Table of content
Volume 1 | Issue 1
Surgical Treatment of Intertrochanteric Fractures in Elderly Patients: Comparing the Effect of Age vs. Physical Status on Patient Outcomes
Ghulam H Saadat, MD1*, Theofilos Karasavvidis, MD2, Daniel Alsoof, BSc3, Ante Rebic,BSc4, Dana Scott Lycans, MD5, Frederic Starr, MD1 and Faran Bokhari, MD1
1Department of Trauma and Burn Surgery, John H Stroger Hospital of Cook County, USA
2School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Central, Macedonia, GR
3University College London, London, UK
4Kansas City University, Kansas City, MO, USA
5Department of Orthopedic Surgery, Marshall University School of Medicine, Huntington, WV, USA
*Corresponding author: Ghulam H Saadat, MD, Department of Trauma and Burn Surgery, John H Stroger Hospital of Cook County 1950 W Polk St, 8th Floor, Chicago, IL 60612, USA, E-mail: firstname.lastname@example.org
Citation: Saadat GH, Karasavvidis T, Alsoof D, Rebic A, Lycans DS, et al. (2021) Surgical Treatment of Intertrochanteric Fractures in Elderly Patients: Comparing the Effect of Age vs. Physical Status on Patient Outcomes. J Surg Clin Rpts 1:008.
Copyright © Saadat GH, et al.
The purpose of this study was to compare the impact of age and physical status on short term (≤ 30 days) outcomes of intertrochanteric fracture (ITF) in elderly patients. The primary outcome of our study was mortality. Secondary outcomes included short term complications.
This retrospective cohort study includes patients from the American College of Surgeons National Quality Improvement Program (ACS NSQIP) from January 2016 to December 2018. All patients with ITF treated with intramedullary nail (IMN) fixation were included in the study. Patients were divided into two age cohorts: 65-75 and 76-89 years-old. Patients' physical status was assessed by the American Society of Anesthesiologists (ASA) Classification System.
A total of 14278 patients met the inclusion criteria: 3811 patients were between 65-75 years, and 10467 patients were 76-89 years-old. Overall, the mortality rate was 1.9%. After adjusting for gender, body mass index (BMI), functional status, and ASA class, age 76-89 years were not associated with mortality (OR = 1.2, P = 0.24). However, age 76-89 years were significantly associated with higher rates of blood transfusion (OR = 1.36, P < 0.001), myocardial infarction (OR = 1.76, P < 0.001), and urinary tract infection (OR = 1.24, P = 0.05). The adjusted odds ratio of mortality for patients with ASA class III and ASA Class IV/V was 2.86 (P < 0.001) and 10.51 (P < 0.001), respectively. Similarly, patients with ASA Class 4/5 had a significantly higher rate of transfusion (OR = 2.1, P = 0.00), pneumonia (OR = 3.43, P < 0.001), stroke (OR = 2.31, P = 0.01), myocardial infarction (OR = 2.96, P < 0.001), urinary tract infection (OR = 1.66, P < 0.001), renal failure/insufficiency (OR = 8.7, P < 0.001), sepsis (OR = 2.4, P < 0.001), surgical site infections (OR = 3.82, P < 0.001), readmission (OR = 2.73, P < 0.001) and revision surgery (OR = 1.94, P < 0.001).
This study has shown that patients aged 76-89 years had no increased risk of 30-day mortality compared with the 65-75 years-old age group. Data showed that in intertrochanteric fractures patients' physical status was a more reliable predictor of adverse outcomes than age.
The United States has the highest annual rate of hip fractures globally, with an estimated incidence of over 300,000 admissions per year [1,2]. Although hip fractures can occur at any age, the vast majority of them involve geriatric patients and the most common fracture observed in this population involves the intertrochanteric region [3,4]. Given the unique anatomic and mechanical characteristics of ITF, surgical treatment is preferred to restore the pre injury functional level of independence within the shortest time possible . However, surgical management carries additional risks for the geriatric population. Previous studies on hip fractures demonstrated that almost 50% of patients would experience at least one short-term complication following surgical repair, and approximately one-fifth of patients will die in the year following surgery [6,7].
