Rev. bras. ortop. vol.51 número5

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Factors

associated

with

mortality

among

elderly

people

hospitalized

due

to

femoral

fractures

夽

Léo

Graciolli

Franco

∗

_,

_Amanda

_Loffi

_Kindermann,

_Lucas

_Tramujas,

_Kelser

_de

_Souza

_Kock

UniversidadedoSuldeSantaCatarina,HospitalNossaSenhoradaConceic¸ão,Tubarão,SC,Brazil

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Articlehistory:

Received29September2015 Accepted15October2015 Availableonline17August2016

Keywords:

Femoralfractures Elderly

Hospitalmortality Survivalanalysis

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Objective:Toanalyzefactorsassociatedwithmortalityamongelderlypeoplehospitalizedin asingle-centerregionalhospitalduetofemoralfractures.

Methods:Thiswasaretrospectivecohortstudy.Patientsaged60yearsoroverwhowere hospitalizedwithadiagnosisoffemoralfracture(ICDS72)between2008and2013were selectedthroughtheelectronicmedicalrecords.

Results:The study evaluated 195individualsof meanage 78.5±9.6years; females pre-dominated(68.2%). Themainmechanismforfallswaslow-energy(87.2%).Surgerywas performedon93.3%ofthepatients;themeanlengthofhospitalstaywas13.6±7.5days andthemeanwaitingtimeforthesurgerywas7.7±4.2days.Theprevalenceof mortal-itywas14.4%,andthisoccurredmostlyamongolderindividuals(p=0.029);patientswith leukocytosis(p<0.001);thosewhoneededintensivecare(p<0.001);andthosewhodidnot undergosurgery(p<0.001).Themeansurvivalwassignificantlylongeramongpatientswho underwentsurgeryandshorteramongthosewhoneededintensivecare.

Conclusion: Womenpredominatedamongthehospitalizations,andthedegreeof leukocy-tosisassociatedwithadvancedagepresentedarelationshipwithmortality,independentof thetypeoflesionorsurgicalprocedure.Morestudiesstillneedtobeconductedinorderto assessotherfactorsassociatedwithmortality.

Fatores

associados

à

mortalidade

em

idosos

hospitalizados

por

fraturas

de

fêmur

Palavras-chave:

Fraturasdofêmur Idoso

Mortalidadehospitalar Análisedesobrevida

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Objetivo:Analisarosfatoresassociadosàmortalidadeemidososhospitalizadosporfratura defêmuremumhospitalunicêntricoregional.

Métodos:Estudo de coorte retrospectiva. Foram selecionados, por meio do prontuário eletrônico,pacientesinternadoscomdiagnósticodefraturadefêmur(CIDS72)com60anos oumaisde2008a2013.

夽

StudyconductedattheHospitalNossaSenhoradaConceic¸ão,Tubarão,SC,Brazil. ∗ _{Corresponding}_author_.

E-mail:leosarandi@hotmail.com(L.G.Franco). http://dx.doi.org/10.1016/j.rboe.2016.08.006

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Resultados: Foramavaliados195indivíduoscomidademédiade78,5±9,6eogênero fem-ininofoimaisprevalente(68,2%).Oprincipalmecanismodequedafoiodebaixaenergia (87,2%),afeituradecirurgiafoide93,3%,otempodeinternac¸ãomédiofoide13,6±7,5dias, otempodeesperaparaacirurgiamédiofoide7,7±4,2dias.Aprevalênciademortalidade foide14,4%,ocorreuprincipalmentenosindivíduosmaisidosos(p=0,029),comleucocitose (p<0,001),comnecessidadedecuidadosintensivos(p<0,001)equenãoforamsubmetidos acirurgia(p<0,001).Asobrevidamédiafoisignificativamentemaiornospacientes sub-metidosacirurgiaeinversamentenospacientesquenecessitaramdaunidadedeterapia intensiva.

Conclusão: Asmulherespredominaramnasinternaçõeseograudeleucocitoseassociado aidadeavançadaapresentourelaçãocomamortalidade,independentementedotipode lesãoeprocedimentocirúrgico.Aindadevemserfeitosmaisestudosparaavaliaroutros fatoresassociadosàmortalidade.

