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Patient survival and surgical re-intervention predictors for intracapsular hip fractures
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Injury, Int. J. Care Injured xxx (2017) xxx–xxx
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Patient survival and surgical re-intervention predictors for intracapsular hip fractures$ David González Quevedoa,* , Iskandar Tamimi Mariñoa , Juan Manuel Sánchez Silesa , Esther Romero Escribanoa , Esther Judith Granero Molinaa , David Bautista Enriquea , cb , Francisco Villanueva Parejaa Tomislav Smoljanovi a b
Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Spain Department of Orthopedic Surgery and Traumatology, University Hospital Centre of Zagreb, Croatia
A R T I C L E I N F O
Keywords: Charlson comorbidity index Hip fractures Total hip replacement Partial hip replacement Hemiarthroplasty Total hip arthroplasty Mortality Survival American Society of Anesthesiologists
A B S T R A C T
Background: Choosing between total hip replacement (THR) and partial hip replacement (PHR) for patients with intracapsular hip fractures is often based on subjective factors. Predicting the survival of these patients and risk of surgical re-intervention is essential to select the most adequate implant. Methods: We conducted a retrospective cohort study on mortality of patients over 70 years with intracapsular hip fractures who were treated between January 2010 and December 2013, with either PHR or THR. Patients’ information was withdrawn from our local computerized database. The age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) score were calculated for all patients. The patients were followed for 2 years after surgery. Survival and surgical reintervention rates were compared between the two groups using a Multivariate Cox proportional hazard model. Results: A total of 356 individuals were included in this study. At 2 years of follow-up, 221 (74.4%) of the patients with ACCI score 7 were still alive, in contrast to only 20 (29.0%) of those with ACCI score > 7. In addition, 201 (76.2%) of the patients with ASA score 3 were still alive after 2 years, compared to 30 (32.6%) of individuals with ASA >3. Patients with the ACCI score > 7, and ASA score > 3 had a significant increase in all-cause 2-year mortality (adjusted hazard ratio of 3.2, 95% CI 2.2–4.6; and 3.12, 95% CI 2.2– 4.5, respectively). Patients with an ASA score > 3 had a quasi-significant increase in the re-intervention risk (adjusted hazard ratio 2.2, 95% CI 1.0–5.1). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively. Conclusions: Both ACCI and ASA scales were able to predict the 2-year survival of patients with intracapsular hip fractures. The ASA scale was also able to predict the risk of re-intervention in these patients. © 2017 Elsevier Ltd. All rights reserved.
Level of Clinical Evidence: 3 Background
$
There are no financial nor non-financial competing interests to declare regarding this article including political, personal, religious, ideological, academic, intellectual, commercial or any other. No external sources of funding were involved in the development of this study. The authors or any member of their families, have not received any financial remuneration related to the subject of the article. * Corresponding author at: Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Carlos Haya Avenue, Málaga 29010, Spain. E-mail address: [email protected] (D. González Quevedo).
Intracapsular hip fractures in elderly patients usually require treatment with joint replacement because of the high risk of femoral head necrosis and non-union in these patients [1], and the high rate of failure and poor functional outcome after internal fixation [2]. The established treatment of these injuries is either with total hip replacement (THR) or partial hip replacement (PHR), either uni- or bi-polar [3]. Each of these options has specific characteristics that make them more suitable for certain patients.
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For example, THR contrary to PHR is associated with lower surgical re-intervention rates, and possibly better functional results, but is more expensive, and has higher dislocation rates, surgical time and blood loss [3,4]. However, the use of PHR is often associated with groin pain as a result of acetabular erosion especially in active individuals [5]. This complication may appear within a year after surgery and progressively increases with time [5], and it is often associated with poor functional outcomes and higher surgical reintervention rates [5]. Therefore, PHR is more suitable for patients with poor general health, while THR should be performed in the patients who are expected to live longer, more mobile with better general health [6,7]. In addition, some authors argue that THR is the treatment of choice for all patients above 60 years with intracapsular hip fractures, because PHR cannot restore neither the anatomical nor biomechanical features of the hip joint; and that PHR should be implanted only in patients with a limited life expectancy [8]. Accordingly, it is essential to carefully select the patients that will undergo PHR to reduce the risk of perioperative mortality and to avoid postoperative complications. The decision of whether to choose one treatment option over the other is often based on the age and overall health of the patient [9]. However, there is no clear guidelines that would help taking this decision, and there is a lack of evidence in the literature providing information on the survival predictors of patients with intracapsular hip fractures [10,11]. For all the above reasons, it was hypothesized that the use of objective comorbidity scores to predict the mortality of patients with intracapsular hip fractures could be a useful tool to help choose between THA or PHR. Accordingly, the main objective of this study is to analyze the 2year survival of patients with intracapsular hip fractures who underwent either PHR or THR by use of two validated comorbidity scales: the age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) physical status classification system score. In addition, the 2-year surgical reintervention rate of patients who underwent the joint replacement surgery will also be analyzed. Methods Patient selection and clinical features A retrospective cohort study was conducted on patients over 70 years with intra-capsular hip fractures who were treated with either PHR or THR during the period between January 2010 and December 2013. Patients’ records were withdrawn from the computerized database of the Orthopedic Surgery Department at Carlos Haya Hospital of Malaga. As there was no direct contact with patients, institutional ethical approval and patients’ informed consent were not obtained. All the intracapsular proximal fractures that occurred within the study period were reviewed (i.e., femoral neck and subcapital fractures). Patients with pathological fractures (i.e., history of malignancy, Paget’s disease, osteomalacia) and patients treated with cannulated screws were excluded from the study. The following information was collected from our local computerized database: age, gender, fracture side, ACCI, ASA score, treatment type (THR or PHR), surgical re-intervention and mortality. Patients were followed until death or end of study (2 years of follow-up). ACCI scores were calculated by the method previously reported by Charlson et al., in which comorbid conditions are weighted and scored, with additional points added for age [12]. The ASA score were calculated following the method described by the American Society of Anesthesiologists [13]. Patients were grouped in two categories according to the ACCI (score: 7 or >7), and ASA (score: 3 and >3). These divisions were
Table 1 Patient demographic and clinical features. Parameter
THR (n = 65)
PHR (n = 291)
P value
Age, years
74.8 0.4
84.6 0.3
<0.01
Gender Male Female
13 (20) 52 (80)
84 (28.9) 207 (71.1)
0.17
Side Left Right
36 (55.4) 29 (44.6)
155 (53.3) 136 (46.7)
0.79
Cementation Cemented Non-cemented
1 (98.5) 64 (1.5)
291 (100) 0 (0)
<0.01
ACCI 7 >7
60 (92.3) 5 (7.7)
227 (78.0) 64 (22.0)
<0.01
ASA 3 >3
53 (81.5) 12 (18.5)
205 (72.2) 79 (27.8)
0.16
Surgical re-intervention
2 (3.1)
28 (9.6)
0.13
Survival at 2 years Alive Dead
58 (89.2) 7 (10.8)
173 (59.5) 118 (40.5)
<0.01
Data are presented as No. (%) or mean SD. Abbreviations: THRtotal hip replacement; PHRpartial hip replacement; ACCI, Ageadjusted Charlson’s comorbidity index; ASA, American Society of Anesthesiologists physical status classification system.
