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The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly
Archives of Gerontology and Geriatrics 39 (2004) 179–185
The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly Hüseyin Doruk a,∗ , M. Refik Mas a , Cemil Yıldız b , Alper Sonmez c , Vecihi Kýrdemir b a
Department of Geriatric Medicine, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey b Department of Orthopedics, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey c Department of Internal Medicine, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey Received 1 October 2003; received in revised form 19 February 2004; accepted 17 March 2004 Available online 2 June 2004
Abstract The optimal time for the operation of hip fractures in elderly is not clear. Most of the data indicate that early operation is associated with better prognosis and improved health quality. We aimed to investigate the effect of timing of surgical intervention on the frequency of post-operative complications, recovery of weight bearing ability, total hospitalization time and activities of daily living (ADL) scores. Sixty five patients subjected to surgical repair were followed up. All were evaluated for their ADL before fracture, post-operative 1st, 3rd, 6th and 12th month. The patients operated within 5 days after hospitalization constituted the early group (n = 38, 24 females, 14 males; mean age = 76.16±7.08 years), and the patients operated after the fifth day served as the late group (n = 27, 18 females, 9 males; mean age = 75.81 ± 7.50). Time of recovery of weight bearing ability and total hospitalization time were significantly higher in the late group (P < 0.05). ADL scores in 1st, 3rd and 6th month after surgery were significantly lower (P < 0.05), and death rates on post-operative 1st and 12th month were significantly higher in the late group (P < 0.05). Elderly, operated within 5 days of the hip fracture have increased survival time and better life quality than those operated after the fifth day of the admission. The data supports the previous reports which indicate the necessity of the early operation of elderly hip fractures. © 2004 Published by Elsevier Ireland Ltd. Keywords: Hip fracture; Surgical timing; Life quality; Activity of daily living
∗
Corresponding author. Tel.: +90-312-3043231; fax: +90-312-3094761. E-mail address: [email protected] (H. Doruk).
0167-4943/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.archger.2004.03.004
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H. Doruk et al. / Archives of Gerontology and Geriatrics 39 (2004) 179–185
1. Introduction Hip fractures are among the major causes of morbidity and mortality in geriatric population. The elderly, falls more frequently and most hip fractures result from relatively minor traumas, such as falls out of bed or from a standing height or lower (Hagino et al., 2004). The reflexes are weaker to cushion the impact of a fall and bones weakened by osteoporosis require less mechanical force to break (Melton et al., 1997). These factors act together to make elderly more susceptible to hip fractures. An estimated 1.3 million such fractures occurred globally in 1990, and the annual rate of hip fracture worldwide is expected to rise considerably as life expectancy and age-specific rates of hip fracture increase (Gullberg et al., 1997). The main goals of management of hip fractures are restoring the anatomic arrangement and bringing back the function of the limb, and rehabilitating the patient effectively. The incidence of post-operative complications is high, and rehabilitation is difficult and long-lasting. Largely as a result of diminished mobility and independence, patients with hip fracture experience a rapid and major deterioration in health-related quality of life. One in five people die in the first year after a hip fracture and one in four elderly requires a higher level of long term care after a fracture (Schurch et al., 1996). Treatment of patients with hip fracture accounts for most of the healthcare spending associated with osteoporosis (about US$ 14 billion annually in the United States) (Ray et al., 1997). Many factors are reported to affect the post-operative mortality and quality of life. Comorbid conditions, age, mental status, operation type and early mobilization are among these factors (Nather et al., 1995; Poor et al., 1995). Some reports indicate that the post-operative quality of life and mortality is related with the early surgical time (Schurch et al., 1996). Surgery is advised as soon as the medical condition of the patient allows, provided that appropriate staffing and facilities are available (Bredahl et al., 1992; Holt et al., 1994; Hamlet et al., 1997). However, there is also data which indicate that there is no association with the early repair and mortality (Grimes et al., 2002; Stoddart et al., 2002). Again it has been reported that surgical repair may be delayed up to 7 days from the fracture episode with no adverse effect on outcome (Kenzora et al., 1984). Most of these controversial data are from the retrospective analyses, performed through databases. Thus, the delayed operations due to poor health conditions were possibly involved in these investigation groups. Preexisting medical problems in the elderly is the most important cause of post-operative complications (Seymour, 1999). In order to prevent any bias between the early and late surgical operation groups, a prospective follow up study was designed by recruiting elderly people with similar health statuses on early and late surgical groups. The aim of this study was to investigate the relation between the frequency of post-operative complications, mortality, quality of life and the timing of surgical repair.
2. Patients and methods The consecutive admissions for hip fractures to the Orthopedics and Traumatology Department of Gülhane Military Medical Academy were prospectively screened from August 2000 to May 2002.