Introduction

TheWorld Health Organization(WHO) classifies aselderly every individual aged 60 years or more.1 _This _population

samplepresents anacceleratedincreasingpercentagerate, generatinganincreaseintheprevalenceofchronic degener-ativediseases.2

AccordingtoMonteiro,fallsoftheelderly–inadditionto theinjuryitself–arealsodamagingthefamily,astheycreate adependencyduetothelossofautonomyafterthetrauma event,representinganimportantsocial,economic,andpublic healthissue.3_It_is_estimated_that_the_number_of_hip_fractures

worldwidewillreach4.5millioncasesin2050.4

Themainfactorsassociatedwithmortalityafterfracture areage, comorbidities,cognitive status,timebetween frac-tureand surgery,and typeofanesthesia used.5–8 _However,

the association of time until surgery and risk of death is controversial. The literatureindicates that there is a rela-tionshipbetweentimeuntilsurgeryandmortality.9_Altered

laboratorybloodexamssuchasleukocytelevels,whichmay present as a associated factor with death, have also been widelyaddressed.10

From this perspective, the data presented herein is expectedtoleadtoabetterunderstandingofthis problem andcontributetoabettercareofelderlypatientswithfemoral fracture.Therefore,thisstudyaimedtoevaluatethe associ-atedfactorswithmortalityinelderlypatientswithhipfracture duringhospitalization.

Material

and

methods

Thepresentstudy wasaretrospectivecohortof275elderly patients who had femoral fractures from January 2008 to December2013andwereadmittedtoasingle-center,regional referencehospital.

For sample selection, the medical patient record ofthe institutionwascontactedinordertostratifyindividuals hos-pitalizedwithadiagnosisoffemoralfracture(ICD-10S72),who wereolderthanorequalto60yearsintheproposedperiod.

The exclusion criteria comprised incomplete data on the medical charts, misdiagnosis at hospitalization, trans-fer to other hospitals, and re-admissions. The study was approved by the Research Ethics Committee under No. 34735814.2.0000.5369.

Thefollowingvariableswerecollected:gender,age, comor-bidities, type and side of fracture, type of fall, surgical treatment, typeof surgeryand timeuntil surgery,hospital lengthofstay,needforintensivecaretreatment,hematocrit andleukocytesinthefirstweekofhospitalization,and out-come,describedasdischargeordeath.

An anatomicalsubdivision wasused toclassifyfemoral fractureregions.Theproximalpartofthefemurcomprisesthe intracapsularandextracapsularfractures;thejointcapsuleis usedasareference.Inturn,theintermediateportion corre-spondstothefemoralshaft;thefinalsubdivisionconsistsof fracturesofthedistalpartofthefemur.11

DatawerestoredinanExcelspreadsheetandthen trans-ferredtotheSPSS20.0softwareforanalysis.Numerical vari-ableswerepresentedascentraltendencyanddispersion,and categoricalvariablesasabsolutefrequenciesandpercentages. Numerical variables were analyzed using the Kolmogorov–Smirnov normality test. To compare these variables with the outcome, Student’s t-test (p<0.05) was used for data with normaldistribution; for nonparametric variables, the Mann–Whitney test was used (p<0.05). For results with significant difference, accuracy was assessed throughtheareaundertheROCcurve.

For comparison amonggender, ICU hospitalization, and performance of surgery, the chi-squared test was used (p<0.05).Therelativerisksofdeath,withtheirrespective95% confidenceintervals,werecalculated.

Thesurvivalrateofpatientswhorequiredintensivecare and underwent surgerywasanalyzed usingCox regression (p<0.05)andpresentedthroughKaplan–Meiercurves.

Results

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Table1–Characteristicsoftheelderlypatients

hospitalizedforhipfracture.