based on a preliminary analysis which showed that 2-year mortality rates were highest in individuals whose scores were above the selected cut-off points. Treatment options Patients who underwent THR were operated through a direct lateral approach, and were implanted a cemented or noncemented stem (CORAIL Hip System, De Puy Synthes1) and a non-cemented acetabular component (PINNACLE Hip System, De Puy Synthes1) with a ceramic on polyethylene bearing. Patients who underwent PHR received a cemented straight femoral stem (Original M.E. Müller, Zimmer1) and a bipolar head (Modular Bipolar Femoral Head, Zimmer1) via a posterior approach. The selection of the treatment method depended mainly on the surgeon’s experience and the age of the patient. All the operated patients followed the same post-operative pain control and rehabilitation protocols. Peri-operative pain control consisted of a combination of oral analgesia and IV opioids as needed. Physiotherapy was initiated from the first day postsurgery, the use of two crutches or a Zimmer frame were recommended for the first 6 weeks after surgery depending on the baseline condition of the patient. Patients were discharged when they were medically stable, able to mobilize safely, and had an adequate pain control. Patients were reviewed in clinic at 4 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Statistical analysis Data were analyzed with SPSS 22.0 software (SPSS Inc, Chicago, IL, USA). Categorical variables were presented as absolute values and percentages. Means were presented with their corresponding standard deviation (SD). The normality of the continuous variables
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Fig. 1. Kaplan-Meier estimates of survival time for individuals with intracapsular hip fractures stratified by age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
was assessed using the Shapiro-Wilk test. Differences between the demographic features were analyzed using t-student test and Chi square test. Patient survival was determined based on KaplanMeier survivorship with ACCI, and ASA comorbidity scales. Survival and surgical re-intervention rates were compared between the two groups using a Multivariate Cox proportional hazard model adjusted to potential confounders: age (only for the ASA scale), gender, cementation, type of surgical intervention (THR/PHR), use of proton pump inhibitor (PPI), beta-blockers, diuretics, bisphosphonates, selective serotonin reuptake inhibitor (SSRI). Results A total of 356 patients fulfilled the inclusion-exclusion criteria (259 females and 97 males) (Table 1). The mean age of the patients was 82.8 0.3 years (PHR 84.6 0.3, and THR 74.8 0.4, p < 0.01). Sixty-five (18.2%) of the patients underwent THR; whereas 291 (81.8%) were treated with PHR. A total of 125 (35.1%) patients died [PHR 118 (40.5%), and THR 7 (10.8%), p < 0.01] during the 2-year follow-up period. Thirty patients (8.4%) underwent surgical reinterventions [PHR 28 (9.6%), and THR 2 (3.1%), p = 0.13], from which 14 (46.7%) died during the follow-up period. A total of 221 (74.4%) of the patients that scored 7 in the ACCI were still alive after 2 years, in contrary to 76 (25.6%) of patients who scored >7. On the other hand, 201 (76.2%) of the patients that scored 3 in the ASA scale were still alive after 2 years, while only Table 2 Association between use of ACCI and ASA scores and all-cause mortality in patients with intracapsular hip fractures. Scale
All cause mortality
Crude HR
Adjusted HR
Alive (n = 231)
Dead (n = 125)
AACCIy 7 >7
221 (74.4) 20 (29.0)
76 (25.6) 49 (71.0)
1 6.8 (3.8–12.2)
1 3.2 (2.2–4.6)
ASAz 3 >3
201 (76.2) 30 (32.6)
63 (23.8) 62 (67.4)
1 6.6 (3.9–11.1)
1 3.12 (2.2–4.5)
Values adjusted to age (only for ASA), gender, cementation, type of surgical intervention (THA/PHA), use of PPI, beta-blockers, diuretics, bisphosphonates, SSRI. Data are presented as No. (%). Abbreviations: THA, total hip arthroplasty; BHA, bipolar hemiarthroplasty; ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPI, proton pump inhibitors. y Score from 0 to 12. z Score from 1 to 6
30 (32.6%) of those with ASA sore >3 were alive after 2 years. (Fig. 1). Patients with the ACCI score >7, had a significant increase in all-cause 2-year mortality compared to those with an ACCI score 7 (adjusted hazard ratio = 3.2, 95% CI 2.2–4.6). In addition, individuals with the ASA score >3 also had a higher 2-year mortality rate compared with patients with ASA score 3; (adjusted hazard ratio = 3.12, 95% CI 2.2–4.5) (Table 2). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively (Table 3). Receiver operating characteristic (ROC) curve analysis demonstrated an area under the curve of 0.79 for ACCI score (standard error, 0.02; 95% confidence interval, 0.75–0.84) and 0.72 for ASA score (standard error, 0.03; 95% confidence interval, 0–67–0.78) in predicting 2-year mortality (Fig. 2). A total of 10 (10.9%) patients who scored >3 in the ASA score, underwent a surgical re-intervention within 2 years of follow-up, compared to 20 (7.6%) in the group with ASA scores 3 (Fig. 3). The patients with an ASA score >3 had a quasi-significant increase in the surgical re-intervention risk compared with those with an ASA score 3 (adjusted hazard ratio 2.2, 95% CI 1.0–5.1). No significant differences in the surgical re-intervention rates were observed between patients with an ACCI> or 7 (Table 4). Discussion ACCI and ASA comorbidity scores and survival of patients with intracapsular hip fractures Both, ACCI and ASA could predict the 2-year mortality of elderly patients with intracapsular hip fractures. Moreover, both scores showed a relatively high specificity, positive predictive value and negative predictive value for mortality in patients with intracapsular hip fractures. The ACCI and ASA scores are valuable survival predictors commonly used in research and clinical practice [12,13], because both ensure minimum group variability and correlate with mortality and morbidity [14]. However, evidence involving the use of these scores in the therapeutic algorithms of patients with intracapsular hip fractures is scare. Two recent studies reported that Charlson’s comorbidity index was a good preoperative indicator of 30-day and 1-year mortality in elderly patients with
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Table 3 Sensitivity, specificity, positive predictive value and negative predictive value of ACCI and ASA scores in the survival prediction of patients with intracapsular hip fractures. Scale
True positive
True negative
False positive
False negative
Sensitivity%
Specificity%
PPV%
NPV%
AACCIy ASAz
49 62
221 201
20 30
76 63
39.2 49.6
91.1 87.0
71.0 67.4
74.4 76.1
Data are presented as No. Abbreviations: ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPV, positive predictive value; NPV, negative predictive value. y Cut-off point score > 7. z Cut-off point score > 3.
