age is the main prognostic factor regarding functional outcome in intertrochanteric fracture

doi:10.21203/rs.3.rs-1953921/v1

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age is the main prognostic factor regarding functional outcome in intertrochanteric fracture

https://doi.org/10.21203/rs.3.rs-1953921/v1

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Objectives: The type of fracture, type of surgery, and patient comorbidities affect the possibility of achieving the best postoperative outcome in intertrochanteric fractures. We aim to evaluate the effect of the patient’s clinical and paraclinical condition before and after surgery on postoperative functional outcomes with the Harris hip score instrument.

Design: Retrospective

Setting: single-center

Patient/Participants: This study included 310 patients undergoing intertrochanteric fracture surgery at one center from November 2016 to September 2020.

Intervention: Patient demographic, comorbidity and pre and postoperative laboratory data, complication, and Harris Hip Score data were collected.

Main Outcome Measurements: Multivariate logistic regression was used to determine the effect of demographic characteristics (sex, age, type of fracture regarding AO/OTA classification, height, weight, body mass index), habitual and past medical history( hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen (BUN), Creatinine (Cr), Na, and K ), surgery-related factors (Anesthesia time and type, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption

after a median of 29.84 months (range: 5-69.4 months ) follow-up on Harris Hip Score of patients undergoing intertrochanteric fracture surgery.

Results: When Harris Hip Score compared between following characteristics the distribution was significant: AO/OTA classification (p=0.037), sex (p=0.017), hypertension (HTN) (p=0.001), Diabetes mellitus (DM) (p=0.038), Anticoagulant consumption (p=0.01), smoke (p=0.000), osteoporosis (p=0.001), anesthesia type (p=0.003), age (p=0.000), hemoglobin (Hb) before surgery (p=0.004), height (p=0.000), BUN before surgery (p=0.010), and Δ Na (p=0.046). in multivariable regression age is the main prognostic factor and Age >69.5 is prognostic factor for poor and fair Harris Hip Score.

Conclusion: To improve the functional outcomes in IT fractures, the patient-related factors (underlying disease and the use of drugs, anemia status as well as electrolytes) and fracture type should be considered. Among the all these, age remains the main prognostic factor.

Level of Evidence: Prognostic Level III.

Hip fracture

Intertrochanteric fracture

analytic factors

Harris Hip Score

Risk factors

Hip fractures are the most common fractures in old age, which is one of the essential concerns of orthopedic surgeons in public health discussion (1). Intertrochanteric (IT) hip fracture incidence is about 171 per 100,000 in the US, accounting for about 14% of all fractures and 72% of fracture health costs (2, 3). In addition, in the first and second years following injuries, the mortality rates are 16.6 and 39.4% (4); The association with various morbidities such as heart disease, diabetes mellitus, hypertension, and blood parameters adds to the significance of paying attention to it (5, 6).

There are several treatment options for IT fractures, such as a dynamic hip screw(DHS), compression hip screw(CHS), intramedullary nailing, and arthroplasty(7). The treatment goal is the patient’s return to proper function after surgery, affected by the type of fracture, type of surgery, and patient’s comorbidities(8, 9).

Various studies have examined factors affecting the prognosis of IT fractures, which has demonstrated a poorer prognosis in patients over 70 years of age and patients with associated morbidities and even male gender(10-12). Studies also showed that patient’s prognosis is not correlated with implant and anesthesia type(11, 13).

Different patient’s reported outcome measures (PROM) were used to evaluate patients’ functional outcomes with hip fracture surgeries, including the Oxford hip score, AAOS hip, knee score, and the Harris Hip Score (HHS)(14-16). HHS as a validated physician-rated tool gives a maximum of 100 points, including 44point for pain, 47 for function,5 for a range of motion, and 4 points for deformity, and the final assessment of patients will be into four categories <70 Poor; 70 – 79 Fair; 80-89 Good; 90 -100 Excellent(14-17). This study aims to evaluate the effect of the patient’s clinical and paraclinical condition before and after surgery, comorbidities, type of fracture, and selected surgery on postoperative functional outcome utilizing the HHS instrument.

All consecutive patients from November 2016 to September 2020 at one center in Tehran (Sina University Hospital, Tehran University of Medical Sciences) with IT fractures were retrospectively included in this study. Patient’s lab data before surgery and after surgery on post operation day 1 (Pod-1), demographic data, general condition, and information pertained to surgery and type of fracture were documented.

Δ Variables are defined as:

Δ Variables = Variable _{on Pod-1} – Variable _{before surgery}

The type of fracture was determined by an expert orthopedic surgeon according to AO/OTA Classification (18). The study endpoint was defined as HHS on at least Five months of follow-up, which was conducted in February 2021. HHS was measured by an orthopedic

research fellowship through a phone call and then categorized into four levels for final analysis. Patients with a second injury which affects functional outcome or reoperation and those with incomplete data were excluded. All participants gave informed consent, and the study was approved by the Tehran University of Medical Sciences review board.