Variables n(%)

Gender

Female 133(68.2)

Male 62(31.8)

Agea_(years) _78.5_±_9.6

Typesoffracture

Intracapsular 79(40.5)

Extracapsular 96(49.2)

Diaphysis 12(6.1)

Distalfemur 4(2.1)

Notreported 4(2.1)

Sideofthefracture

R 91(46.7)

L 100(51.3)

RandL 1(0.5)

Notreported 3(1.5)

Typeoffall

Low-energy 170(87.2)

High-energy 7(3.6)

Notreported 18(9.2)

Surgery

Yes 182(96.3)

No 13(6.7)

Typeofsurgery

Osteosynthesis 95(48.7)

Totalarthroplasty 44(22.6)

Partialarthroplasty 26(13.3)

Othersb ₃₀_(15.4)

Waitingtimeuntilsurgery 7.7±4.2 Waitingtimeuntilsurgery(days) 13.6±7.5 Hematocritatadmissiona_(days) _33.5_±_5.7 Leukocytesatadmissiona_(mm2₎ ₈₉₂₂_±_5972.6

Comorbidities

Systemichypertension 90(46.2)

Diabetesmellitus 43(23.6)

Cardiacdiseases 41(21.0)

Others 21(9.2)

Outcome

Death 28(14.4)

a _Mean_±_{standard-deviation.}

b _Did_not_undergo_surgery,_type_of_procedure_not_reported,_bipolar

arthroplasty,Ilizarov.Heartfailure,chronicrenalfailure,tumor, COPD,stroke,dementia,hypothyroidism,hearingloss,arthritis.

records,aswellasadmissionswithoutactualfractures,with consequentdischarge,transfers,orre-admissions.Therefore, asampleof195patientswasobtained.Table1describes pop-ulationcharacteristics.

Table2showsthecomparisonbetweentimeuntilsurgery andhospitalization,andhematocritandleukocytecountat admission, forboth discharge and deathgroups. A signifi-cantdifferencewasobservedonlyregardingageandleukocyte count.

Intheanalysisofthenumericalvariablesthatpresented significantdifferencebetweendischargeanddeathfromthe perspectiveofthe ROCcurve,theaccuracyfordeath prog-nosisobtainedbythe areaunderthe curvewas0.761(95%

1.0

0.8

0.6

0.4

0.0 0.2 0.4 0.6

1 - Specificity

Sensitivity

0.8 Leukocytes Age Reference line

1.0 0.2

0.0

Fig.1–ROCcurveofage,whitebloodcells,anddeath prognosis.

CI:0.664–0.859), p<0.001for leukocytes,and 0.643 (95%CI: 0.525–0.762),p<0.023forage(Fig.1).

In the comparison of outcome and gender, no signifi-cantdifferencewasobserved:16.2%malesand13.5%females (p<0.630).However,individualsrequiringICUadmission pre-sented a relative risk of death of 10 (95% CI: 4.1–24.4); non-performanceofsurgeryshowedarelativeriskof30.4(95% CI:7.6–120.6),bothwithstatisticalsignificance(p<0.001).

ThemeansurvivalofpatientshospitalizedintheICUwas 28.2 days(95%CI:22.1–34.4);forthosewho didnotrequire ICU admission,47 days(95% CI:36.5–57.5),with significant difference(p<0.001)(Fig.2).

Themeansurvivalofpatientswhodidnotreceivesurgery was 11.7 days (95%CI:7.9–15.5); forthose who underwent surgery,itwas45.8days(95%CI:37.9–53.8),withsignificant difference(p<0.001)(Fig.3).

Discussion

Regardinggender,thepresentstudyobservedahighernumber ofwomenwhohadsufferedfemoralfracture.Thisfindingis similartothatofaretrospectivestudyintheLazioregion,with 6896patients,inwhich78%oftheelderlypatientsadmitted withfemoralfracturewerefemales.12

Regarding typeoffractures,ahigherincidenceof extra-capsular fractures was observed when compared with intracapsularfractures.Thisdataiscorroboratedbya retro-spectivestudyof1911elderlypatientswithfemoralfractures thatobservedsimilarprevalence.13

Asforthedynamicsoftrauma,thisstudyshowedahigh prevalenceoflow-energytrauma.Thisfindingisjustifiedby thecharacteristicsofthesample,whichwascomprised pri-marily ofelderly patients. Moraeset al.14 _stated _that _such

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Table2–Comparisonofthenumericalvariablesaccordingtotheoutcomeofdeath.

Discharge Death p-Value

n=167 n=28

85.60% 14.40%

Agea_(years) ₇₈_±_9.5 _82.1_±_9.8 _0.029c

Timeuntilsurgerya_(days) _7.5_±_4.0 _9.44_±_5.1 _0.105

Hospitallengthofstaya_(days) _13.6_±_7.5 _13.6_±_7.7 _0.811

Hematocritb_(%) _33.4_±_5.7 _31.2_±_5.5 _0.06

Leukocytesa_(/mm2₎ _8323.3_±_4645.9 _13,037.9_±_10,836.4 _<0.001c

a _{Mann–Whitney}_test.

b _Student’s_t_-test.

c _p_-Value_<_0.05.

years and ismostlikely tooccur infemales,which would explainthegreaterexposureofwomentofemoralfractures.