hip fractures [10,11]. Kirkland et al. found mortality in those patients to be 8% within the first one month [11], whereas, Lau et al. reported that the mean in-patient, 30-day, and 1-year mortality rate in patients with hip fractures was 0.8%, 2.5%, and 16.3%, respectively [10]. These studies did not analyze patient survival beyond 1 year, and did not provide statistical measures on the performance of the test (i.e. sensitivity, specificity, positive predictive value, and negative predictive value). Moreover, these studies did not identify the cut-off point in both the ACCI and ASA scores where the 2-year mortality of the patients drops below 50% (e.g., ACCI > 7, ASA > 3); this has significant clinical relevance because it could help physicians select the most appropriate treatment based on the expected survival time of the patients. Other scales such as the Sernbo score and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) surgical scoring system have also been used to predict the mortality of patients with neck of femur fractures [15] [16]. However, these studies have only analyzed the 30-day mortality in patients with hip fractures. Dawe et al., reported relatively low predictive values (i.e. 15.6%) of the POSSUM system in patients with hip fractures [16]. Another study reported that the Sernbo score had a sensitivity of 92% and a specificity of 51% to predict mortality in the first 30-days after a hip fracture [15].
Fig. 2. Comparison of area under receiver operating characteristic curve (AUC) for mortality rate between age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
We believe that the use of either ACCI or ASA score or a combination of them could have a great potential in the management of elderly patients with hip fractures. Moreover, our results show that both the ACCI and ASA scores can accurately predict the survival of patients with intracapsular hip fractures. Perhaps, the rapid classification and simplicity of the ASA score make it easier to apply in clinical practice (although the ACCI score has a higher specificity). Advantages and disadvantages of THR and PHR In this study, we did not find significant differences in the reintervention rates between PHR an THR. Both treatments are widely accepted options for femoral neck fractures [17]. Compared to PHR, the use of THR is associated with lower re-intervention rates, and possibly better functional results, but is more expensive, needs longer surgical time and is related with more blood loss [3,4]. In addition, PHR is easier to implant and has lower dislocation rates [6,7]. Accordingly, it is essential to individualize each case in order to provide the best surgical treatment for patients with intracapsular hip fractures, and to take into consideration various factors such as age, comorbidities and mobility [18]. In this study, we found that patients with PHR had higher mortality rates than those with THR. However, previous studies have reported no significant differences in the mortality rates between these procedures [5,19]. These differences could be attributed to the older mean age of patients who underwent PHR group compared with the THR group. On the other hand, several reports have shown no differences in the infection rates, and overall general complication rates between these two surgical options [6,19–21]. Nevertheless, PHR is associated with risk of acetabular erosion and has lower dislocation rates than THR [5,22]. Acetabular erosion is considered the most serious late complication after PHR [23], because the significant pain and limitation associated with this condition [24]. The risk of developing acetabular erosion within the first 4 years after undergoing PHR ranges from 7.0% to 31.7% [25,5]. Several factors have been found to influence acetabular erosion such as age, mobility, presence of concomitant diseases, overweight, and the position of the prosthetic head [23,26]. The risk of acetabular erosion increases with time [5]; therefore, younger and in general healthier individuals have a higher risk of developing acetabular erosion following treatment with PHR [18]. On the other hand, no significant differences were found in the re-intervention rate between PHR and THR. Our results are consistent with previous reports that have found no significant differences in the re-intervention rate between PHA and THA within 2 years of follow-up [6,27] or within the first 4 years after surgery [20,21,27–29]. However, PHR have higher re-intervention rates than THR with more than 4 years of follow-up [19,30]. In these cases surgery may be required to treat stem loosening or acetabular erosion [18,31,23]. Moreover, the re-intervention rate
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Fig. 3. Kaplan-Meier estimates of re-intervention time for individuals with intracapsular hip fractures stratified by age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
Table 4 Association between use of ACCI and ASA scores and re-intervention rates in patients with intracapsular hip fractures. Scale
All cause re-intervention
Crude HR
Adjusted HR
24 (8.3) 6 (8.7)
1 1.0 (0.4–2.7)
1 1.2 (0.4–3.2)
20 (7.6) 10 (10.9)
1 1.6 (0.7–3.3)
1 2.2 (1.0–5.1)
Non re-intervened (n = 326)
Re-intervented (n = 30)
AACCIy 7 >7
263 (91.6) 63 (91.3)
ASAz 3 >3
244 (92.4) 82 (89.1)
Values adjusted to age (only for ASA), gender, cementation, type of surgical intervention (THA/PHA), use of PPI, beta-blockers, diuretics, bisphosphonates, SSRI. Data are presented as No. (%). Abbreviations: THA, total hip arthroplasty; BHA, bipolar hemiarthroplasty; ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPI, proton pump inhibitors; SSRI, selective serotonin reuptake inhibitors. y Score from 0 to 12. z Score from 1 to 6.
