İbrahim Deniz CANBEYLİ, Meriç ÇIRPAR, Birhan OKTAŞ, Mehmet ÇOBAN

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture

Objective: This study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors formortality in the management of geriatric hip fractures.Methods: A total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60-108] years) with AO/OTA 31A2.2 intertrochantericfractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. Thetreatment type was decided by the responsible surgeon according to the patients’ pre-injury activity level, bone quality, and features of thefracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time tosurgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-yearmortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified thepossible risk factors for mortality.Results: A total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS,2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 withhemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advancedage (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality.Conclusion: We demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated withhigher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factorsin the management of intertrochanteric hip fractures in the geriatric population. Level of Evidence: Level IV, Prognostic Study

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1. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med 1997; 103(2A): 51S-63S; discussion S-4S.

2. Parker M, Johansen A. Hip fracture. BMJ 2006; 333: 27-30.

3. Taylor M, Hopman W, Yach J. Length of stay, wait time to surgery and 30-day mortality for patients with hip fractures after the opening of a dedicated orthopedic weekend trauma room. Can J Surg 2016; 59: 337-41.

4. Browner WS, Pressman AR, Nevitt MC, Cummings SR. Mortality following fractures in older women. The study of osteoporotic fractures. Arch Intern Med 1996; 156: 1521-5.

5. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality following clinical fractures. Osteoporos Int 2000; 11: 556-61.

6. Whitehouse MR, Berstock JR, Kelly MB, et al. Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures. Bone Joint J 2019; 101-B: 83-91.

7. Nie B, Wu D, Yang Z, Liu Q. Comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: A meta-analysis. Medicine (Baltimore) 2017; 96: e7446.

8. Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J 2017; 99-B: 128-33.

9. Geiger F, Zimmermann-Stenzel M, Heisel C, Lehner B, Daecke W. Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg 2007; 127: 959-66.

10. Gurger M. Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study. Niger J Clin Pract 2019; 22: 648-51.

11. Ercin E, Bilgili MG, Sarı C, et al. Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients. Eur J Orthop Surg Traumatol 2017; 27: 101-6.

12. Hu F, Jiang C, Shen J, Tang P, Wang Y. Preoperative predictors for mortality following hip fracture surgery: A systematic review and meta-analysis. Injury 2012; 43: 676-85.

13. Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: Systematic review and meta-analysis. CMAJ 2010; 182: 1609-16.

14. Ireland AW, Kelly PJ, Cumming RG. Risk factor profiles for early and delayed mortality after hip fracture: Analyses of linked Australian Department of Veterans’ Affairs databases. Injury 2015; 46: 1028-35.

15. Zuckerman JD. Hip fracture. N Engl J Med 1996; 334: 1519-25.

16. Jain R, Basinski A, Kreder HJ. Nonoperative treatment of hip fractures. Int Orthop 2003; 27: 11-7.

17. Chlebeck JD, Birch CE, Blankstein M, Kristiansen T, Bartlett CS, Schottel PC. Nonoperative geriatric hip fracture treatment is associated with increased mortality: A matched cohort study. J Orthop Trauma 2019; 33: 346-50.

18. Brox WT, Roberts KC, Taksali S, et al. The American Academy of Orthopaedic Surgeons evidence-based guideline on management of hip fractures in the elderly. JBJS 2015; 97: 1196-9.

19. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001; 15: 394-400.

20. Folbert EC, Hegeman JH, Vermeer M, et al. Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment. Osteoporos Int 2017; 28: 269-77.

21. Jiang HX, Majumdar SR, Dick DA, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res 2005; 20: 494-500.

22. Endo Y, Aharonoff GB, Zuckerman JD, Egol KA, Koval KJ. Gender differences in patients with hip fracture: A greater risk of morbidity and mortality in men. J Orthop Trauma 2005; 19: 29-35.

23. Dobbs RE, Parvizi J, Lewallen DG. Perioperative morbidity and 30-day mortality after intertrochanteric hip fractures treated by internal fixation or arthroplasty. J Arthroplasty 2005; 20: 963-6.

24. Ereth MH, Weber JG, Abel MD, et al. Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992; 67: 1066-74.

25. Khan MA, Hossain FS, Ahmed I, Muthukumar N, Mohsen A. Predictors of early mortality after hip fracture surgery. Int Orthop 2013; 37: 2119-24.

26. Gremillet C, Jakobsson JG. Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study. F1000Res 2018; 7: 1009.

27. White SM, Moppett IK, Griffiths R, et al. Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2). Anaesthesia 2016; 71: 506-14.

28. Sullivan KJ, Husak LE, Altebarmakian M, Brox WT. Demographic factors in hip fracture incidence and mortality rates in California, 2000-2011. J Orthop Surg Res 2016; 11: 4.

29. Bilsel K, Erdil M, Gulabi D, Elmadag M, Cengiz O, Sen C. Factors affecting mortality after hip fracture surgery: A retrospective analysis of 578 patients. Eur J Orthop Surg Traumatol 2013; 23: 895-900.