In the analysis of survival curve and comparison of individuals with or without surgical indication, a signifi-cantdifferencewasobservedbetweenthesegroups;survival ratewassignificantlyhigherinindividualswho underwent surgery.Rocheet al.15 _concluded_that _the_greatest_risk

fac-torformortalitywasdirectlyrelatedtothepresenceofthree ormorecomorbiditiesevaluatedpreoperatively.Incontrast, anotherstudyshowedthat,forpatientswithoutclinical condi-tionsforsurgery,notperformingsurgerywasthebestchoice, and there was no significant difference in functional out-come and mortalitywhen compared with patients treated surgically.16_Although_the_present_study_did_not_compare

mor-talitywithmorbidities,itcanbededucedthattheearlydeath observedisrelatedtothenumberofcomorbiditiesinthese patients.

Regardingtypeofprocedure,osteosynthesisandtotalor partialarthroplasty were the most frequentchoices. How-ever,surgicalapproachhadnosignificantrelationshipwith recoverytime, nor with death.A Norwegianstudy of4335 elderlypatientscomparedosteosynthesiswitharthroplasty inthetreatment offemoralneckfracture andobservedno

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Time

Survival

60 N Y

Fig.2–Survivalinpatientswhowereorwerenotadmitted totheICU.

differencesinmortalityratesoneyearaftersurgery.Thissame studyfoundthatpatientsundergoingosteosynthesisreported higherpainlevels,greaterdissatisfactionwiththeresultsof surgery,andlowerqualityoflifethanthearthroplastygroup.17

Regardingwaitingtimeuntilsurgery,therewasno signif-icant differencebetweendischargeand deathoutcomesfor thesepatients.Althoughtheliteratureisquitecontroversial,9

accordingtoGrimesetal.,18_time_between_trauma_and_surgery

appearstoinfluencemortalityinelderlypatientswithfemoral fractures.Inastudyof8383subjects,patientswere divided into threegroups:firstgroupwereoperatedwithinthefirst 24hoursafterfracture;secondgroup,after24hoursof frac-ture, but without activedisease; and third groupwas also operated after24hours, but withactivepathology.Patients withactivediseasehadtheirsurgerypostponedduetothe presenceofdecompensateddisease.Attheendofthestudy, the mortality of the individuals operated within the first 24hourswaslower.However,whenthegroupswere homog-enized for presence of associateddiseases, this difference disappeared.18

Thereareseveralpossibleexplanationsforthisfinding.The firstpossibilitymaybelinkedtothefactthattheoccurrence ofmanypost-surgicalcomplicationsinpatientswhodiedmay

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notnecessarilybeassociatedwithwaitingtime.Secondly, dur-ingthecollectionphase,amarkedpatternofpostponementof surgicalprocedureswasobserved(althoughnotdescribedin thestudy),duetoeitherlackofbedsintheICUorinadequate clinicalconditionsofpatients, bothofthosewho were dis-chargedandthosewhodied.However,anobservationalstudy of2660patientsfoundthatdelayingsurgerybyuptofourdays didnotaffectmortality,whileadelayofmorethanfourdays significantlyincreasedmortalityrates.19_{Nevertheless,}_a

sys-tematicreviewof256,367patientsobservedthatadelay of morethan48hoursincreasestheriskofall-causemortalityat 30daysaftersurgerybyupto41%.20

MeansurvivalofpatientswhodidnotrequireICU admis-sion was higher than that of those who did. The main hypothesiswasthatthelatterhadamoreunfavorable clin-icalpicture,agreaternumberofcomorbidities,andolderage whencomparedwithpatientswhodidnotrequireintensive care.However,Fuchsetal.,21_with₇₂₆₅_patients_over₆₅_years,

observedthatthemainreasonforICUadmissionwas asso-ciatedcomorbidities.Oldageshouldbeconsideredasarisk factor,especiallyforpatientsolderthan75yearsadmittedin theseunits.