may be influenced by the surgical approach, use of cement, age of the patient and by the presence of previous degenerative joint disease, that may require secondary conversion to THR, especially in patients with higher physical demands [18,31,23,32]. Type of procedure and ACCI and ASA comorbidity scores: Patients with ACCI score 7 or ASA score 3, had higher 2-year survival rates compared with individuals with ACCI score > 7 or ASA score > 3, respectively. Moreover, patients with an ASA score > 3 had a quasi-significant higher risk of re-intervention. These findings could eventually improve the outcome of patients with intracapsular hip fractures, by subjectively identifying relatively fit elderly patients. Due to their longer life expectancy, these patients are at a higher risk of suffering the long-term complications associated with PHR and would benefit more from a THR. Therefore, identifying them could avoid the long-term complications of PHR. The average initial cost difference between PHR and THR has been reported to range between approximately $1000 and $1300 in favor of less expensive PHR [33]. In addition, THR is likely to be associated with a higher cost during the initial 2-years after surgery [34]. However, on the long term THR appears to be more cost-effective than PHR [34]. Accordingly, an adequate patient
evaluation and implant selection at the time of surgery could potentially optimize the cost efficiency of joint replacement surgery in patients with intracapsular hip fractures. Therefore, THR is expected to be cost effective in elderly patients with intracapsular hip fracture who are likely to survive more than 2 years (i.e., ACCI score 7 and ASA score 3) despite THR being more invasive procedure compared to the PHR. Strengths and limitations To the best of our knowledge, this is the first study that reports the potential value of the ACCI and ASA scores as survival and reintervention predictors in patients with intracapsular hip fractures. In addition, the results of this study were adjusted to potential confounders that could influence mortality and reintervention rates, using a Cox proportional hazard model. Nevertheless, there are a series of limitation associated with this work. First, the retrospective design of the study made it exposed to errors due to confounding and former exposure to risk variables; however, in order to address this potential bias odds rations were adjusted to potential confounders. Surgical procedures were performed by different surgeons with different degrees of clinical experience, this could have eventually influenced the re-intervention rates. In addition, the surgical approaches used in the different
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procedures were also different. On the other hand, the follow-up time in this study was limited to 2 years; therefore, it was not able to assess the long term predictive effect of ACCI and ASA on allcause mortality and surgical re-intervention rates. Conclusions Both ACCI and ASA scores were able to predict the 2-year survival of patients with intracapsular hip fractures. The ASA score was also able to predict the risk of re-intervention in these patients. The prediction scores could be used as tools for treatment selection of patients with intraarticular hip fracture undergoing joint replacement in order to decrease their exposure to unnecessary extensive surgery, optimize outcomes and rationale health care costs. Competing interests The authors declare that they have no competing interests. References [1] Karaeminogullari O, Demirors H, Atabek M, Tuncay C, Tandogan R, Ozalay M. Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery. Adv Ther 2004;21(5):335–42. [2] Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br Vol 2002;84(2):183–8. [3] Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplast. 2012;27(4):583–90. [4] Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010;6:Cd001706. [5] Wang F, Zhang H, Zhang Z, Ma C, Feng X. Comparison of bipolar hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis. BMC Musculoskelet Disord 2015;16:229. [6] Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technol Assess (Winch Engl) 2005;9(41)1–65 iii–iv, ix–x. [7] Yang B, Lin X, Yin XM, Wen XZ. Bipolar versus unipolar hemiarthroplasty for displaced femoral neck fractures in the elder patient: a systematic review and meta-analysis of randomized trials. Eur J Orthop Surg Traumatol Orthop Traumatol 2015;25(3):425–33. [8] Ossendorf C, Scheyerer MJ, Wanner GA, Simmen HP, Werner CM. Treatment of femoral neck fractures in elderly patients over 60 years of age – which is the ideal modality of primary joint replacement? Patient Saf Surg 2010;4(1):16. [9] Florschutz AV, Langford JR, Haidukewych GJ, Koval KJ. Femoral neck fractures: current management. J Orthop Trauma 2015;29(3):121–9. [10] Lau TW, Fang C, Leung F. Assessment of postoperative short-term and longterm mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score. Hong Kong Med J=Xianggang yi xue za zhi/ Hong Kong Acad Med 2016;22(1):16–22. [11] Kirkland LL, Kashiwagi DT, Burton MC, Cha S, Varkey P. The Charlson Comorbidity Index Score as a predictor of 30-day mortality after hip fracture surgery. Am J Med Qual 2011;26(6):461–7. [12] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–83. [13] Owens WD, Felts JA, Spitznagel Jr. EL. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49(4):239–43. [14] Lavelle EA, Cheney R, Lavelle WF. Mortality prediction in a vertebral compression fracture population: the ASA physical status score versus the charlson comorbidity index. Int J Spine Surg 2015;9:63.
[15] Dawe EJ, Lindisfarne E, Singh T, McFadyen I, Stott P. Sernbo score predicts survival after intracapsular hip fracture in the elderly. Ann R Coll Surg Engl 2013;95(1):29–33. [16] Ramanathan TS, Moppett IK, Wenn R, Moran CG. POSSUM scoring for patients with fractured neck of femur. Br J Anaesth 2005;94(4):430–3. [17] Alolabi N, Alolabi B, Mundi R, Karanicolas PJ, Adachi JD, Bhandari M. Surgical preferences of patients at risk of hip fractures: hemiarthroplasty versus total hip arthroplasty. BMC Musculoskelet Disord 2011;12:289. [18] Rogmark Cecilia FAM, Leonardssonab Olof, Engesætercd B Lars, Kärrholmbe Johan, Furnescd Ove, Garellickbe Göran, et al. Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients. Acta Orthop 201485(1). [19] van den Bekerom MP, Hilverdink EF, Sierevelt IN, Reuling EM, Schnater JM, Bonke H, et al. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. J Bone Joint Surg Br Vol 2010;92(10):1422–8. [20] Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am Vol 2006;88(12):2583–9. [21] Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Tornkvist H, Ponzer S, et al. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone Joint Surg Am Vol 2011;93(5):445–50. [22] Zhao Y, Fu D, Chen K, Li G, Cai Z, Shi Y, et al. Outcome of hemiarthroplasty and total hip replacement for active elderly patients with displaced femoral neck fractures: a meta-analysis of 8 randomized clinical trials. PLoS One 2014;9(5): e98071. [23] Skala-Rosenbaum J, Bartonicek J, Bartoska R. Acetabular erosion after hip hemiarthroplasty: clinical and biomechanical study. Rozhledy v chirurgii: mesicnik Ceskoslovenske chirurgicke spolecnosti 2009;88(10):596–602. [24] Murena L, Fattori R, Scamacca V, Cau P, Ratti C, Canton G. Treatment of intracapsular fractures of the proximal femur with bipolar hemiarthroplasty in patients under the age of 70: clinical and radiographic results at mean 20 years follow-up. Acta Bio-Med Atenei Parmensis 2016;87(Suppl. 1):53–9. [25] Jia Z, Ding F, Wu Y, Li W, Li H, Wang D, et al. Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2015;10:8. [26] Trueba Davalillo C, Minueza Mejia T, Gil Orbezo F, Ponce Tovar V, Garcia Velazco R. Risk factors that have influence on acetabular erosion after a hip hemiarthroplasty in the treatment of subcapital fractures. Acta Ortop Mex 2007;21(3):121–7. [27] Cadossi M, Chiarello E, Savarino L, Tedesco G, Baldini N, Faldini C, et al. A comparison of hemiarthroplasty with a novel polycarbonate-urethane acetabular component for displaced intracapsular fractures of the femoral neck: a randomised controlled trial in elderly patients. Bone Joint J 2013;95-b (5):609–15. [28] Mouzopoulos G, Stamatakos M, Arabatzi H, Vasiliadis G, Batanis G, Tsembeli A, et al. The four-year functional result after a displaced subcapital hip fracture treated with three different surgical options. Int Orthop 2008;32(3):367–73. [29] Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplast 1986;1(1):21–8. [30] Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur?13 year results of a prospective randomised study. Injury 2000;31(10):793–7. [31] Viberg B, Overgaard S, Lauritsen J, Ovesen O. Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more. Acta Orthop 2013;84(3):254–9. [32] Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ (Clin Res Ed) 2010;340:c2332. [33] Horriat S, Hamilton PD, Sott AH. Financial aspects of arthroplasty options for intra-capsular neck of femur fractures: a cost analysis study to review the financial impacts of implementing NICE guidelines in the NHS organisations. Injury 2015;46(2):363–5. [34] Carroll C, Stevenson M, Scope A, Evans P, Buckley S. Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis. Health Technol Assess (Winch Engl) 2011;15(36):1–74.
