Rev. bras. ortop. vol.52 suppl.1

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

Article

Influence

of

proximal

femur

fractures

in

the

autonomy

and

mortality

of

elderly

patients

submitted

to

osteosynthesis

with

cephalomedullary

nail

夽

Rodrigo

Souto

Borges

Petros

∗

_,

_Paula

_Emília

_Valente

_Ferreira,

_Rafael

_Souto

_Borges

_Petros

CentroOrtopédicoTraumatológicoTijuca,HospitalTijutrauma,RiodeJaneiro,RJ,Brazil

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Articlehistory:

Received30November2016 Accepted26January2017 Availableonline26August2017

Keywords:

Hipfractures Femoralfractures Independentliving Ambulation Elderly

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Objective:Todeterminetheautonomyandmortalityofelderlypatientssubmittedto proxi-malfemoralosteosynthesiswithcephalomedullarynailafterhipfracture.

Methods:Retrospectivestudywith61patientswithproximalfemoralfracturessubmittedto cephalomedullarynailosteosynthesis.Theauthorsanalyzedthemedicalrecordsand col-lectedinformationfromthepreoperativeperiod.Patientswerequestionedregardingpain, postoperativeautonomy,anddegreeofsatisfaction.Thetotalnumberofdeathswasverified. Theresultswerethencorrelated.

Results:Themeanagewas84years,predominantlyfemale(82%).Inthepostoperative eval-uation,45%ofthepatientspresentedworsenedlevelsofautonomy.Themajorityofpatients presentedmildpain(61%)ontheVASscale.Themortalityratewas24.6%,andthemean timeofpreoperativehospitalizationwasthreedays.Thefactorsthatpresentedstatistical significanceregardingpostoperativeautonomywerethetimeelapsedfromthetraumauntil themomentofsurgery,ASAscore,fracturestability,andpreviousfunctionalstatusofthe patients.Themortalityratewasassociatedwiththreemainfactors:advancedage,ASA score,andpreoperativehospitalizationtime.

Conclusion: Thepatient’spreviousautonomypositivelyinfluencedthefunctionaloutcome andpostoperativerecovery.Unstablefracturespresentedworseresultsforpainand ambu-lationinafollow-upof27months.Hipfractureisariskfactorassociatedwithmortalityand decreasedindependenceinpatientsover65yearsofage.

夽

StudyconductedatHospitalTijutrauma,CentroOrtopédicoTraumatológicoTijuca,RiodeJaneiro,RJ,Brazil.

∗ _{Corresponding}_author_.

E-mail:rodpetros@yahoo.com.br(R.S.Petros).

http://dx.doi.org/10.1016/j.rboe.2017.08.014

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Influência

das

fraturas

do

fêmur

proximal

na

autonomia

e

mortalidade

dos

pacientes

idosos

submetidos

a

osteossíntese

com

haste

cefalomedular

Palavras-chave:

Fraturasdoquadril Fraturasdofêmur Vidaindependente Deambulac¸ão Idoso

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e

s

u

m

o

Objetivo: Determinara autonomiaeamortalidadedepacientesidososapósfraturado quadrilsubmetidosaosteossíntesedofêmurproximalcomhastecefalomedular.

Métodos: Estudoretrospectivocom61pacientescomfraturadofêmurproximalsubmetidos aosteossíntesecomhastecefalomedular.Osprontuáriosforamanalisadoseosregistros clínicosdopré-operatórioforamcoletados.Ospacientesforamreavaliadoseperguntados emrelac¸ãoador,autonomiapós-operatóriaegraudesatisfac¸ão.Foiverificadoonúmero totaldeóbitos.Osresultadosforamentãocorrelacionados.

