Factors affecting postoperative mortality of patients with displaced femoral neck fracture

doi:10.1016/j.injury.2006.02.046

Injury

Volume 37, Issue 8, August 2006, Pages 705-711

https://doi.org/10.1016/j.injury.2006.02.046 Get rights and content

Summary

Displaced femoral neck fractures are known to be associated with high rates of mortality. The purpose of the present study is to investigate pre- and postoperative factors which influence this mortality in a series of 1186 consecutive Danish patients presenting to one hospital's orthopaedic department with Garden type 3–4 fractures. Subsequent mortality data was obtained from the state population register (224 were still alive). The stepwise Cox proportional hazards model was used for multivariate analysis in order to obtain the predictors of postoperative mortality.

The median survival of male subjects fell from 5.2 years in an age-matched control population to 1.6 years in the patients. In women survival time fell from 6.6 to 2.8 years. Almost all excess mortality occurred during the first 3 months following hemiarthroplasty. In order of significance, key factors negatively influencing mortality at 3 months were: cardiac complications, dementia, male sex, age, waiting time before operation, stroke and dislocation of the prosthesis and perioperative fracture. Of these, waiting time for surgery and dislocation of the prosthesis could be modified. A number of other studies have confirmed the importance of optimising these factors.

Introduction

Hip fractures, associated with high morbidity and mortality rates (as well as being a major cause of health care expenditure in the elderly), are expected to increase exponentially in frequency over the next 50 years. This is both a result of increased life expectancy and population growth.³¹ In Sweden, it has been estimated that after the age of 50 years, 19.5% of all women will sustain a hip fracture.¹⁵ In the United States, it is estimated that hip fractures account for almost 140,000 nursing home admissions annually.¹³

Several previous studies have investigated factors associated with high rates of morbidity and mortality following operation for a displaced femoral neck fracture. The mortality found in these patients, and especially the mortality in short follow-up studies, varies both across studies and from country to country. Mortality at 3 months has been found to vary between 5% and 24%, while at 1 year, mortality has been found to be between 24% and 29%.8, 10, 18, 27, 29 The most important causes of death seem to be related to cardiac and pulmonary factors.5, 6 However, causes of death vary across studies. This is probably due to the fact that the exact cause of death in the elderly population is often difficult to determine. Hemiarthroplasty is generally used for patients with impaired health. Amongst patients with a proximal femoral fracture, this group of patients has the highest mortality rate.¹⁰ Anaesthetic technique does not seem to have a major impact on postoperative survival.¹⁶ The importance of the interval between injury and surgery has been hotly debated, with conflicting results reported for mortality due to operative delay.1, 3, 9, 17, 18, 32

Though a number of studies have shown a high mortality amongst these patients, more specific pre- and postoperative factors which influence mortality and morbidity are as yet only weakly defined. Most previous studies have included patients with different hip related fracture types: subtrochanteric, intertrochanteric, intracapsular, etc.5, 9, 15, 18, 27, 32 We therefore decided to investigate a population with a more homogenous fracture pattern. Throughout the years, large numbers of patients have been treated for displaced, intracapsular, femoral neck fracture (Garden type 3–4) with hemiarthroplasty in our department. Postoperative outcome with respect to mortality is well-defined for these patients using the Danish nationwide civil registration system. The purpose of this study is thus to investigate which pre- and postoperative factors influence mortality and morbidity in this large series of Danish patients with Garden types 3–4 fractures.

Section snippets

Patients and methods

From 1985 to 1999, a consecutive series of 1700 hemiarthroplasties were performed in our hospital for an intracapsular, displaced fracture of the femoral neck. The indication for hemiarthroplasty was a displaced fracture combined with age over 75 years or with co-morbid severe, disabling illness. Of those included, 87% of patients were older than 75 years and 95% were older than 70 years. The operations were performed by a total of 156 different surgeons on call from the department's staff,

Statistics

For continuous parameters, un-paired t-tests were used to test for differences between groups and for discontinuous parameters, Chi square statistics were used to detect differences between groups. Kaplan–Meier curves were used to describe mortality distributions and the log-rank test was used for comparisons. Stepwise Cox proportional hazards modelling was used for multivariate assessment of the predictors for postoperative mortality.

A significance level of p = 0.05 was used and all calculations

Results

At the time of admission, the median age of the patients was 84 years (range 41–101 years). Patient characteristics are summarised in Table 1. The majority of the patients were female (82%).

Table 2 summarises operative variables: waiting time for surgery, duration of operation, bleeding, blood transfusion and the number of reoperations. Operation time of day (not shown in the tables) was also assessed. Of the 1186 hemiarthroplasties, 42.7% were performed during the day shift (8 a.m. to 4 p.m.),

Discussion

Excess mortality in patients presenting with hip fracture, compared to a background or control population has been well-documented in numerous previous studies.2, 4, 7, 8, 12, 14, 22, 25, 28 One study, however, found excess mortality only in hip fracture patients younger than 85 years.²² In the present study, we found median survival to be reduced by 59% for female fracture patients and by 69% for males compared with the background population rates. To highlight the risk associated with hip

Conclusions

This study of 1186 displaced, intracapsular, femoral neck fractures (Garden type 3–4) treated at the same department in Denmark from 1985 to 1999, concludes that:

(1)
Median survival in male fracture patients was reduced from 5.2 years in age-matched controls to 1.6 years. For female subjects, life expectancy was reduced from 6.6 to 2.8 years.
(2)
Most excess mortality occurred during the first 3 postoperative months.
(3)
In order of significance, the five factors associated with increased mortality at 3

References (32)