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Sixty five patients (42 females, 23 males, mean age = 76.02 ± 7.20 years) who met the criteria were enrolled in the study. The admission criteria of the patients were as follows: (1) patients older than 65 years; (2) hip fractures were not pathological (i.e. not secondary to metastasis); and (3) ambulatory patients with or without assistive devices. All the patients were examined and followed by geriatricians and orthopedists for metabolic and psychological stabilization both pre-operative and post-operative periods. The baseline characteristics of the patients and the activities of daily living (ADL) scale were assessed for all patients before fracture, and 1, 3, 6 and 12 months after surgery (ADL 0, 1, 3, 6, 12, respectively) (Katz et al., 1970). The ADL 0 was judged after the admission to hospital with an interview about the patients’ daily activities before fracture. The comorbid conditions of the patients were reported as hypertension, heart failure, coronary artery disease, cerebrovascular diseases, rheumatic diseases, dementia, Parkinson’s disease, diabetes mellitus and chronic obstructive lung disease. The patients who had poor control of chronic diseases, inappropriate intake of medicine, and inadequate pre-hospital care were stabilized before the operation. The pre-operative physiological statuses of the patients were graded with simplified acute physiologic score (SAPS) (Le Gall et al., 1984). The patients were arranged into two groups according to the operation time: 38 patients (mean age = 76.2 ± 7.1 years; M/F ratio = 24/14) were in the early group and 27 patients (mean age = 75.8 ± 7.5 years; M/F ratio = 18/9) in the late group. The early group was operated within 5 days after hospitalization, while the late group was undertaken for surgery after the fifth day of admission. Both groups received anticoagulant therapy with low molecular weight heparin after hospitalization. Intra and post-operative antibiotic prophylaxis with Cefazolin (1000 mg, i.v. bid.) was also done. All patients received partial hip prosthesis. The surgical procedures were based on patients’ clinical situation and did not conform to any pre-established protocol. During the post-operative follow-up, physiotherapists and diet consultants were also included to give a better quality of medical support. Post-operative rehabilitation usually began within 24 h after surgery, with mobilization out of bed to a chair and progression to ambulation training. Weight bearing status was determined by the clinical assessment of the surgeon and physiotherapists. The post-operative follow up was monitored by the orthopedic surgeon and geriatcian and was assisted by the clinical resident staff. 2.1. Statistical analysis Statistical analysis was performed using commercially available statistical software (SPSS 10.0, SPSS Inc., Chicago USA). All the results were reported as mean ± standard deviation. Continuous variables were compared using Mann–Whitney U test. Comparisons between the death rates of two groups were made by Chi-square test. Differences were accepted as statistically significant if calculated P value was found below 0.05. 3. Results The mean age and gender distribution of the patient groups were not different. The weight bearing times after the operation and the total hospitalization periods were significantly
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Table 1 Baseline characteristics of the patients
Mean age (years) Gender (F/M) Intertrochanteric fracture Collum femoris fracture Admission time (days) Pre-operative period (days) Weight bearing (days) Total hospitalization period (days) SAPS
Early group (n = 38)
Late group (n = 27)
Total patients (n = 65)
76.2 ± 7.3 24/14 22 16 0.95 ± 1.4 3.5 ± 1 a 4.8 ± 3 c 24.9 ± 13 e 14.3 ± 3.2
75.8 ± 8.4 18/9 14 13 1.48 ± 1.40 11.7 ± 7 b 7.8 ± 6 d 40.4 ± 25 f 16.2 ± 4.2
76.0 ± 7.5 42/23 36 29 1.17 ± 1.41 6.90 ± 5.83 5.94 ± 4.18 30.58 ± 19.87 15.2 ± 3.8
Mann–Whitney U test. P < 0.05 for a vs. b, c vs. d and e vs. f. Table 2 The ADL scores of the patients Early group ADL 0 ADL 1 ADL 3 ADL 6 ADL 12 a
10.8 ± 1.8 (n = 38) 8.55 ± 2.5 (n = 38) 9.7 ± 2.4 (n = 37) 10.35 ± 2.05 (n = 34) 10.07 ± 1.9 (n = 33)
Late group
Pa
10.9 ± 1.35 (n = 27) 7.15 ± 2.3 (n = 22) 8.2 ± 2.2 (n = 20) 8.8 ± 2.15 (n = 19) 10.3 ± 1.95 (n = 17)
NS <0.05 <0.05 <0.05 NS
Mann–Whitney U test.
longer in the late group (P < 0.05 for both). The baseline characteristics of the patients are shown in Table 1. The ADL scores before the fracture and on the 12th month of the operation were not different between the two groups. The ADL scores on the 1st, 3rd and 6th month were significantly lower in the late group (P < 0.05 for each). The ADL scores of both groups are shown in Table 2. Within the post-operative first month, five patients died in the late group. The causes of death of the patients are as follows: (1) cerebral embolism and acute renal failure (ARF), (2) right total atelectasis and upper gastrointestinal bleeding, (3) pulmonary embolism, (4) stroke, (5) ARF and bronchopneumonia. Between post-operative 1st and 3rd month, two patients of the late group and one from the early group died. The cause of death of the patient of the early group was acute myocardial infarction (MI). The causes of death in the late group were stroke, MI and ARF. Between post-operative 3rd and 6th month, three patients
Table 3 The mortality rates of the early and late subgroups Post-operative mortality
Early group (n = 38)
Late group (n = 27)
Pa
1st month 12th month
0 (0%) 5 (13.2%)
5 (18.5%) 10 (37%)
<0.05 <0.05
a
Chi-square test.