Statistical Analysis

For the statistical analysis, SPSS version 23 for windows (IBM, Armonk, New York) was used. Data are presented as the mean and standard deviation. Statistical comparison, when relevant, was performed using a Fisher exact test for categorical data. Continuous variables were compared using ANOVA or Kruskal-Wallis test whenever the data did not appear to have normal distribution or when the assumption of equal variances was violated across the study groups. A p-value of <0.05 was considered significant for univariate analysis.

To perform multiple variable regression, the outcome was converted to a binary variable .

Furthermore, we conducted Receiver operating characteristic (ROC) analysis to reach a screening test. A p-value of <0.05 was considered significant for binary logistic regression analysis. For ROC analysis a p-value of <0.05 was considered significant and Area under curve (AUC) > .75 was acceptable to achieve a screening test with maximum sensitivity and specificity.

The study included 310 patients. 105 patients were dead (in-hospital (10) or long-term (95)) and 39 patients lost to follow-up. The follow-up duration was 5-69.4 months and a mean of 29.84 ± 13.91 months. The average age was 67.85 ± 16.19 years at the time of surgery, and 56.6% of the patients were male. Baseline parameters are shown in Table 1.

In February 2021, 166 patients were left for analysis. Patients HHS is shown in table 1. 39.2% were included in the good category of HHS.

When HHS compared between following qualitative characteristics the distribution was significant: AO/OTA classification (p=0.037), sex (p=0.017), hypertension (HTN) (p=0.001), Diabetes mellitus (DM) (p=0.038), Anticoagulant consumption (p=0.01), smoking (p=0.000),

osteoporosis (p=0.001), and anesthesia type (p=0.003). female had worse functional outcome as those with HTN, DM, Osteoporosis or consume anticoagulant. HHS tends to be higher in those who smoke or was operated under general anesthesia. The results are shown in the table 2. When HHS compared between following quantitative characteristics the distribution was significant: age (p=0.000), hemoglobin (Hb) before surgery (p=0.004), height (p=0.000), BUN before surgery (p=0.010), Δ Na (p=0.046). The results are demonstrated in the table 3. Older patients have lower HHS. The mean difference of age is significant between different categories of HHS (all p <0.05) and the only exception is the comparison of poor and fair HHS which is not (p >0.05). The level of Hb before surgery was lower in patients with fair HHS than in those with good (Mean Difference = -0.90 mg/dL; p=0.040) and excellent (Mean Difference = -1.72 mg/dL; p=0.011) HHS. Patients with a lower HHS have lower Hb levels, although the mean difference is not always significant. HHS in respect of Hb level illustrates a different pattern when compared with fair and poor levels. Patients with lower HHS are shorter but the mean difference is only significant when comparing excellent score with poor (Mean Difference = 12.75 cm; p=0.001), fair (Mean Difference = 11.62 cm; p=0.000), and good (Mean Difference = 10.27 cm; p=0.002) score. BUN before surgery is lower in those with better HHS except for pattern of poor and fair HHS comparison and the mean difference is only significant when you compare fair and excellent HHS (Mean Difference = 16.94 mg/dL; p=0.021). Poor and fair score considered as Level 1 and good and Excellent score considered Level 2. Δ Na, osteoporosis and height were excluded from final regression model due to high number of missing values. Finally, age (ꞵ-coefficiency=0.179; p=0.000) was the main significant variable. the results are demonstrated in table 4. When ROC analysis conducted for age and binary HHS an AUC = 0.916 ([95% CI] = 0.871 to 0.961; p=0.000) was observed. Age >69.5 is prognostic factor for poor and fair Harris Hip Score with sensitivity=0.897 and specificity=0.835. the results are shown on figure 1.

This retrospective study was carried out on 310 patients who underwent orthopedic surgery due to intertrochanteric fractures to investigate the effect of laboratory data and comorbidities on functional outcomes. Our study showed that AO/OTA classification, sex, hypertension, diabetes mellitus, anticoagulant consumption, smoking, osteoporosis, type of anesthesia, age, hemoglobin level before surgery, height, BUN level before surgery and ΔNa were the significant factors which affect the patients’ functional outcomes.

Fractures with the stable pattern, according to the revised AO/OTA classification (AO 31A1), were associated with superior outcomes compared to other types. Our findings regarding the fracture type and surgical outcome was the same as the previous studies(9, 19, 20). Before, it was shown that unstable intertrochanteric fracture patterns need more health care system involvement(9, 21).

Hip fractures are generally not age- or gender-specific, but intertrochanteric fractures are more common in the elderly and women (22, 23). Our study found that high age and male gender are associated with worse consequences after surgery which is in line with the most previous studies (24-27). Outcome differences in terms of age remained still with binary logistic regression analysis. According to previous studies, men with intertrochanteric fracture appear to be more likely to have the underlying disease at the time of trauma than women(23, 28, 29). Studies also showed the higher risk of infection and postoperative mortality in men than women (28, 30). Kuo et al. considered the higher smoking rate in men than women as one of the reasons for higher infection(31).