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Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Patient survival and surgical re-intervention predictors for intracapsular hip fractures$ David González Quevedoa,* , Iskandar Tamimi Mariñoa , Juan Manuel Sánchez Silesa , Esther Romero Escribanoa , Esther Judith Granero Molinaa , David Bautista Enriquea , cb , Francisco Villanueva Parejaa Tomislav Smoljanovi a b
Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Spain Department of Orthopedic Surgery and Traumatology, University Hospital Centre of Zagreb, Croatia
A R T I C L E I N F O
Keywords: Charlson comorbidity index Hip fractures Total hip replacement Partial hip replacement Hemiarthroplasty Total hip arthroplasty Mortality Survival American Society of Anesthesiologists
A B S T R A C T
Background: Choosing between total hip replacement (THR) and partial hip replacement (PHR) for patients with intracapsular hip fractures is often based on subjective factors. Predicting the survival of these patients and risk of surgical re-intervention is essential to select the most adequate implant. Methods: We conducted a retrospective cohort study on mortality of patients over 70 years with intracapsular hip fractures who were treated between January 2010 and December 2013, with either PHR or THR. Patients’ information was withdrawn from our local computerized database. The age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) score were calculated for all patients. The patients were followed for 2 years after surgery. Survival and surgical reintervention rates were compared between the two groups using a Multivariate Cox proportional hazard model. Results: A total of 356 individuals were included in this study. At 2 years of follow-up, 221 (74.4%) of the patients with ACCI score 7 were still alive, in contrast to only 20 (29.0%) of those with ACCI score > 7. In addition, 201 (76.2%) of the patients with ASA score 3 were still alive after 2 years, compared to 30 (32.6%) of individuals with ASA >3. Patients with the ACCI score > 7, and ASA score > 3 had a significant increase in all-cause 2-year mortality (adjusted hazard ratio of 3.2, 95% CI 2.2–4.6; and 3.12, 95% CI 2.2– 4.5, respectively). Patients with an ASA score > 3 had a quasi-significant increase in the re-intervention risk (adjusted hazard ratio 2.2, 95% CI 1.0–5.1). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively. Conclusions: Both ACCI and ASA scales were able to predict the 2-year survival of patients with intracapsular hip fractures. The ASA scale was also able to predict the risk of re-intervention in these patients. © 2017 Elsevier Ltd. All rights reserved.
Level of Clinical Evidence: 3 Background
$
There are no financial nor non-financial competing interests to declare regarding this article including political, personal, religious, ideological, academic, intellectual, commercial or any other. No external sources of funding were involved in the development of this study. The authors or any member of their families, have not received any financial remuneration related to the subject of the article. * Corresponding author at: Department of Orthopedic Surgery and Traumatology, Regional University Hospital of Málaga, Carlos Haya Avenue, Málaga 29010, Spain. E-mail address: [email protected] (D. González Quevedo).
Intracapsular hip fractures in elderly patients usually require treatment with joint replacement because of the high risk of femoral head necrosis and non-union in these patients [1], and the high rate of failure and poor functional outcome after internal fixation [2]. The established treatment of these injuries is either with total hip replacement (THR) or partial hip replacement (PHR), either uni- or bi-polar [3]. Each of these options has specific characteristics that make them more suitable for certain patients.