Fewstudieshavesoughttoanalyzetheprognosticimpact ofinflammatorycellsinfemurfractures.Inthisstudy,a sig-nificantdifferencewasobservedintherelationshipbetween total leukocyte countduring hospitalization and death. In thisrespect,accordingtotheROCcurveanalysis,leukocytes wereshowntohaveadiscriminativeabilitytoidentifythose patientswithfemoralfracturewhohadahigherriskofdeath. Whiteetal.10_observed_a_prevalence_of_leukocytosis_of_43.5%.

However, the high leukocyte count was at the expense of increasingthenumberofneutrophils; thisvariablewasnot evaluatedinthepresentstudy.Thisfindingisrelatively com-moninpatientswithhipfracture,indicatingpossiblepresence ofaprevious infectionor aninfectionthat developedafter thefracture.10 _Thus,_it _is_important_to_note _that _the

cellu-larandhumoralelementsdecreasewithincreasingage;the presentstudyconsistedofelderlypatientswithamean82.1 yearsinthehighermortalitygroup,whichmayexplainthe highermeantotalleukocytecountinpatientswho died.In addition,whenanalyzingtheROCcurve,agealsopresenteda discriminativeabilitytoidentifyindividualsathigherriskof death.

Theoverallmortalityof14.4%canbeconsideredhigh,and isconsiderablydifferentfrom the resultsfoundin interna-tionalstudies,wheredeathrateswerelower.Inaretrospective study inCanada with3981patients, the hospitalmortality ratewas6.3%.22 _In_this_context,_another_{retrospective}_study

inItalywith6629elderlypatients presentedanevenlower rateof5.4%.23_Furthermore,_at_the_national_level,_the_results

ofthisstudyweresimilartoaretrospectivestudythatreported amortality rateof 14.61%. Theliteratureshows that over-all mortality inrelationship to thesetypes offracture has variedamongservices, depending onthe existing hospital complex.24

This study was conducted in a single-center reference regionalhospital.Inthiscontext,theliteratureindicatesthat ininstitutions withhigher volumeofhip surgeries,higher mortalityratesareobserved.Higherin-hospitalmortalityin thesehospitals,whencomparedwithlower-demandservices,

was reflectedinthe present study.24 _In_order_to _generalize

dataforelderlypatientshospitalizedforvarioustypesofhip fracture,theauthorsbelievethereisnoreasonforthistobe different,whichcouldexplainthepresentfindingsregarding deathrates. Moreover,another factorto beassessedisthe perioperativemortality,whichalsocontributestooverall mor-talityrateandisnotassociatedwithqualityofthetherapeutic approachoffered,butrathertotheclinicalconditionofthese patients,whichisusuallyhigh-riskduetotheirageandthe presenceofmanyassociatedcomorbidities.

The association of the fracture site with mortality was notsignificantinthepresentstudy.However,inasystematic reviewwith544,733patients,mortalitywashigherinpatients withintracapsularfracture.Thatstudyalsoobservedageover 85yearsasafactorassociatedwithmortality.Thisfindingis similartothatofthepresentstudy,whichhadasimilarmean ageatdeath.25

Themainlimitationofthepresentstudywasthe inabil-itytocollectdatarelatedtocertainvariables,duetolackof informationinthemedicalcharts,whichmayhave underesti-matedtheactualclinicalconditionofthepatients.Inaddition, thepresentstudywasobservational,sotheassociationsfound donotimplycausality;thepresentfindingsshouldbe con-firmedbyfurtherstudies.

Conclusion

Inthepresentstudy,itwasobservedthatwomencomprised themajorityofadmissions,andthatthedegreeofleukocytosis associatedwithadvancedagewascorrelatedwithmortality, regardlessoftypeofinjuryandsurgicalprocedure.Ahigher meansurvivalrateofpatientswhodidnotrequireICU admis-sionwasalsoobserved.Itisnoteworthythatthewaitingtime forsurgeryand hospitalstay werenot associatedwith the in-hospital mortalityoutcome.Thesefindingshighlight the importanceofdevelopingprotocols forbettermanagement of these patients. They alsoemphasize the importanceof including theassessmentofleukocytesratesintothe clini-calevaluation,asthisvariablepresentedanimportantability topredictworseoutcomes.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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