Incidence and Co-relates of Mortality among Elderly Patients after Surgical Intervention for Fracture Neck of Femur in a Medical College of Himachal Pradesh

Dr. Rohit Rai Vatsyan¹, Dr. Pankit Shekhar², Dr. Virender Singh^*3 and Dr Bhanu Awasthi⁴

¹Dr. Rohit Rai Vatsyan, Medical Officer Specialist at R. H. Una, Himachal Pradesh, India

²Dr. Pankit Shekhar, Medical Officer Specialist at Dr. R. P. G. M. C., Tanda, Himachal Pradesh, India

^*3Dr. Virender Singh, Medical Officer Specialist at R. H. Reckongpeo, Himachal Pradesh, India

⁴Dr Bhanu Awasthi, Principal Dr R.P.G.M.C., Tanda, Himachal Pradesh, India

INTRODUCTION

Hip fracture is a major public health problem that has a significant financial impact on patients and health care systems [1,2]. The incidence of hip fracture varies by age and sex; it is more common in older people. Hip fracture in elderly osteoporotic patients most often results from low-energy trauma such as falling down. [3-5].

Since fracture neck of femur prevalence increases exponentially with age, as population age and longevity increases worldwide, these injuries are likely to occur at accelerated rates. This is important because among those who sustain fracture neck of femur and survive, an increasing number continue to experience various degrees of subsequent disability including a high risk for falls and further injury likewise. Hip fractures remain a persistent cause of excessive morbidity, reduced life quality and premature mortality among elderly [6].

The incidence of hip fractures is increasing and the annual number worldwide is estimated to rise from 1.7 million in 1990 to 6.3 million by the year 2050 [7]. This will be a major challenge to the health care system and society. Most hip fractures are related to osteoporosis [8]. The cumulated risk for hip fracture is 20% for an 80-year-old woman and almost 50% for a 90-year-old woman [9].

In elderly fracture neck of femur are frequent and typically result from mild to moderate trauma in osteoporotic bones while in young adults these fractures are generally due to high energy trauma, such as road accidents. This is mainly because elderly people are unable to dissipate energy as compared to the young person and diminished ambulatory speed. Their protective responses are also diminished because of slow reaction time, weakness, disorientation and the side effect of medication [10].

Hip fractures in elderly patients are serious injuries that can lead to immobility and permanent dependence, negatively impacting patients’ quality of life and resulting in a financial burden for health systems and societies [11]. Hip fractures can also lead to death. Mortality rates among the elderly following hip fractures range from 14% to 36% within 1 year of the injury. During the first three months after hip fracture, elderly patients have a 5- to 8-fold increased risk of dying. The increased mortality risk persists up to ten years. Because of a predicted increase in life expectancy in western countries over the next decades, hip fractures and their consequences will have an even larger impact on health systems and societies in the future [12].

Fractures of the femoral neck are a devastating injury that extends far beyond the musculoskeletal trauma, with significant long-term consequences for the quality of life of both patients and careers. The fractures are common in the elderly. Patient care is complex, requiring multidisciplinary teams and integrated care pathways. Patients above the age of 90 represent a challenging subgroup as they have a number of concurrent medical co-morbidities, and are susceptible to postoperative complications and poorer outcomes [13].

Fracture neck of femur pose a number of management dilemmas depending on the age, sex, nutritional status, co-morbidities, status of the bones and type of fractures. Advanced age and associated co-morbidities are two decisive factors of mortality secondary to fracture neck of femur.

Poor nutritional status is known to be both a common causative factor of fracture neck of femur and predictor of excess mortality following surgical intervention. Many methods including anthropometry, the mini nutritional assessment, nutrition-related blood parameters and dietary analysis are used for nutritional status assessment in clinics. Serum albumin and total lymphocyte count are two of the most important blood parameters for nutritional status and have been recognized as prognostic factors of fracture neck femur.

Hip fractures in the elderly lead to functional decline and a diminished quality of life. Furthermore, these fractures are associated with an in-hospital mortality rate of 7-14%, reaching 14-36% within 1 year of surgery. Hip fractures are also complicated by a 0-49% need for revision surgery, which is influenced heavily by fracture characteristics and surgical interventions [14].

Factors that influence prognosis of elderly patients after hip fracture are age, gender, co-morbidities, anticoagulation therapy, and general physical health status at the time of injury. Furthermore, timing of surgery is thought to play an important role regarding survival. Although international clinical practice guidelines recommend surgical treatment of acute hip fracture within 24 to 48 hours after admission, these recommendations are still discussed controversially. Some researchers argue that early surgery can lead to an increased risk of peri-operative complications, including pneumonia, deep venous thrombosis, bleeding, pulmonary embolism, urinary tract infections and decubital ulcerations because clinicians do not have enough time to optimize patients’ medical conditions preoperatively [15].

Thus, the present study was carried out to determine the Incidence and co-relates of mortality among elderly patients after surgical intervention for fracture neck of femur presenting to the department of Orthopedics at Dr. R. P. G. M. C., Tanda.

METHODOLOGY:

The present study, an open cohort, prospective study, was conducted in patients with fractures neck of femur (age 60 years and above) presenting to the Department of Orthopaedics, Dr. R. P. G. M. C., Kangra at Tanda and undergoing surgical intervention.