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For example, THR contrary to PHR is associated with lower surgical re-intervention rates, and possibly better functional results, but is more expensive, and has higher dislocation rates, surgical time and blood loss [3,4]. However, the use of PHR is often associated with groin pain as a result of acetabular erosion especially in active individuals [5]. This complication may appear within a year after surgery and progressively increases with time [5], and it is often associated with poor functional outcomes and higher surgical reintervention rates [5]. Therefore, PHR is more suitable for patients with poor general health, while THR should be performed in the patients who are expected to live longer, more mobile with better general health [6,7]. In addition, some authors argue that THR is the treatment of choice for all patients above 60 years with intracapsular hip fractures, because PHR cannot restore neither the anatomical nor biomechanical features of the hip joint; and that PHR should be implanted only in patients with a limited life expectancy [8]. Accordingly, it is essential to carefully select the patients that will undergo PHR to reduce the risk of perioperative mortality and to avoid postoperative complications. The decision of whether to choose one treatment option over the other is often based on the age and overall health of the patient [9]. However, there is no clear guidelines that would help taking this decision, and there is a lack of evidence in the literature providing information on the survival predictors of patients with intracapsular hip fractures [10,11]. For all the above reasons, it was hypothesized that the use of objective comorbidity scores to predict the mortality of patients with intracapsular hip fractures could be a useful tool to help choose between THA or PHR. Accordingly, the main objective of this study is to analyze the 2year survival of patients with intracapsular hip fractures who underwent either PHR or THR by use of two validated comorbidity scales: the age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) physical status classification system score. In addition, the 2-year surgical reintervention rate of patients who underwent the joint replacement surgery will also be analyzed. Methods Patient selection and clinical features A retrospective cohort study was conducted on patients over 70 years with intra-capsular hip fractures who were treated with either PHR or THR during the period between January 2010 and December 2013. Patients’ records were withdrawn from the computerized database of the Orthopedic Surgery Department at Carlos Haya Hospital of Malaga. As there was no direct contact with patients, institutional ethical approval and patients’ informed consent were not obtained. All the intracapsular proximal fractures that occurred within the study period were reviewed (i.e., femoral neck and subcapital fractures). Patients with pathological fractures (i.e., history of malignancy, Paget’s disease, osteomalacia) and patients treated with cannulated screws were excluded from the study. The following information was collected from our local computerized database: age, gender, fracture side, ACCI, ASA score, treatment type (THR or PHR), surgical re-intervention and mortality. Patients were followed until death or end of study (2 years of follow-up). ACCI scores were calculated by the method previously reported by Charlson et al., in which comorbid conditions are weighted and scored, with additional points added for age [12]. The ASA score were calculated following the method described by the American Society of Anesthesiologists [13]. Patients were grouped in two categories according to the ACCI (score: 7 or >7), and ASA (score: 3 and >3). These divisions were
Table 1 Patient demographic and clinical features. Parameter
THR (n = 65)
PHR (n = 291)
P value
Age, years
74.8 0.4
84.6 0.3
<0.01
Gender Male Female
13 (20) 52 (80)
84 (28.9) 207 (71.1)
0.17
Side Left Right
36 (55.4) 29 (44.6)
155 (53.3) 136 (46.7)
0.79
Cementation Cemented Non-cemented
1 (98.5) 64 (1.5)
291 (100) 0 (0)
<0.01
ACCI 7 >7
60 (92.3) 5 (7.7)
227 (78.0) 64 (22.0)
<0.01
ASA 3 >3
53 (81.5) 12 (18.5)
205 (72.2) 79 (27.8)
0.16
Surgical re-intervention
2 (3.1)
28 (9.6)
0.13
Survival at 2 years Alive Dead
58 (89.2) 7 (10.8)
173 (59.5) 118 (40.5)
<0.01
Data are presented as No. (%) or mean SD. Abbreviations: THRtotal hip replacement; PHRpartial hip replacement; ACCI, Ageadjusted Charlson’s comorbidity index; ASA, American Society of Anesthesiologists physical status classification system.
based on a preliminary analysis which showed that 2-year mortality rates were highest in individuals whose scores were above the selected cut-off points. Treatment options Patients who underwent THR were operated through a direct lateral approach, and were implanted a cemented or noncemented stem (CORAIL Hip System, De Puy Synthes1) and a non-cemented acetabular component (PINNACLE Hip System, De Puy Synthes1) with a ceramic on polyethylene bearing. Patients who underwent PHR received a cemented straight femoral stem (Original M.E. Müller, Zimmer1) and a bipolar head (Modular Bipolar Femoral Head, Zimmer1) via a posterior approach. The selection of the treatment method depended mainly on the surgeon’s experience and the age of the patient. All the operated patients followed the same post-operative pain control and rehabilitation protocols. Peri-operative pain control consisted of a combination of oral analgesia and IV opioids as needed. Physiotherapy was initiated from the first day postsurgery, the use of two crutches or a Zimmer frame were recommended for the first 6 weeks after surgery depending on the baseline condition of the patient. Patients were discharged when they were medically stable, able to mobilize safely, and had an adequate pain control. Patients were reviewed in clinic at 4 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Statistical analysis Data were analyzed with SPSS 22.0 software (SPSS Inc, Chicago, IL, USA). Categorical variables were presented as absolute values and percentages. Means were presented with their corresponding standard deviation (SD). The normality of the continuous variables
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Fig. 1. Kaplan-Meier estimates of survival time for individuals with intracapsular hip fractures stratified by age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
was assessed using the Shapiro-Wilk test. Differences between the demographic features were analyzed using t-student test and Chi square test. Patient survival was determined based on KaplanMeier survivorship with ACCI, and ASA comorbidity scales. Survival and surgical re-intervention rates were compared between the two groups using a Multivariate Cox proportional hazard model adjusted to potential confounders: age (only for the ASA scale), gender, cementation, type of surgical intervention (THR/PHR), use of proton pump inhibitor (PPI), beta-blockers, diuretics, bisphosphonates, selective serotonin reuptake inhibitor (SSRI). Results A total of 356 patients fulfilled the inclusion-exclusion criteria (259 females and 97 males) (Table 1). The mean age of the patients was 82.8 0.3 years (PHR 84.6 0.3, and THR 74.8 0.4, p < 0.01). Sixty-five (18.2%) of the patients underwent THR; whereas 291 (81.8%) were treated with PHR. A total of 125 (35.1%) patients died [PHR 118 (40.5%), and THR 7 (10.8%), p < 0.01] during the 2-year follow-up period. Thirty patients (8.4%) underwent surgical reinterventions [PHR 28 (9.6%), and THR 2 (3.1%), p = 0.13], from which 14 (46.7%) died during the follow-up period. A total of 221 (74.4%) of the patients that scored 7 in the ACCI were still alive after 2 years, in contrary to 76 (25.6%) of patients who scored >7. On the other hand, 201 (76.2%) of the patients that scored 3 in the ASA scale were still alive after 2 years, while only Table 2 Association between use of ACCI and ASA scores and all-cause mortality in patients with intracapsular hip fractures. Scale
All cause mortality
Crude HR
Adjusted HR
Alive (n = 231)
Dead (n = 125)
AACCIy 7 >7
221 (74.4) 20 (29.0)
76 (25.6) 49 (71.0)
1 6.8 (3.8–12.2)
1 3.2 (2.2–4.6)
