One-year mortality rate after hip fracture in the western region of Saudi Arabia A retrospective by Prof. Dr. Hesham N. Mustafa

S P E C I A L F O C U S

Trauma One-year mortality rate after hip fracture in the western region of Saudi Arabia: A retrospective cohort study Amro Al-Hebshi, MDa, Adel Hegaze, MDa, Hesham N. Mustafa, MDb, Bayan Tash, MBBCha, Dana Sawan, MBBCha and Khalid Al-Faris, MBBCha a

Orthopedic Department, Faculty of Medicine, King Abdulaziz Hospital, Saudi Arabia Anatomy Department, Faculty of Medicine, King Abdulaziz University, Saudi Arabia

Level of Evidence: Level IV.

ABSTRACT Background: The mortality rate of elderly patients who sustain a hip fracture is high compared to the general population. Identifying risk factors can help predict patients at risk of hip fracture to reduce the mortality rate. No studies have shown the mortality rate of patients with hip fractures in the western region of Saudi Arabia. Therefore, this study aimed to identify the risk factors associated with the mortality of patients with hip fractures admitted to the King Abdulaziz Hospital and compare the results with other studies. Methods: The mortality rate (within 1 yr or less) in 177 patients over the age of 60 yr who were admitted to the university hospital between July, 2007, and September, 2012, with hip fractures was retrospectively studied. The patients were assessed with regard to gender, age, type of hip fracture, and type of surgical intervention. Results: The overall mortality rate 1 yr after hip fracture was 12.43%, and the mean age was 77.77 yr old. The risk factors most associated with mortality were as follows: advanced age (71 to 80 and 81 to 90 yr old), male, peritrochanteric (extracapsular) fracture, and operative fixation with dynamic hip screw. Conclusions: The mortality rate of patients with hip fractures within 1 yr has a high-risk potential, especially for male patients over 71 yr of age with peritrochanteric (extracapsular) fractures. Surgical treatment with dynamic hip screw also was shown to be a risk factor between the different treatment options.

Financial Disclosure: The authors report no conﬂicts of interest. Correspondence to Hesham N. Mustafa, MD, Anatomy Department, Faculty of Medicine, King Abdulaziz University, P.O. Box 80205, Jeddah 21589, Saudi Arabia Tel: +966 126 400000; fax: +966 126 400000; e-mail: hesham977@hotmail.com. 1941-7551 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Key Words hip fracture, one-year mortality, peritrochanteric, femoral fracture.

INTRODUCTION

ccording to the World Health Organization’s estimation, the population of those 65 yr and older is estimated to reach about 1.5 billion by 2050, representing 16% of the global population.1 Hip fracture is a signiﬁcant cause of mortality1 as the aging population rapidly increases, and it is one of the most common clinical diseases among elderly patients because they are more often osteoporotic and are more likely to fall than younger people.2 Therefore, hip fractures will become more common as people live longer. By the year 2050, there will be an estimated 6.3 million hip fractures worldwide.3 Hip fracture is a serious and life-changing event for an older person. After an initial hip fracture, a person may not be able to live independently.2 In addition, there is an association between hip fracture and an increase in mortality. The 1-year mortality rate after a hip fracture is estimated to be between 17% and 27%,3 although some studies have shown this rate to be between 14% and 36%.4,5 Previous studies have discussed many factors that could be related to the mortality of elderly patients after hip fracture in different medical centers and countries.2,3,6 However, knowledge about mortality rate after hip fractures in Saudi Arabia is deﬁcient; no previous studies have reported outcomes after hip fracture in the western region of Saudi Arabia. Therefore, the purpose of this study was to evaluate the risk factors for mortality in elderly patients with hip fractures in this region during a 5-year period and to compare the 1-year mortality rate of these patients with those of different centers. The study also analyzed proposed risk factors that might help with preventive measures. These risk factors included age, gender, type of fracture, and treatment modality. Current Orthopaedic Practice

115

Time to surgery/day

Age

Length of stay/day

Readmission

Home care

Dementia

Blood loss/ml

Surgical time/min

Surgeon

General

100

Liver carcinoma

General

400

127

General

100

Cardiac (sudden death) Head trauma

General

100

24 27

0 0

200 300

101 158

C C

General Neuroaxial (Epidural) General

Cardiac & renal dysfunction Cardiac arrest Renal failure

5 6

1 13

87 81

250

120

Cardiac arrest

General

500

100

Cardiac arrest

300

100

Neuroaxial (Spinal) Neuroaxial (Epidural) Neuroaxial (Spinal)

300

General

Anesthesia

Cause of death

Comorbidity

ASA

Treatment

Diabetes High blood urea anemia Liver carcinoma Anemia

III E

DHS

II E

Total Hip

High renal function High blood glucose Diabetic Renal failure Anemia Renal impairment

III E

DHS

IV E

DHS

II E III E

Bipolar Bipolar

IV E

DHS

III E

DHS

Cardiac arrest

Ischemic heart Diabetic Hypertensive Diabetic Impairment liver function Renal impairment