Age and poorly controlled systemic diseases are among the important factors associated with worse patient outcomes [8,9]. Previous studies have found that a relatively higher annual mortality rate is associated with increasing age and comorbidities, but much of the literature considers elderly patients a homogenous group [10,11]. Also, relevant published studies commonly pool all types of hip fractures and surgical procedures into one study group. However, substantial differences are seen among fracture types as well as the type of surgical implant used [12,13]. Because of the potential negative clinical ramifications of increased age and comorbidities, it is valuable for surgeons to understand the risks pertaining to treating ITFs in such patients and counsel them correspondingly.
To this end, we sought to evaluate short-term (≤ 30 days) mortality and complications of ITFs treated by IMN in elderly patients. The purpose of this study was to investigate if patient age and physical status significantly affect postoperative outcomes. We hypothesized that; 1) mortality and complications in elderly patients are not affected by age, and 2) patients' physical status has a more significant influence on patient outcomes than age.
The data for this study were retrospectively collected from the American College of Surgeons National Quality Improvement Program (ACS NSQIP) from January 1, 2016, to December 31, 2018. The ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based program to assess and enhance surgical care quality . The program collects data on more than 150 variables, including preoperative risk factors, intra-operative variables, and 30-day postoperative outcomes for patients undergoing major surgical procedures .
The study subjects included patients aged 65 to 89 years with ITFs and were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) diagnosis codes (S72.14). Only patients treated with IMN were included, and these patients were identified using the Current Procedural Terminology code (27245). Patients with missing variables on age and ASA classification were excluded from the study. The population was dichotomized into two groups: 65-75 years and 76-89 years. The American Society of Anesthesiologists (ASA) classification system was used to assess patients' physical status (Table 1). The ASA classification system assesses patient comorbidities that can help predict perioperative risks . Studies have shown that ASA classification has a strong, independent association with postoperative outcomes across procedures . In this study, ASA classes were combined into three groups: Patients with no or mild systemic disease (Class I/II), patients with severe systemic diseases (Class III), and patients with life-threatening systemic diseases or being moribund (Class IV/V). The institutional review board exempted the study and waived the patient's written informed consent because the data were deidentified. The study was performed according to the strengthening the reporting of observational studies in epidemiology (STROBE) guidelines .
Definition of variables and outcomes
Patients' preoperative variables included age, gender, race, BMI, functional status, and ASA Classification. Outcomes were defined as adverse events within the first 30 days after the surgical procedure. The primary outcome analyzed was mortality. Secondary outcomes assessed included blood transfusion, pneumonia, stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism, urinary tract infection, renal failure/insufficiency, sepsis, surgical site infections, readmission, revision surgery, and postoperative length of stay.
Descriptive statistics were reported as frequencies and percentages for categorical variables. Postoperative length of stay was reported both as mean ± standard deviation as well as a median and inter quartile range due to its abnormal distribution.
We performed univariate analysis to investigate the difference in patient characteristics and postoperative outcomes with age groups. The Chi-square test was used for categorical data, and the Mann-Whitney U test was used for the postoperative length of stay. The statistically significant (P < 0.05) and clinically significant variables were included in the multivariable model. After adjusting for gender, BMI, functional status, and ASA class, a multivariable regression model was developed to evaluate whether the age group was a potential predictor of postoperative adverse events. Similarly, after controlling for age, gender, BMI, and functional status, multivariable regression analysis was used to determine the effect of patients' physical status, based on the ASA class, on postoperative outcomes. Odds ratios (ORs) with corresponding 95% confidence interval (CI) were used to report the results of multivariable regression. The threshold for statistical significance was P < 0.05, and all reported P values are 2-tailed. All analyses were performed with IBM SPSS Statistics 25.0 (Armonk, NY: IBM Corp.).
Among 14278 patients who met the inclusion criteria, 3811 patients were between 65-75 years, and 10467 patients were 76 to 89 years-old. 69.8% of the patients were female, and 78.2% were white. Almost two-thirds (64%) of the patients had severe systemic diseases (ASA class III), and 19.8% had life-threatening systemic diseases or were moribund (Class IV/V). Overall, 8.2% had unplanned readmission to the hospital, and the mortality rate was 1.9% (Table 2).