Resultados: Amédiadeidadefoide84anos,compredominânciadosexofeminino(82%). Na avaliação pós-operatória, 45% dos pacientes apresentaram pioria em seu nível de autonomia.A maioriados pacientesapresentoudor leve(61%)pelaescalaEVA.Ataxa de mortalidadeencontradafoi de24,6%eotempomédiodeinternação pré-operatória foi detrêsdias.Osfatoresqueapresentaramsignificânciaestatísticaquantoà autono-miapós-operatóriaforamotempodecorridodotraumaatéomomentodacirurgia,escore ASA,estabilidadedafraturaeestadofuncionalpréviodopaciente.Ataxademortalidade foiassociadaatrêsfatoresprincipais:idadeavançada,escoreASAetempodeinternação pré-operatória.

Conclusão:Aautonomiapréviadopacienteinfluencioupositivamenteoresultadofuncional earecuperaçãopós-operatória.Fraturasinstáveisapresentarampioresresultadosparador edeambulaçãoemumseguimentode27meses.Afraturadoquadriléumfatorderisco associadoàmortalidadeediminuiçãodaindependênciaempacientesacimade65anos.

Introduction

Theincidenceofproximalfemoralfractureshasincreased sig-nificantlyinthelastdecadesandisexpectedtodoublewithin thenext25years,duetoincreasinglifeexpectancy.Olderage andassociatedcomorbiditiesare responsible forhigh mor-bidity and mortality, as well as higher costs oftreatment and hospitalization.1 _Among _proximal _femoral _fractures,

the transtrochantericfracture is animportantgroup, since theyare commonandusuallyaffectdebilitatedandelderly patients.2,3_These_fractures_are_defined_as_those_occurring_in

theareaextendingfromtheextracapsularregionofthebase ofthe femoral neckto a proximalregion along the minor trochanter.4

Thistypeoffractureiscommonintheelderlypopulation duetoosteoporosis,andismainlyassociatedwithlow-energy trauma,suchasfallfromtheirownheight.Itisestimatedthat nineoutoftentrochantericfracturesoccurinindividualsolder than65years.5,6

Hip fracture is a devastating injury in elderly patients, affectingtheirphysical,mental,functional,andsocial func-tion.Itreflectstheagingprocessofthepopulation,andhas permanentconsequenceson patientsurvivaland indepen-dence.

Surgical stabilization isthe option of choiceto manage trochantericfractures,regardlessofdeviationtypeorpattern. Thegoalofsurgicaltreatmentistoachievestablereduction

andfixation,allowingearlyactiveandpassivemobilization. Sinceelderlyindividualsarenotalwaysabletowalkwithout placing some load on the fractured limb, due to the pre-existing conditions,fracturestabilizationmustbesufficient toallowacertainloadtoleratedbythepatient.7

Studies demonstrate that up to 50% of patients with proximal femoralfractures diewithin the first sixmonths after trauma, and that many patients submitted to sur-gical treatment do not regain their baseline function and independence.8

Thisstudy aimedto determinetheautonomy and mor-tality ofelderly patientswho underwent proximalfemoral osteosynthesiswithcephalomedullarynailafterhipfracture.

Methods

Alongitudinal,retrospective,anddescriptivestudywas per-formedwith61patientswithproximalfemoralfracturewho underwentosteosynthesiswithcephalomedullarynailfrom March 2012to March2014, at the Hospitalde Ortopedia e Traumatologia,RiodeJaneiro,Tijutrauma.

Patients’medicalrecordswereanalyzedandinformation fromthepre-operativeclinicalrecords(clinicalevolutionand surgicalrisk)wascollected.

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(ASA)score;andpre-traumaautonomy,dividedintofive walk-ingpatterns:(1) Walksoutsidehomecommunity distances withouthelp;(2)Walksoutsidehomecommunitydistances withhelp; (3) Walkshousehold distanceswithout help; (4) Walks household distances with help; (5) Non-ambulatory orwheelchairuser.Patientswithincompletemedicalcharts wereexcludedfromthesample.