ASAz 3 >3
201 (76.2) 30 (32.6)
63 (23.8) 62 (67.4)
1 6.6 (3.9–11.1)
1 3.12 (2.2–4.5)
Values adjusted to age (only for ASA), gender, cementation, type of surgical intervention (THA/PHA), use of PPI, beta-blockers, diuretics, bisphosphonates, SSRI. Data are presented as No. (%). Abbreviations: THA, total hip arthroplasty; BHA, bipolar hemiarthroplasty; ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPI, proton pump inhibitors. y Score from 0 to 12. z Score from 1 to 6
30 (32.6%) of those with ASA sore >3 were alive after 2 years. (Fig. 1). Patients with the ACCI score >7, had a significant increase in all-cause 2-year mortality compared to those with an ACCI score 7 (adjusted hazard ratio = 3.2, 95% CI 2.2–4.6). In addition, individuals with the ASA score >3 also had a higher 2-year mortality rate compared with patients with ASA score 3; (adjusted hazard ratio = 3.12, 95% CI 2.2–4.5) (Table 2). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively (Table 3). Receiver operating characteristic (ROC) curve analysis demonstrated an area under the curve of 0.79 for ACCI score (standard error, 0.02; 95% confidence interval, 0.75–0.84) and 0.72 for ASA score (standard error, 0.03; 95% confidence interval, 0–67–0.78) in predicting 2-year mortality (Fig. 2). A total of 10 (10.9%) patients who scored >3 in the ASA score, underwent a surgical re-intervention within 2 years of follow-up, compared to 20 (7.6%) in the group with ASA scores 3 (Fig. 3). The patients with an ASA score >3 had a quasi-significant increase in the surgical re-intervention risk compared with those with an ASA score 3 (adjusted hazard ratio 2.2, 95% CI 1.0–5.1). No significant differences in the surgical re-intervention rates were observed between patients with an ACCI> or 7 (Table 4). Discussion ACCI and ASA comorbidity scores and survival of patients with intracapsular hip fractures Both, ACCI and ASA could predict the 2-year mortality of elderly patients with intracapsular hip fractures. Moreover, both scores showed a relatively high specificity, positive predictive value and negative predictive value for mortality in patients with intracapsular hip fractures. The ACCI and ASA scores are valuable survival predictors commonly used in research and clinical practice [12,13], because both ensure minimum group variability and correlate with mortality and morbidity [14]. However, evidence involving the use of these scores in the therapeutic algorithms of patients with intracapsular hip fractures is scare. Two recent studies reported that Charlson’s comorbidity index was a good preoperative indicator of 30-day and 1-year mortality in elderly patients with
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Table 3 Sensitivity, specificity, positive predictive value and negative predictive value of ACCI and ASA scores in the survival prediction of patients with intracapsular hip fractures. Scale
True positive
True negative
False positive
False negative
Sensitivity%
Specificity%
PPV%
NPV%
AACCIy ASAz
49 62
221 201
20 30
76 63
39.2 49.6
91.1 87.0
71.0 67.4
74.4 76.1
Data are presented as No. Abbreviations: ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPV, positive predictive value; NPV, negative predictive value. y Cut-off point score > 7. z Cut-off point score > 3.
hip fractures [10,11]. Kirkland et al. found mortality in those patients to be 8% within the first one month [11], whereas, Lau et al. reported that the mean in-patient, 30-day, and 1-year mortality rate in patients with hip fractures was 0.8%, 2.5%, and 16.3%, respectively [10]. These studies did not analyze patient survival beyond 1 year, and did not provide statistical measures on the performance of the test (i.e. sensitivity, specificity, positive predictive value, and negative predictive value). Moreover, these studies did not identify the cut-off point in both the ACCI and ASA scores where the 2-year mortality of the patients drops below 50% (e.g., ACCI > 7, ASA > 3); this has significant clinical relevance because it could help physicians select the most appropriate treatment based on the expected survival time of the patients. Other scales such as the Sernbo score and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) surgical scoring system have also been used to predict the mortality of patients with neck of femur fractures [15] [16]. However, these studies have only analyzed the 30-day mortality in patients with hip fractures. Dawe et al., reported relatively low predictive values (i.e. 15.6%) of the POSSUM system in patients with hip fractures [16]. Another study reported that the Sernbo score had a sensitivity of 92% and a specificity of 51% to predict mortality in the first 30-days after a hip fracture [15].
Fig. 2. Comparison of area under receiver operating characteristic curve (AUC) for mortality rate between age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
We believe that the use of either ACCI or ASA score or a combination of them could have a great potential in the management of elderly patients with hip fractures. Moreover, our results show that both the ACCI and ASA scores can accurately predict the survival of patients with intracapsular hip fractures. Perhaps, the rapid classification and simplicity of the ASA score make it easier to apply in clinical practice (although the ACCI score has a higher specificity). Advantages and disadvantages of THR and PHR In this study, we did not find significant differences in the reintervention rates between PHR an THR. Both treatments are widely accepted options for femoral neck fractures [17]. Compared to PHR, the use of THR is associated with lower re-intervention rates, and possibly better functional results, but is more expensive, needs longer surgical time and is related with more blood loss [3,4]. In addition, PHR is easier to implant and has lower dislocation rates [6,7]. Accordingly, it is essential to individualize each case in order to provide the best surgical treatment for patients with intracapsular hip fractures, and to take into consideration various factors such as age, comorbidities and mobility [18]. In this study, we found that patients with PHR had higher mortality rates than those with THR. However, previous studies have reported no significant differences in the mortality rates between these procedures [5,19]. These differences could be attributed to the older mean age of patients who underwent PHR group compared with the THR group. On the other hand, several reports have shown no differences in the infection rates, and overall general complication rates between these two surgical options [6,19–21]. Nevertheless, PHR is associated with risk of acetabular erosion and has lower dislocation rates than THR [5,22]. Acetabular erosion is considered the most serious late complication after PHR [23], because the significant pain and limitation associated with this condition [24]. The risk of developing acetabular erosion within the first 4 years after undergoing PHR ranges from 7.0% to 31.7% [25,5]. Several factors have been found to influence acetabular erosion such as age, mobility, presence of concomitant diseases, overweight, and the position of the prosthetic head [23,26]. The risk of acetabular erosion increases with time [5]; therefore, younger and in general healthier individuals have a higher risk of developing acetabular erosion following treatment with PHR [18]. On the other hand, no significant differences were found in the re-intervention rate between PHR and THR. Our results are consistent with previous reports that have found no significant differences in the re-intervention rate between PHA and THA within 2 years of follow-up [6,27] or within the first 4 years after surgery [20,21,27–29]. However, PHR have higher re-intervention rates than THR with more than 4 years of follow-up [19,30]. In these cases surgery may be required to treat stem loosening or acetabular erosion [18,31,23]. Moreover, the re-intervention rate
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Fig. 3. Kaplan-Meier estimates of re-intervention time for individuals with intracapsular hip fractures stratified by age-adjusted Charlson comorbidity index (ACCI) score and American Society of Anesthesiologists (ASA) score.