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in the early group (two from MI and one from pneumonia), and one patient in the late group (stroke) died. Between 6th and 12th month, one death from ARF in the early group, and two deaths (one of which from stroke and the other from coronary artery disease) in the late group were observed. Mortality rates are shown in Table 3.
4. Discussion Hip fractures cause significant mortality in the elderly as compared with normal population (Poor et al., 1995). The intractable pain, loss of mobility and independent life are the most important problems meaning to exhaustion or death for the elderly patient (Lyons, 1997). The optimal timing of the surgery is said to be essential in order to prevent mortality and morbidity of the hip fractures. The reports indicate that 4 week mortality rate decreases from 12 to 8% when the operation is done in 12 h after hospitalization (Davis et al., 1987) while mortality rate increases if the operation is delayed more than 48 h (Todd et al., 1995). As well as causing distress to the patient, a delay of more than 24 h in operative fixation is associated with increased morbidity and mortality, and with reduced chance of successful internal fixation and rehabilitation (Villar et al., 1986; Davis et al., 1988). Current guidelines indicate that patients be operated on as soon as possible (within 24 h), during standard daytime working hours, including weekends, if their medical conditions allows (Scottish Intercollegiate Network Guidelines, 2002). The evidence indicates that early operations reduce the risk of deep vein thrombosis (Hefley et al., 1996) and of fatal pulmonary embolism after hip fracture (Perez et al., 1995). Delay in surgery however will result in a postponement of full weight bearing status, leading to delayed functional recovery (Zuckerman et al., 1995). Prolonged bed rest may increase the risk of medical complications such as deep venous thrombosis, pulmonary complications, urinary tract infection, and skin breakdown (Bredahl et al., 1992; Zuckerman, 1996). Among the causes of the operational delays are the insufficient control of chronic diseases, inappropriate intake of medicine, dementia and inadequate pre-hospital care of the patients. Failure to stabilize coexisting medical conditions prior to surgery may increase the risk of post-operative complications (Zuckerman, 1996). Although the current evidence is in favor of early surgery, most of the data about the timing of the surgery are obtained from the retrospective analyses of the cases. Preexisting medical problems in the geriatric population play the most important role both in quality of daily life and success of rehabilitation (Nather et al., 1995; Poor et al., 1995). Thus it is possible that the patients, who were operated later because of poor health conditions, contributed to increased mortality and morbidity and caused a bias towards early operation. Several reports indicate that there is no association with the early repair and mortality (Stoddart et al., 2002). There is also substantial data supporting delayed operations. Lorhan and Shelby (1964) reported increased mortality if the surgery is done in the first 12 h after hospitalization. Kenzora et al. (1984) reported 1 year mortality as 34% if the surgery had been done in the first 24 h and 6% between second and fifth day. They concluded that, side effects are decreased if the operation is postponed up to 7 days after the medical stabilization of the patients. It has also been demonstrated that surgical treatment conducted as night-time emergency increases mortality (Lunn et al., 1993). Finally, a large study on hip fractures
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indicate that patients who had surgery more than 96 h after admission do not have increased mortality compared with patients who had surgery 24–48 h after admission (Grimes et al., 2002). The later study reported that the comorbidities but not the mortality rates increase because of the delay in surgery. In the present study the aim was to stabilize patients before the operation and provide optimal pre-operative physical statuses. Because of the stabilization of the patients the pre-operative SAPS and the ADL scores of the early group were not different from the late operation group. Therefore poor physiological statuses of the patients were not indicators for the consequences of the study. However, according to the results, the post-operative complications and mortality is significantly increased in patients who were operated in the late group. On the other hand, recovery of weight bearing occurred in a shorter time, duration of total hospitalization and ADL were regained in 6 months in the early operation group. The ADL scores indicate that the early intervention group also has a good quality of life after the operation. The lack of difference of the ADL scores 1 year after the operation between the two groups was attributed to the death of the patients in the late group who already had poor conditions. In conclusion, the results of the present study indicate that operation within 5 days of the fracture is associated with increased survival time and better life quality than the operation after the fifth day of the admission among the elderly hip fractures with similar ADL and SAPS. These data support the previous reports which indicate the necessity of the early operation of the hip fractures in the elderly.