Table 3 shows patients' characteristics and outcomes by age groups. Patient preoperative variables, including gender, race, BMI, functional status, and ASA class, were significantly different between the age groups (P < 0.001). Mortality was not found to significantly different between the age groups (2.1% vs. 1.7%, P = 0.1). However, compared to the age 65-75 years, the older age group demonstrated a higher rate of blood transfusion (32.9% vs. 23.9%, P < 0.001), myocardial infarction (2.1% vs. 1.3, P < 0.001) and urinary tract infection (4.1% vs. 3.2%, P = 0.01). Notably, those in the76-89 age group were found to be associated with a statistically significant longer postoperative length to stay (4.33 ± 7.64 vs. 4.59 ± 8.87 days, P = 0.001) (Table 4). However, this difference cannot be considered clinically significant. There was no other difference in the 30-day postoperative adverse events between the two groups.
Multivariable analysis by age groups
By multivariate regression analysis and after adjusting for gender, BMI, functional status and ASA class, age of 76-89 years was not an independent predictor of 30-day mortality (OR = 1.2, 95% CI = 0.89-1.63, P = 0.24). However, this group showed significantly higher rates of blood transfusion (OR = 1.36, 95% CI = 1.25-1.49, P = 0.00), myocardial infarction (OR = 1.76, 95% CI = 1.26-2.46, P = 0.00), and urinary tract infection (OR = 1.24, 95% CI = 1-1.54, P = 0.05) (Table 5).
Multivariable analysis by ASA classification
After adjusting for age, gender, BMI and functional status, multivariable regression analysis showed that compared to ASA class I/II, the adjusted odds ratio of mortality was 2.86 (95% CI = 1.43-1.8, P < 0.001), and 10.51 (95% CI = 1.81-2.36, P < 0.001) for patients with ASA class III and ASA Class IV/V, respectively. Patients with ASA class III had an odds ratio of 1.6 for transfusion (95% CI = 0.43-1.8, P < 0.001), 1.79 for pneumonia (95% CI = 1.27-2.52, P < 0.001), 1.41 for UTI (95% CI = 1.27-2.52, P = 0.01), 2.74 for renal failure/insufficiency (95% CI = 1.09-6.89, P = 0.03), 2.6 for surgical site infections (95% CI = 1.11-6.05, P = 0.02), and 1.68 for hospital readmission (95% CI = 1.35-2.08, P < 0.001). Similarly, patients with ASA Class IV/V demonstrated significantly a higher rate of transfusion (OR = 2.1, 95% CI = 1.81-2.36, P < 0.001), pneumonia (OR = 3.43, 95% CI = 2.4-4.92, P < 0.001), stroke (OR = 2.31, 95% CI = 1.16-4.58, P = 0.01), myocardial infarction (OR = 2.96, 95% CI = 1.88-4.68 P < 0.001), urinary tract infection (OR = 1.66, 95% CI = 1.2-2.3, P < 0.001), renal failure/insufficiency (OR = 8.7, 95% CI = 3.44-22.16, P < 0.001), sepsis (OR = 2.4, 95% CI = 1.32-4.68, P < 0.001), surgical site infections (OR = 3.82, 95% CI = 1.55-9.43, P < 0.001), readmission (OR = 2.73, CI = 2.15-3.47, P < 0.001) and revision surgery (OR = 1.94, CI = 1.24-3.04, P < 0.001) when compared to patients with ASA Class I/II (Table 6).
This was an observational retrospective study of 14278 patients with ITF who underwent IMN surgery. The present study reported similar mortality rates between patient's age 75 or less and over 75 years. However, age over 75 was associated with significantly more blood transfusions, myocardial infarctions, and urinary tract infections. No other differences were identified between the two age groups in terms of 30-day postoperative complications. Interestingly, the study demonstrated that patients' physical status, as assessed by ASA classification, was found to be a reliable predictor of postoperative adverse events and mortality.
