture pattern, and more medial nail-shaft-axis in those with advanced CKD.

There was no difference in functional outcome assessed by HHS between CKD and non-CKD groups. Similarly, in Zhang's study,¹⁸ the CKD and non-CKD have shown no significant difference in mechanical failure after PFNA fixation. The CKD group combined all the CKD patients, meaning that only the more advance stages of CKD have enough compelling consequences, such as sarcopenic status and bone quality, leading to more comminuted fracture type and lower post operative functional scores. Our result suggested that the effect starts from stage 4 of chronic kidney disease. However, poor bone quality suspected in advanced stage CKD patients does not represent through their bone mass density (BMD) results as there is no statistical difference between groups and the BMD data is only available in 60–70% of all patients. This limitation should be carefully interpreted. Lower BMI in advanced CKD stages may also indirectly correlate to the functional outcomes through sarcopenia and nutritional status.

Other factors that could potentially affect post-operative outcome suggested by precedented investigation,¹³^,¹⁴^,¹⁸ such as quality of reduction measured by Cleveland zone and Baumgartner criteria, are comparable between groups. Nevertheless, advanced stages of CKD have a more unstable intertrochanteric fracture pattern, which could lead to more unfavorable events. A non-significant difference in bone mineral density, which represents bone quantity, could suggest that advanced CKD may affect the bone quality or other factors such as sarcopenia or higher fall risk that can lead to a more severe fracture pattern.

Nail-shaft-axis³³ represent the position of the intramedullary nail, especially at the entry point. Our study displays that the nail-shaft-axis became more medial as the stages advanced. After discussions with the operating surgeons, we concluded that the more comminuted fracture type could potentially have made anatomic reduction more difficult. Moreover, the concern of lateral wall fracture of more advanced CKD patients and comminuted fracture type made the surgeons choose more medial entry points than usual. However, the quality of reduction and surgical complications (including mechanical failure within 1 year) are not different between groups.

The mortality rate is insignificant between stages of CKD at one year. The already high rate of mortality of osteoporotic hip fracture may have more impact in our study, or the small sample size of our advanced stages patients may be too limited to determine the difference in the first-year mortality. Our overall 1-year mortality is 10.6%, comparable to other studies treated operatively.¹⁵ Nevertheless, Bae³⁴ claimed that advanced stages of CKD do affect the mortality rate at one year post-operatively.

Our study firstly demonstrated the distinction of functional outcome of operatively treated intertrochanteric fracture at one year between advanced stage CKD patients and non-advanced ones. We also showed that the fracture pattern became more severe with the advancement of CKD. However, the study's constraints are retrospective to design and limited sample size.

5 Conclusion

Advanced stage CKD (eGFR <30 ml/min/1.73m2) is associated with a lower functional outcome of intertrochanteric fracture treated with PFNA fixation at one year. Sepsis is more prone to occur after surgery in CKD stage 5. The vulnerable group required constant care from the pre, intra, and postoperative periods.

Ethical approval and consent to participate

This study followed the “Declaration of Helsinki” and was approved by the Institutional Review Board. The study has been approved with a code of S032h/64_Exp.

Consent to publish

Consent was obtained from all patients to publish quotations anonymously.

Author's contributions

All authors designed the protocol, read, and approved the final manuscript.

O.P. Generating the idea, collecting data, writing the manuscript, S.P. and Y.S. collecting data, sorted out the material and assisting in the discussion part, A.L. assisting in the discussion part and analyzing the data.

Funding

There is no funding for this article.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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