C. Bredahl et al.
Mortality after the hip fracture: results of operation within 12 h admission
Injury
(1992)
J.A. Casaletto et al.
Post-operative mortality related to waiting time for hip fracture surgery
Injury
(2004)
J.R. Center et al.
Mortality after all major types of osteoporotic fracture in men and women: an observational study
Lancet
(1999)
J.E. Clague et al.
Predictors of outcome following hip fracture. Admission time predicts length of stay and in-hospital mortality
Injury
(2002)
J.P. Grimes et al.
The effects of time-to-surgery on mortality and morbidity in patients following hip fracture
Am J Med
(2002)
J.A. Kanis et al.
The components of excess mortality after hip fracture
Bone
(2003)
W.S. Browner et al.
Mortality following fractures in older women. The study of osteoporotic fractures
Arch Intern Med
(1996)
S. Eiskjaer et al.
Risk factors influencing mortality after bipolar hemiarthroplasty in the treatment of fracture of the femoral neck
Clin Orthop
(1991)
S. Eiskjaer et al.
Years of potential life lost after hip fracture among postmenopausal women
Acta Orthop Scand
(1992)
L. Forsen et al.
Survival after hip fracture: short-and long-term excess mortality according to age and gender
Osteoporos Int
(1999)

T. Heikkinen et al.

Hip fractures in Finland and Great Britain—a comparison of patient characteristics and outcomes

Int Orthop

(2001)

G.K. Ions et al.

Prediction of survival in patients with femoral neck fractures

J Bone Joint Surg Br

(1987)

L.J. Melton

Adverse outcomes of osteoporotic fractures in the general population

J Bone Miner Res

(2003)

L.J. Melton et al.

Long-term trends in hip fracture prevalence: the influence of hip fracture incidence and survival

Osteoporos Int

(1998)

A. Oden et al.

Lifetime risk of hip fracture is underestimated

Osteoporosis Int

(1998)

D.A. O’Hara et al.

The effect of anesthetic technique on postoperative outcome in hip fracture repair

Anesthesiology

(2000)

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Although a rare complication, dislocation following hemiarthroplasty (HA) for a femoral neck hip fracture is associated with increased mortality, readmission, and possible revision surgery. To date many of the specific risk factors have been difficult to demonstrate. Patient factors, surgical factors, as well as morphological factors need to be assessed. Therefore, the purpose of this study was to elucidate the risk factors for dislocation of HA following femoral neck hip fractures in the geriatric population.
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Hemiparesis increases the risk of femoral neck fracture (FNF) in the elderly, which frequently necessitates hemiarthroplasty. There are limited reports on the outcomes of hemiarthroplasty in patients who have hemiparesis. The purpose of this study was to evaluate hemiparesis as a potential risk factor for medical and surgical complications following hemiarthroplasty.
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Citation Excerpt :
Approximately half of these fractures will be intracapsular for which hemiarthroplasty is the most commonly used method of treatment [2]. Dislocation of a hemiarthroplasty is a devastating complication with a high mortality and occurs in 1–5% of such cases [3–6]. Previous studies have suggested that the risk of dislocation may be increased in those with dementia or neuromuscular conditions [7–10].
The aim of this study is to identify if there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for neck of femur fractures.
Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. Pathological fractures and patients treated with other treatment modalities were excluded. The study population is composed of four groups; patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with mental impairment.
A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe mental impairment with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p = 0.02) while none of the other neuromuscular conditions were statistically significant.
Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson's disease in comparison to other groups. No increase was apparent for those with mental impairment or weakness from a previous stroke.
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Hip fractures often occur in elderly people and are a major global health challenge causing many consequences, both in health and socioeconomic costs. This review aimed to identify complications that occur in patients with postoperative hip fracture between 30 days and 60 months after discharge. This review was conducted on articles published from 2005 to 2017 obtained from the EBSCO, PubMed, ProQuest and Google Scholar databases. The literature search followed PRISMA Guidelines. Key search words included the terms: hip fracture, complication, postoperative, community, and nursing. Articles were considered eligible if discussed the complications of hip fracture with surgical treatment, occurring post hospital discharge and the patient was in the community. In this review, 23 articles were included that met the inclusion criteria. There were 16 articles that cohort studies, 3 were retrospective studies, 3 were randomized control trials and 1 article was an observational study. The time of observation varied from 30 days to the longest of 5 years. Quality assessment of the levels of evidence used the Oxford CEBM recommendations. The review results found that postoperative hip fracture patients after discharge still experienced various complications after 30 days and up to 1–3 years post-operation.
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Factors affecting postoperative mortality of patients with displaced femoral neck fracture

Summary

Introduction

Section snippets

Patients and methods

Statistics

Results

Discussion

Conclusions

Injury

Injury

Lancet

Injury

Am J Med

Bone

Mortality following fractures in older women. The study of osteoporotic fractures

Arch Intern Med

Risk factors influencing mortality after bipolar hemiarthroplasty in the treatment of fracture of the femoral neck

Clin Orthop

Years of potential life lost after hip fracture among postmenopausal women

Acta Orthop Scand

Survival after hip fracture: short-and long-term excess mortality according to age and gender

Osteoporos Int

Hip fractures in Finland and Great Britain—a comparison of patient characteristics and outcomes

Int Orthop

Prediction of survival in patients with femoral neck fractures

J Bone Joint Surg Br

Adverse outcomes of osteoporotic fractures in the general population

J Bone Miner Res

Long-term trends in hip fracture prevalence: the influence of hip fracture incidence and survival

Osteoporos Int

Lifetime risk of hip fracture is underestimated

Osteoporosis Int

The effect of anesthetic technique on postoperative outcome in hip fracture repair

Anesthesiology