Hypertension is one of the most common comorbidities in patients with hip fracture (32). Our finding similar to Kang et al (33) showed that hypertension can lead to future Katz Index of Activities of Daily Living/ Lawton And Brody Index of Instrumental Activities Of Daily Living limitation or disability. Notably, consumption of anti-hypertensive medications reduced the negative effects and mortality rate of hypertention (34).

Some previous studies concluded that patients with diabetes have worse rehabilitation outcomes than non-diabetic patients (35). They believe that DM can lead to functional damage stem from different reasons (36) which is compatible with our results. On the other hand, some studies indicated that diabetes does not affect functional implications. Still, they admitted that some postoperative complications, such as UTI, are more likely to occur in diabetic patients (37).

To prevent bleeding, anticoagulated patients with a hip fracture are exposed to a delay in surgical fixation and higher mortality rate (38). Although some articles believe that the outcomes between anticoagulated and non-anticoagulated patients have no significant difference (39), our reviews express the opposite. The poor results could stem from the underlying disorder which necessitates these drugs.

In the study by Solbakken et al. smoking was a risk factor of mortality after hip fracture (40). In patients with hip fragility fractures, smoking habits were independently linked to reduced bone stiffness. Furthermore, trabecular strength and toughness were also adversely affected by smoking(41). Smoking is also an independent risk factor for hip fracture (42). These findings are in contrast with what we observed in our data registry.

Osteoporosis causing fractures is one of the most common reasons of morbidity and mortality in elderly. In 2015, Makridis et al (43) claimed that treatment of osteoporosis before and after the fracture, improves clinical and functional implications. Although we did not study the effect of treatment, we found that osteoporotic patients are at increased risk for lower functional outcome. The treatment and rehabilitation should begin as soon as possible.

There are several studies investigating the role of anemia in hip fractures. Some believe that anemia at the time of admission is the predictor of the worse consequences (44, 45), but some others claim that this is true regarding the anemia at the time of discharge (46, 47). We found that lower pre-operative hemoglobin level was associated with lower postoperative HHS. Still more studies are needed to evaluate the effect of anemia correction before surgery on the functional outcome in IT fractures. In addition, the complications of transfusion should be considered.

Seyedi et al (48) who considered 204 patients with hip fractures, represented the triple risk of mortality in patients with high BUN before surgery compared to those with normal BUN which is in line with our findings. ΔNa is also shown to be effective in our study and other studies (49, 50). Since sodium level is a good marker for dehydration, and due to the high prevalence of dehydration in elderly with hip fractures (54), it seems necessary to examine this electrolyte.

General anesthesia had a better outcome than thos with spinal anesthesia according to our study. There is some evidence that general anesthesia patients have more pain than patients under spinal anesthesia in the short-term after surgery (51). In the other hand, rashid et al. have reported that type of anesthesia doesn’t affect surgical outcome (52).

Distribution of cases in AO/OTA and type of ansthesisa subgroups was unbalanced and this makes comparison impossible. The number of cases which lost to follow-up were remarkable and the final analysis was conducted with 166 patients. Type of fracture in our study was determined by one orthopedic surgeon, however, the reliability and accuracy of AO/OTA classification is questionable (53).

To improve the functional outcomes in IT fractures, patient-related factors (underlying disease and the use of drugs, anemia status as well as electrolytes) and fracture type should be considered. Among all these factors age remains the main prognostic factor.

IT: intertrochanteric, DHS: dynamic hip screw, CHS: compression hip screw, PROM: patient’s reported outcome measures, HHS: Harris Hip Score, Pod-1: post-

operation day 1, AUC: Area under curve, ROC: Receiver operating characteristic, HTN: hypertension, DM: Diabetes mellitus, Hb: hemoglobin, BUN: Blood Urea Nitrogen, Cr: Creatinine

Conflict of interest: There is no conflict of interest with the authors to declare
Funding: There is no funding source for authors to declare
Ethical approval: The ethics committee of Tehran University of Medical Sciences, Tehran, Iran, has approved This manuscript. All methods were carried out in accordance with relevant guidelines and regulations or Declaration of Helsinki
Informed consent: an informed consent signed by all the precipitants of the study
Consent for publication: Not applicable.
Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Authors' contributions: MB, and HS contributed in data gathering and data analysis. MB, MS, MG, and AG contributed in writing the manuscript. All authors have read the final manuscript and sent their approval for submission.
Acknowledgements: Not applicable.

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Tables 1 to 4 are available in the Supplementary Files section

No competing interests reported.

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age is the main prognostic factor regarding functional outcome in intertrochanteric fracture

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1. Introduction

2. Material And Methods

3. Results

4. Discussion

5. Limitations

6. Conclusion

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