Aftercollection ofcomplete preoperative data, patients wereinterviewedandunderwentclinicalevaluationtoassess painthroughavisualanalogscale(VAS),postoperative walk-ingstatus,anddegreeofsatisfaction.Atfollow-up,thetotal numberofdeathsaftersurgicaltreatmentwasusedto deter-mine the mortality rate. Patients who did not attend the intervieworwhowerelostfollow-upwereexcluded.

Datacollectedinthepre-andpostoperativeperiodswere then correlated with mortality and with influence on the patients’autonomy.

Forstatisticalanalysisoftheresults,tableswithabsolute and relative frequencydistribution were used. The associ-ationswere testedbyPearson’schi-squaredtestorFisher’s exacttest.NormalitywasassessedbytheShapiro–Wilktest, andcontinuousvariableswereassessedbyStudent’st-testor ANOVA.

Results

Themeanageofthepatientswas84years(±7.2),rangingfrom 67to97.Themalegrouppresentedaslightlyhighermeanage thanthefemalegroup(86[±8.0]yearsvs.83[±7.0], respec-tively,withoutstatisticalsignificance[p=0.260]).Lateralityof theaffectedhipwassimilar(50.8%and49.2%,respectively).

Asignificant difference wasobserved in the prevalence betweensex(p<0.001);asmostcases(82.0%)werefemale,that is,onaverage,surgicalproceduresforproximalfemoral frac-turewereperformed4.5timesmoreofteninwomenthanin men(Fig.1).

Regardingfractureclassification,24 patients(39.3%) pre-sentedTronzo typeIII, whiletypeIIwasobservedin24.6% (Table1).

Meanhospitalizationtimewas9days,rangingfrom2to 27.Meanhospitalizationtimebeforesurgerywas3days,

ran-Female 82% p < 0.0001 Males

18%

Fig.1–Frequencybysexoftheelderlysubmittedto surgicaltreatmentwithtranstrochantericfracture.

Table1–Correlationbetweenoperatedpatientsandthe Tronzoclassification.

Tronzo n %

I 5 8.2

II 15 24.6

III 24 39.3

IV 12 19.7

V 5 8.2

Total 61 100

0 2 4 6 8 10 12 14 16 18 20

V IV

III II

I

Days

Tronzo

Comparison between the Tronzo classification and time of hospital stay

Pre-operative hospitalization Total time of hospital stay

Fig.2–ComparisonbetweentheTronzoclassificationand hospitalizationtime.

gingfrom1to14.PatientsclassifiedasTronzotypeVhadthe highestmeanpre-operativehospitalization:7days(p=0.0047) (Table2andFig.2).

Inthepreoperativeassessment,21patientswereableto walk outside homeforcommunitydistanceswithout help. Aftersurgery,15patients(71.4%)maintainedthiscondition and33.3%worsenedtheirwalkingstatus.Ofthepatientswho wereabletowalkoutsidetheirhomeforcommunitydistances withhelp,six(50%)maintainedtheirconditionand50% wors-ened.Ofthe10patientswhowereabletowalkforhousehold distanceswithouthelp,44.4%maintainedtheirconditionand 55.6%worsened. Ofthe patientswhowere abletowalkfor householddistanceswithhelp,60.0%maintainedtheir con-ditionand40.0%worsened.Therefore,whencomparingthe pre-andpost-operativegeneralambulationstatus,45%ofthe patientspresentedadecreaseintheirleveloffunctional inde-pendence(Table3).TheVASscalewasappliedaftersurgery and mostpatients (60.9%)presentedmildpainwhile37.0% presentedmoderate pain. Onlyone patient(2.2%) reported severepain.Whenaskedaboutthedegreeofsatisfaction,90% ofthepatientsweresatisfiedwiththeresultofthesurgery;the remaining10%weredissatisfiedwithnotbeingabletowalk orwithlivinginnursinghomes,astheydidnotregaintheir previousindependence.

Patients with a moresevere Tronzo score had a higher meanVAS,butthedifferencewasnotstatisticallysignificant (p=0.057).