Increased patient age has frequently been associated as a critical indicator of higher mortality rates following hip fracture [11,19]. Studies have shown that age was among the strongest predictors of early mortality (< 30 days) following hip fracture repair [20,21]. A meta-analysis also illustrated that the absolute risk for death and the excess all-cause mortality in patients with hip fracture are largely dependent on age . However, our study did not show a statistically significant difference in the 30-day mortality rate between patients age 75 or less and over 75 years. Additionally, the mortality rate recorded in this study (1.8%) is lower than the reported range of 7.1%-50.6% in the previous studies [20,21]. This may have contributed to the lack of difference in mortality between the two age groups in our study. Furthermore, previous studies assessed mortality after pooling all types of hip fractures compared to only intertrochanteric fracture in this study.
Following intertrochanteric hip fractures, there are critical postoperative complications that are well described in the literature. Our study identified three postoperative outcomes of ITFs that were significantly associated with increased patient age: Blood transfusion, myocardial ischemia, and urinary tract infections (UTIs). However, there is a literature gap in understanding how these complications are associated with older age. A possible explanation would be that the elderly population generally has a higher prevalence of anemia; thus, it is more likely to require blood transfusion during or after surgery . Additionally, the use of anticoagulation medications are relatively more prevalent in the elderly population and are likely a contributor to increased intra-operative bleeding [6,22]. Of note, prior studies demonstrated a higher rate of myocardial infarction associated with increasing age, and this is in line with the finding of this study [23,24]. Finally, increased risk of urinary tract infection may be attributed to immobility and use of a foley catheter for an extended period following hip fracture surgery in the elderly population .
Patient comorbidities have been shown to profoundly affect the course of patient outcomes following hip fractures [26,27]. Our study used the ASA classification system to rank patients based on their comorbid physical status. We found that mortality was significantly higher in ASA class III (OR = 2.86, P < 0.001) and ASA class IV/V (OR = 10.51, P < 0.001) compared with those in ASA class I/II. This finding is consistent with a systematic review by Xu, et al., in which 8 out of 9 papers showed a greater mortality rate with higher ASA grades . Both ASA class III and ASA class IV/V were associated with significantly increased rates of complications, but specific adverse outcomes such as stroke, myocardial infection, sepsis, and revision surgery were only statistically significant in patients with ASA class IV/V. This suggests that it is not only the presence of comorbidity that impacts outcomes but also the severity. The severity of complications in ASA class IV/V is also the likely cause of increased mortality in this group.
Approximately one-third of patients with a hip fracture will die in the year following injury, and many more will experience debilitating adverse outcomes . Thus, it should be highlighted that, especially for elderly patients, regaining pre-fracture functional status is critical. Interestingly, in our study, most patients that underwent IMN for ITF were either in ASA class III (63.38%) or class IV/V (19.9%) groups. Our study found that patients in these groups had significantly higher mortality rates and complications. The higher complication rate in patients with higher ASA class warrants medical optimization prior to surgery . While medical optimization of high-risk patients may delay surgery, operating on a stable patient can lower risks of readmission and revision surgery .
This was a pragmatic study and thus should be interpreted in the context of observational research and its limitations inherent to its design. First, our study's nonrandomized nature limits the generalizability of our results due to potential selection bias. Second, retrospective chart reviews have the disadvantage that questions are asked in a non-uniform way across different patients and providers. Also, besides patients' physical status, adjusting for patients' physiological status before surgery would have been helpful, but the ACS-NSQIP database does not report such variables.
This study investigated the association of age and physical status with mortality and complications in patients with intertrochanteric fractures treated with IMN fixation. We found that 30-day mortality was not significantly different in patients aged 76-89 years compared to 65-75 years. However, patients aged 76-89 years presented more frequently with the need for blood transfusions, myocardial infarctions, and urinary tract infections. The results suggest that patients' physical status per ASA Classification is a more reliable predictor of mortality and morbidity than age.
Conflicts of Interest Statement
All authors have no conflicts of interest to disclose.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conception and design: Saadat and Bokhari; Acquisition of data: Saadat; Statistical analysis of data: Saadat Interpretation of data: All authors; Drafting of the manuscript: Saadat, Karasavvidis, Alsoof and Rebic; Critical revision of the manuscript for important intellectual content: Lycans, Starr and Bokhari; Final revision of the version to be published: All authors; Administrative, technical, or material support: Bokhari; Supervision: Bokharis
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