III E

DHS

Cardiac arrest

Anemia

Bipolar

Renal failure

II E

DHS

400

116

Renal and Liver failure

II E

Bipolar

600

153

Wound infection

III E

DHS

Neuroaxial (Spinal) General

Diabetic Hypertension Renal impairment Tuberculosis lymphadenopathy Hepatocellular carcinoma Renal & Hepatic failure Diabetic

100

Renal failure

III E

Bipolar

General

100

Wound infection (Septacemia) Liver failure

II E

DHS

General

100

Anemia Electrolyte imbalance Liver impairment Anemia

IV E

DHS

General

300

108

III E

Bipolar

Local

Cardiac arrest

III E

Traction

350

139

Respiratory failure

II E

Bipolar

300

105

DHS

Pulmonary embolism Cardiac arrest

III E

Neuroaxial (Epidural) Neuroaxial (Spinal) Local

II E

Traction

Cardiac arrest

Diabetic Hypertension Ischemic heart Diabetic Hypertension Renal failure Bradycardia Chronic obstructive airway disease Anemia Uremia Renal failure Ischemic heart Diabetic Renal failure

Megaloblastic anemia Malignant otitis media

No procedure

ASA, American Society of Anesthesiologists; C, consultant; DHS, dynamic hip screw; E, for emergency; I, No organic disease; II, Mild systemic disease; III, Severe systemic disease {not incapacitating}; IV, Severe disease {constant threat to life}.

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TABLE 1. Mortality and complication data

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FIGURE 1. Mortality percentage regarding age and gender. FIGURE 2. Findings of femoral neck and pertrochanteric fracture.

MATERIALS AND METHODS Ethical Review and Study Design This retrospective cohort study was conducted at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The study was performed in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans, and the privacy rights of the human subjects were respected. Patients signed informed consent for the procedures. The study was approved by the Unit of Biomedical Ethics Research Committee in Faculty of Medicine, King Abdulaziz University (approval no. 590-17).

Data Collection Patients with hip fractures who were admitted to the hospital for management from July, 2007 to September, 2012 were identiﬁed, and their medical records were retrospectively reviewed. The factors investigated were age, gender, type of fracture, and type of management. The data were collected on a routine basis, and the analysis was carried out retrospectively. The patients were followed-up for 1 yr after surgery or until death.

Statistical Analysis Continuous variables were compared using the Wilcoxon rank sum test or Student’s independent t test, as appropriate. Categorical variables were compared using the chi-square test. A P value <0.05 was considered to show statistical signiﬁcance. All statistical analyses were conducted using SPSS 24 (IBM Corp, Armonk, NY, USA).

RESULTS One hundred and seventy-seven patients with hip fractures were admitted during the period of study, and 22 (12.43%) of these

patients died within 1 yr (14 patients died in the hospital; Table 1). The mean age of the patients was 77.77 ± 10.24 (range, 60 to 99) years. The mean age of male patients was 76.69 ± 8.68 (range, 60 to 90) years, and the mean age of female patients was 79 ± 12.56 (range, 65 to 99) years. Male patients had a higher incidence of hip fractures (13 patients [59.1%]; 95% CI, 8.000; P ≤ 0.05) than female patients (nine patients [40.9%]; 95% CI, 1.333; P ≤ 0.05). Mortality was higher for patients between 81 to 90 yr old (31.82%) and for male patients (22.73%; Figure 1). The fracture sides of patients who died were equal (11 patients for each side [50%]). Of the patients who died, 13 had pertrochantric (extracapsular) fractures (59.1%) and nine had femoral neck (intracapsular) fractures (40.9%; Table 2). Pertrochantric fractures were higher in patients ranging in age from 71 to 80 and 91 to 100 yr and were equal in patients ages 60 to 70 and 81 to 90 yr (Table 2; Figure 2). Regarding operative management, a dynamic hip screw (DHS) was used in the majority of patients who died (50%), and the majority of patients receiving this intervention were women (Table 3; Figure 3). In the deceased group, nonoperative management was used in two patients (skeletal traction; 9.1%), and no procedure was used with one patient (4.5%; Tables 3 and 4A, B).

DISCUSSION Many studies have reported an increase in the mortality rate of patients with hip fractures compared to controls,7 but the risk factors are still unrecognized in many countries. Multiple factors have been speculated as risk factors for mortality after hip fracture, such as age, gender, comorbidities, types of fracture, types of operations, and timing of surgery.8 In this study, the age, gender, type of fracture, and types of operation were evaluated. To the authors’ knowledge, this was the ﬁrst study to review the

TABLE 2. Findings of femoral neck and petrochanteric fractures Fracture type Frequency % Valid percent Cumulative percent

Femoral neck

Petrochanteric

Total

Age group

Femoral neck

Petrochanteric

9 40.9 40.9 40.9

13 59.1 59.1 59.1

22 100 100

60-70 71-80 81-90 91-100 Total

3 2 4 0 9

3 4 4 2 13

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TABLE 3. Comparison of different management modalities

Hemiarthroplasty Total hip arthroplasty Dynamic hip screw Traction No procedure Total