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Table2–ComparisonbetweentheTronzoclassificationandmeantimeofhospitalstay.

Tronzo Meanpre-operativehospitalization p Meantotaltimeofhospitalstay p

I 1.8 0.0047 6.6 0.0020

II 3.6 10.3

III 2.0 7.0

IV 3.3 9.3

V 7.0 18.0

Total 3.1 9.1

Table3–Comparisonbetweenpre-andpost-operative walkingstatus.

Walkingstatus Evaluation

Pre-operative Post-operative

n % n %

Walksoutsidehomefor communitydistances withouthelp

21 45.7 15 32.6

Walksoutsidehomefor communitydistances withhelp

6 13 8 17.4

Walksforhousehold distanceswithouthelp

9 19.6 3 6.5

Walksforhousehold distanceswithhelp

10 21.7 13 28.3

Non-ambulatory, wheelchairuser

0 0 7 15.2

Total 46 100 46 100

0 2 4 6 8 10 12

Moderate or severe Mild

Days

EVA

Comparison between level of pain (VAS) and time of hospital stay

Pre-operative hospitalization Total time of hospital stay

Fig.3–Comparisonbetweenlevelofpain(VAS)and hospitalizationtime.

scale (p=0.016), aswastotal hospitalizationtime (p=0.026;

Fig.3).

Fifty-eightpatients(95.1%)hadatleastonepreoperative comorbidity.Onlythreepatients (4.9%)had nopre-existing disease.

The five most common co-morbidities were: SAH (39 patients; 63.9%), dyslipidemia(14 patients, 22.9%),diabetes (10patients,16.4%),cardiopathy(sevenpatients,11.5%),and hypothyroidism(sevenpatients,11.5%).

The mortality rate found in the study was 24.6% (15 deaths). Three factors were significantly associated with highermortalityinthesepatients:advancedage,ASAscore, andpreoperativehospitalizationtime(Table4).Meanageof the patients who died was 87.6 years,versus 82.5 ofthose patientswhowerealive(p=0.016).PatientsclassifiedasASAIII

Table4–Factorsassociatedwithhighermortalityrate.

Variable Alive

n=46

Death

n=15

p

Age–mean(±SD) 82.5(±6.7) 87.6(±7.5) 0.16

Gender–n(%)

Male 7(63.3%) 4(36.4%) 0.810 Female 39(78.0%) 11(22.0%)

Tronzo–n(%)

Stable 16(80.0%) 4(20.0%) 0.561 Unstable 30(73.2%) 11(26.8%)

ASA–n(%)

IandII 26(86.7%) 4(13.3%) 0.45 IIIandIV 20(64.5%) 11(35.5%)

Preoperativehospitalization–n(%)

Upto48h 30(85.7%) 5(14.3%) 0.30 Over48h 16(61.5%) 10(38.5%)

Associatedlesion,n(%)

Zeroto3 35(81.4%) 8(18.6%) 0.093 Over3h 11(61.1%) 7(38.8%)

Totaltimeofhospitalstay–n(%)

Upto7days 25(78.1%) 7(21.9%) 0.605 Over7days 21(72.4%) 8(27.6%)

orIVpresentedahighermortalityratethanthoseclassifiedas ASAIorII:35.5%versus13.3%,respectively.Regardingthe pre-operativehospitalizationtime,themortalityrateofpatients whowereoperatedonwithin48hofthefracturewas14.3%.In patientswhowereoperatedonafterover48hofthefracture, themortalityrateincreasedto38.5%.

Factors suchas Tronzoclassification,gender, numberof associateddiseases,andtotalhospitalizationtimewerenot associatedwithmortality.