All cases presenting to the department and fulfilling the criteria were studied for a period of one year starting from the date of start of the study. In first six months all patients fulfilling the inclusion criteria were recruited and followed up for next six months. The last patient was recruited 6 months from the day of start of study.

The study was initiated following approval from Institutional Ethics Committee. The patients were given the right to abstain from participation in the study or to withdraw at any time of the study without reprisal.

• Inclusion Criteria:

• Patients of age ≥60 yrs with fracture neck of femur undergoing surgical intervention.

• Those giving consent for inclusion in the study.

• Exclusion Criteria:

• Concomitant trauma involving other systems

• Associated fracture of the pelvis

• Bilateral hip fracture

• Pathological fracture

• Who do not give consent

• Evaluation and Classification:

For classification of co-morbidities in the study population, the American Society of Anaesthesiologist (ASA) score was used. For assessment of general condition on the day of admission, TCCS was used. It is important in demonstrating the general condition of the patient on the day of admission after sustaining a hip fracture. Using the CCI, three scores were calculated—the Total Charlson Co-morbidity Score (TCCS) is the sum of all co- morbidities combined with the score derived from the patient’s age; the Highest Charlson Co-morbidity Score (HCCS) is the highest single co-morbidity score of a patient; and the Charlson Co-morbidity Score (CCS) is the sum of all co-morbidity scores without consideration of age. All these scores were used to analyze and correlate with different mortality rates.

Nottingham Hip Fracture Score (NHFS) was used to predict 30-days mortality after hip fracture surgery. Bone Mineral Density was evaluated using Singh's Index. The Singh index is commonly used to assess osteoporosis and is based on the radiological appearance of the trabecular bone structure of the proximal femur on a plain antero-posterior radiograph.

• Study Procedure:

After a detailed history, patients were clinically evaluated at the time of admission and details on socio-demographic data of the patients such as age, sex, socio- economic status were recorded according to the Udai Pareek or Kuppuswamy scale for patients from rural or urban area respectively.

All data regarding pre-existing co-morbidities, type of fracture, degree of osteoporosis and type of surgical procedure, hospital stay and perioperative mortality and condition of patient at the time of admission and discharge were collected using the following indices.

After surgery, patients were discharged on the fourth day if the clinical conditions permitted. The telephone number of the investigator was written on the discharge card. The patients were followed up in Orthopedics OPD on the 15^th postoperative day for sutures removal and further on 3^rd month and 6^th month postoperative day for assessment of outcome using defined indices as annexure number 4, 5, 6, 7 and 8.

The patient or their attendant were also contacted on phone by the investigator regarding the welfare of the patient every 15^th day.

At the time of discharge the attendant were requested to inform the well- being of the patient to the investigator on the telephone mentioned on discharge card.

All patients reported as dead during the period of study were evaluated using the verbal autopsy performa. The queries enquired by the investigator investigated the attributable factors for mortality such as death, major cardiac or pulmonary complications, deep vein thrombosis, urinary tract complications, blood loss, surgical wound complications etc.

• Statistical Analysis:

The data were presented as frequency, percentages or mean±SD whereas applicable. Student t-test was used to compare continuous variables between 2 groups. Chi-square test was used to compare categorical variables. P value <0.05 was considered significant. Statistical analysis was performed using Epi Info version 3.4.3.

RESULTS:

A total of 84 patients with fracture neck of femur were included in the study over a period of one year.

Table 1: Socio-demographic characteristics of enrolled patients

Out of total, 47.6% (n=40/84) patents had fracture of left femur while 52.4 % (n=44/84) had fracture of right femur.

Bone density measurement by Singh’s index showed that 4/84 patients were in grade 1 and grade 2 each. Majority of the patients (32.1%; 27/84) were in grade 4 while 22.6% (19/84) patients were in grade 6. There were 12/84 (14.3%) patients in grade 3 and 18/84 (21.4%) in grade 5.

Table 2: Bone Density Measurement (Singh’s Index)

The most common surgery done was bipolar hemiarthroplasty which was done in 53 (63.1%) patients. Total hip replacement was done in 29 (34.5%) patients while CRIF with DHS and PTCS was done in 1 patient each.

Table 3: Type of surgery done

Table 4 summarizes that after 15 days post surgery, there were 3 (3.6%) patients with infected wound and 3 months later 1 (1.2%) out of those 3 patient had infection.

Table 4: Wound status after day 15 and 3^rd month

Mortality:

Table 5 summarizes the mortality of the patients after 9^th month and 12^th month. In our study, 1 (1.2%) patient died after 9^th month of surgery. Overall mortality during 1 year was 7.14%.

Table 5: Distribution of patients on basis of survival

There were 14 patients with diabetes and out of them 2 were not taking medication regularly. There were 11 patients of both hypertension and diabetes and all were taking their medication regularly.

Table 6: Diabetes and hypertension in enrolled patients

Other Co-morbidities:

There were 9 (10.7%) patients who were suffering from coronary artery disease followed by 6 (7.1%) patients with thyroid anomaly. 2 (2.4%) patients were having TB and bed sores each and 1 (1.2%) had asthma.