Frequency

Percent

Valid percent

Cumulative percent

7 1 11 2 1 22

31.8 4.5 50.0 9.1 4.5 100.0

31.8 36.4 86.4 95.5 100.0

morbidity and mortality of patients with hip fracture in the western region of Saudi Arabia.9,10 Studies concerning the 1-year mortality rate after hip fracture have shown different rates, with some ranging from 8.4% to 36%11,12 and others ranging from 6.22% to 23.45%.13 In the current work, the mortality rate was about 12.43%, which was within the ranges shown by other studies. A higher mortality rate was identified for male patients; this agreed with other studies that showed a higher mortality rate of men compared to women.12–14 No clear reason has been shown behind the higher mortality rate of male patients, but some studies have considered male gender as a risk factor for postoperative complications.15 Additionally, a higher mortality rate was found for men between the ages of 71 to 80 and 81 to 90 yr14 and for women between 60 and 70 yr old.16 Surgical management is advised for hip fractures to decrease the period of immobilization and reduce the mortality rate. A higher mortality rate was shown for pertrochantric (extracapsular) fracture (59.1%), and most of these fractures were managed by DHS (50%). This intervention requires prolonged postoperative immobilization, whereas arthroplasty offers early mobilization.15,16 In our study 50% of mortality occurred in patients who had surgical treatment using DHS, although in other studies this was significantly associated with the survival group.15–18 The literature, however, does not indicate a difference between the types of implant.17,18 In our study there were factors other than time causing these mortalities in DHS osteosynthesis. The mean blood loss was 250 mL/l, the mean time of operation was 92.8 min, mean time of postoperative hospital stay was 18.45 days, the American Society of Anesthesiologist (ASA) classification was III E in 54.5% of patients, the mean age was 81.45 yr, and the days from admission until operation was 5 days. The most prevalent comorbidities were diabetes mellitus, hypertension, and renal function impairment. This study has a number of limitations, including its retrospective nature, short-term follow-up, a limited number

FIGURE 3. Comparison of different management modalities.

TABLE 4. Comparison between the condition of all deceased patients and those treated by DHS N

Mean ± Std. deviation

A. Descriptive statistics for deceased Age Days in hospital before surgery Days in hospital after surgery Readmission Blood loss (ml) Time in surgery (min) Valid N (listwise)

patients 22 22 22 22 22 22 22

B. Descriptive statistics for deceased hip screw Age Days in hospital before surgery Days in hospital after surgery Readmission Blood loss (ml) Time in surgery (min) Valid N (listwise)

patients treated with dynamic 11 11 11 11 11 11 11

81.23 ± 10.62 4.36 ± 3.14 19.45 ± 12.76 0.86 ± 1.13 223.63 ± 165.46 88.95 ± 41.06

81.8182 ± 12.82 5.0909 ± 2.55 18.4545 ± 10.80 0.6364 ± 1.03 250.0000 ± 174.64 92.8182 ± 26.89

of patients, no comparisons with other groups receiving other types of revisions, and measurement bias, as the outcome assessors were not masked to the study. Based on our limitations, we recommend future prospective studies with longer follow-up and larger numbers of patients as well as comparative studies between the technique used in this study and other groups receiving other types of revisions.

CONCLUSIONS Hip fracture is considered a major cause of mortality in elderly patients. The mortality rate of elderly patients who sustained hip fractures in a hospital in the western region of Saudi Arabia was shown to be higher in men over 71 yr of age with pertrochantric fractures treated by DHS. In the future, more collective studies should be implemented for all regions of Saudi Arabia. REFERENCES 1. Al-Amin MM, Resa HM, Saadi HM, et al. Astaxanthin ameliorates aluminum chloride-induced spatial memory impairment and neuronal oxidative stress in mice. Eur J Pharmacol. 2016; 777:60–69. 2. Lin WT, Chao CM, Liu HC, et al. Short-term outcomes of hip fractures in patients aged 90 years old and over receiving surgical intervention. PloS One. 2015; 10:e0125496. 3. Sullivan KJ, Husak LE, Altebarmakian M, et al. Demographic factors in hip fracture incidence and mortality rates in California, 2000-2011. J Orthop Surg Res. 2016; 11:4. 4. Ozturk A, Ozkan Y, Akgoz S, et al. The risk factors for mortality in elderly patients with hip fractures: postoperative one-year results. Singapore Med J. 2010; 51:137–143. 5. Pioli G, Barone A, Giusti A, et al. Predictors of mortality after hip fracture: results from 1-year follow-up. Aging Clin Exp Res. 2006; 18:381–387. 6. Liu Y, Peng M, Lin L, et al. Relationship between American Society of Anesthesiologists (ASA) grade and 1-year mortality in nonagenarians undergoing hip fracture surgery. Osteoporos Int. 2015; 26:1029–1033. 7. Vestergaard P, Rejnmark L, Mosekilde L. Increased mortality in patients with a hip fracture-effect of pre-morbid conditions and post-fracture complications. Osteoporos Int. 2007; 18:1583–1593.

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