Discussion

Transtrochantericfemoralfracturesarethemostfrequently operatedfracturetype,andpresentthehighestpostoperative mortalityrate;theyhavebecomeapublichealthcareissue, duetothehighcostoftreatmentandthedifficultyof recover-ingpostoperativefunctionalindependence.4

Theepidemiologicalprofileoftheindividualsinthepresent sample was not much different from those observed in Brazilian and internationalstudies.In the present study,a predominanceoffemaleswasobserved,ata4.5:1ratio;their mean age was 84 years.Comparing withBrazilianstudies, HungriaNetoetal.2_found_a_predominance_of_women_in_the

proportionof2:1andameanageof78.2years;Ramalhoetal.9

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Inthepresentstudy,weobservedthatthedegreeof auton-omydecreasedaftersurgicaltreatment.8_Nonetheless,_55%_of

thepatientsrecoveredtheirfunctionallevel.Asimilarfinding wasobservedbyHerreraetal.10_in_their_work_with₂₅₀_patients

treatedwithcephalomedullarynail,inwhichapproximately 50%recoveredtheirpreviouswalkingstatusafteroneyear.

Patients’ previous autonomy positively influenced the functional outcome and the postoperative recovery. We observedthat71.4%ofpatientswhowereabletowalk out-sidehomeforcommunitydistanceswithouthelpmaintained theirlevelaftersurgery.Thisdemonstratesthatmore physi-callyindependentpatientspresentbetterresults.Zuckerman etal.11,12 _observed_that_the_group_of_patients_with_the_best

pre-fracturescorerecoveredalmost100%oftheirfunctional capacity.

Regarding pain intensity after surgical treatment of transtrochanteric fractures, most operated patients (60%) had mildpain; similar datawere retrieved inthe Brazilian literature.13

Themortalityratein thepresent study was 24.6%,ata meanfollow-upof27months.Inastudywith1448patients, Rossoetal.14_found_a_mortality_rate_of_18.8%_in_one_year_of

follow-up,whileDousaetal.,15_in_a_study_with₄₂₈₀_patients,

observeda30%deathrate.

Cooperetal.16_stated_that_the_consequences_of_a_hip

frac-tureincludeprematuredeath(around20%inoneyear),lossof function(in30%),inabilitytowalkindependently(40%),and lossofatleastoneindependentdailyactivity(in80%ofthe patientstreated).

Some factors were statisticallysignificant formortality, suchastimeelapsedfromtraumatosurgery,ASAscore, frac-turestability,andageatthetimeoftrauma.

Inthepresentstudy,patientswithpreoperative hospital-izationtime greater than 48h had a 38.5% mortality rate, whilepatientswho underwent surgical treatmentin up to 48hhadalowerrate,14.3%.Regardingthetimeofsurgical delay,Hamlet et al.17 _demonstrated _that _patients _operated

withinthefirst 24hofadmissionhad lowermortalitythan thoseoperatedafter24h,regardlessofthepreoperativeASA score.Thehighermortalityrateassociatedwithsurgicaldelay demonstratestheimportanceoftheearlytreatmentofthese fractures,whicharenowtreatedasorthopedicemergencies. Somefactorsunderminetheimprovementofthistreatment, suchasovercrowdingofpublichospitals,bureaucracyfor sur-gical authorization, availability ofthe necessary materials, andavailabilityofmedicalstaff.

Anotherfactorthatwasstatisticallysignificantfor mortal-itywastheASAscore.Onlyfourdeaths(6.5%)wereobserved inpatientsclassifiedasASAIandII,versus11(18%)inpatients classifiedasASAIIIandIV.Micheletal.18_demonstrated_that

patients classified as ASA III or IV had a nearly nine-fold greaterriskofdeathinthefirstpostoperativeyearthanthose classifiedasASAIorII(p<0.001).

Conclusion

Patient’spreviousautonomypositivelyinfluencedfunctional outcomeandpostoperativerecovery.

Inafollow-upof27months,unstablefracturespresented worseresultsforpainandwalkingstatus.

Hipfractureisariskfactorassociatedwithmortalityand decreased autonomyinpatients agedover 65 years.These fractures are devastatinginjuriesthatshould betreatedas orthopedicemergencies.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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