Table 4 Association between use of ACCI and ASA scores and re-intervention rates in patients with intracapsular hip fractures. Scale
All cause re-intervention
Crude HR
Adjusted HR
24 (8.3) 6 (8.7)
1 1.0 (0.4–2.7)
1 1.2 (0.4–3.2)
20 (7.6) 10 (10.9)
1 1.6 (0.7–3.3)
1 2.2 (1.0–5.1)
Non re-intervened (n = 326)
Re-intervented (n = 30)
AACCIy 7 >7
263 (91.6) 63 (91.3)
ASAz 3 >3
244 (92.4) 82 (89.1)
Values adjusted to age (only for ASA), gender, cementation, type of surgical intervention (THA/PHA), use of PPI, beta-blockers, diuretics, bisphosphonates, SSRI. Data are presented as No. (%). Abbreviations: THA, total hip arthroplasty; BHA, bipolar hemiarthroplasty; ACCI, Age-Adjusted Charlson’s Comorbidity Index; ASA, American Society of Anesthesiologists physical status classification system; PPI, proton pump inhibitors; SSRI, selective serotonin reuptake inhibitors. y Score from 0 to 12. z Score from 1 to 6.
may be influenced by the surgical approach, use of cement, age of the patient and by the presence of previous degenerative joint disease, that may require secondary conversion to THR, especially in patients with higher physical demands [18,31,23,32]. Type of procedure and ACCI and ASA comorbidity scores: Patients with ACCI score 7 or ASA score 3, had higher 2-year survival rates compared with individuals with ACCI score > 7 or ASA score > 3, respectively. Moreover, patients with an ASA score > 3 had a quasi-significant higher risk of re-intervention. These findings could eventually improve the outcome of patients with intracapsular hip fractures, by subjectively identifying relatively fit elderly patients. Due to their longer life expectancy, these patients are at a higher risk of suffering the long-term complications associated with PHR and would benefit more from a THR. Therefore, identifying them could avoid the long-term complications of PHR. The average initial cost difference between PHR and THR has been reported to range between approximately $1000 and $1300 in favor of less expensive PHR [33]. In addition, THR is likely to be associated with a higher cost during the initial 2-years after surgery [34]. However, on the long term THR appears to be more cost-effective than PHR [34]. Accordingly, an adequate patient
evaluation and implant selection at the time of surgery could potentially optimize the cost efficiency of joint replacement surgery in patients with intracapsular hip fractures. Therefore, THR is expected to be cost effective in elderly patients with intracapsular hip fracture who are likely to survive more than 2 years (i.e., ACCI score 7 and ASA score 3) despite THR being more invasive procedure compared to the PHR. Strengths and limitations To the best of our knowledge, this is the first study that reports the potential value of the ACCI and ASA scores as survival and reintervention predictors in patients with intracapsular hip fractures. In addition, the results of this study were adjusted to potential confounders that could influence mortality and reintervention rates, using a Cox proportional hazard model. Nevertheless, there are a series of limitation associated with this work. First, the retrospective design of the study made it exposed to errors due to confounding and former exposure to risk variables; however, in order to address this potential bias odds rations were adjusted to potential confounders. Surgical procedures were performed by different surgeons with different degrees of clinical experience, this could have eventually influenced the re-intervention rates. In addition, the surgical approaches used in the different
Please cite this article in press as: D. González Quevedo, et al., Patient survival and surgical re-intervention predictors for intracapsular hip fractures, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.06.014
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procedures were also different. On the other hand, the follow-up time in this study was limited to 2 years; therefore, it was not able to assess the long term predictive effect of ACCI and ASA on allcause mortality and surgical re-intervention rates. Conclusions Both ACCI and ASA scores were able to predict the 2-year survival of patients with intracapsular hip fractures. The ASA score was also able to predict the risk of re-intervention in these patients. The prediction scores could be used as tools for treatment selection of patients with intraarticular hip fracture undergoing joint replacement in order to decrease their exposure to unnecessary extensive surgery, optimize outcomes and rationale health care costs. Competing interests The authors declare that they have no competing interests. References [1] Karaeminogullari O, Demirors H, Atabek M, Tuncay C, Tandogan R, Ozalay M. Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery. Adv Ther 2004;21(5):335–42. [2] Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br Vol 2002;84(2):183–8. [3] Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplast. 2012;27(4):583–90. [4] Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010;6:Cd001706. [5] Wang F, Zhang H, Zhang Z, Ma C, Feng X. Comparison of bipolar hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis. BMC Musculoskelet Disord 2015;16:229. [6] Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technol Assess (Winch Engl) 2005;9(41)1–65 iii–iv, ix–x. [7] Yang B, Lin X, Yin XM, Wen XZ. Bipolar versus unipolar hemiarthroplasty for displaced femoral neck fractures in the elder patient: a systematic review and meta-analysis of randomized trials. Eur J Orthop Surg Traumatol Orthop Traumatol 2015;25(3):425–33. [8] Ossendorf C, Scheyerer MJ, Wanner GA, Simmen HP, Werner CM. Treatment of femoral neck fractures in elderly patients over 60 years of age – which is the ideal modality of primary joint replacement? Patient Saf Surg 2010;4(1):16. [9] Florschutz AV, Langford JR, Haidukewych GJ, Koval KJ. Femoral neck fractures: current management. J Orthop Trauma 2015;29(3):121–9. [10] Lau TW, Fang C, Leung F. Assessment of postoperative short-term and longterm mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score. Hong Kong Med J=Xianggang yi xue za zhi/ Hong Kong Acad Med 2016;22(1):16–22. [11] Kirkland LL, Kashiwagi DT, Burton MC, Cha S, Varkey P. The Charlson Comorbidity Index Score as a predictor of 30-day mortality after hip fracture surgery. Am J Med Qual 2011;26(6):461–7. [12] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–83. [13] Owens WD, Felts JA, Spitznagel Jr. EL. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49(4):239–43. [14] Lavelle EA, Cheney R, Lavelle WF. Mortality prediction in a vertebral compression fracture population: the ASA physical status score versus the charlson comorbidity index. Int J Spine Surg 2015;9:63.
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Please cite this article in press as: D. González Quevedo, et al., Patient survival and surgical re-intervention predictors for intracapsular hip fractures, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.06.014