References Bredahl, C., Nyholm, B., Hindsholm, K.B., Mortensen, J.S., Olesen, A.S., 1992. Mortality after hip fracture: results of operation within 12 h of admission. Injury 23, 83–86. Davis, F.M., Woolner, D.F., Frampton, C., Wilkinson, A., Grant, A., Harrison, R.T., Roberts, M.T., Thadaka, R., 1987. Prospective multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Br. J. Anaesth. 59, 1080–1088. Davis, T.R.C., Sher, J.L., Porter, B.B., Checketts, R.G., 1988. The timing of surgery for intertrochanteric femoral fractures. Injury 19, 244–246. Grimes, J.P., Gregory, P.M., Noveck, H., Butler, M.S., Carson, J.L., 2002. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am. J. Med. 112, 702–709. Gullberg, B., Johnell, O., Kanis, J.A., 1997. World-wide projections for hip fracture. Osteoporos. Int. 7, 407–413. Hagino, H., Nakamura, T., Sakamoto, K., Yamamoto, K., Endo, N., Mori, S., Mutoh, Y., Yamamoto, S., Harada, A., Kushida, K., Tanizawa, T., Hotokebuchi, T., Takaoka, K., Tomita, K., Kawai, S., Takahashi, H.E., Inoue, T., Kurokawa, T., Yamamto, H., 2004. Nationwide survey of hip fractures in Japan Committee for Osteoporosis Treatment of The Japanese Orthopaedic Association. J. Orthop. Sci. 9, 1–5. Hamlet, W.P., Lieberman, J.R., Freedman, E.L., Dorey, F.J., Fletcher, A., Johnson, E.E., 1997. Influence of health status and the timing of surgery on mortality in hip fracture patients. Am. J. Orthop. 26, 621–627. Hefley Jr., F.G., Nelson, C.L., Puskarich-May, C.L., 1996. Effect of delayed admission to the hospital on the pre-operative prevalence of deep-vein thrombosis associated with fractures about the hip. J. Bone Joint Surg. Am. 78, 581–583. Holt, E.M., Evans, R.A., Hindley, C.J., Metcalfe, J.W., 1994. 1000 femoral neck fractures: the effect of pre-injury mobility and surgical experience on outcome. Injury 25, 91–95. Katz, S., Downs, T.D., Cash, H.R., Grotz, R.C., 1970. Progress in development of the index of ADL. Gerontologist 10, 20–30.
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Kenzora, J.E., McCarthy, R.E., Sledge, R.D., Lowell, J.D., 1984. Hip fracture mortality, relation to age, treatment, pre-operative illness, time of surgery and complications. Clin. Orthop. 186, 45–56. Le Gall, J.R., Loirat, P., Alperovitch, A., Glaser, P., Granthil, C., Mathieu, D., Mercier, P., Thomas, R., Villers, D., 1984. A simplified acute physiologic score for ICU patients. Crit. Care Med. 12, 975–977. Lorhan, P.H., Shelby, E.A., 1964. Factors influencing mortality in hip fractures. Anesth. Analg. 43, 539–543. Lunn, J.N., Devlin, H.B., Hoile, R.W., Campling, E.A., 1993. The national confidential enquiry into perioperative deaths. Br. J. Anaesth. 70, 382. Lyons, A.R., 1997. Clinical outcomes and treatment of hip fractures. Am. J. Med. 103, 51S–54S. Melton III, L.J., Thamer, M., Ray, N.F., Chan, J.K., Chesnut III, C.H., Einhorn, T.A., Johnston, C.C., Raisz, L.G., Silverman, S.L., Siris, E.S., 1997. Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation. J. Bone Miner. Res. 12, 16–23. Nather, A., Seow, C.S., Iau, P., Chan, A., 1995. Morbidity and mortality for elderly patients with fractured neck of femur treated by hemiarthroplasty. Injury 26, 187–190. Perez, J.V., Warwick, D.J., Case, C.P., Bannister, G.C., 1995. Death after proximal femoral fracture—an autopsy study. Injury 26, 237–240. Poor, G., Atkinson, E.J., O’Fallen, W.M., Melton, L.J., 1995. Determinants of reduced survival following hip fractures in men. Clin. Orthop. 319, 260–265. Ray, N.F., Chan, J.K., Thamer, M., Melton III, L.J., 1997. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J. Bone Miner. Res. 12, 24–35. Schurch, M.A., Rizzoli, R., Mermilod, B., Vassey, H., Michel, J.P., Bonlour, J.P., 1996. A prospective study on the socio-economic aspects of fracture of the proximal femur. J. Bone Miner. Res. 11, 1935–1942. Scottish Intercollegiete Guidelines Network, 2002. Prevention and management of hip fracture in older people. A national clinical guideline. Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ. Seymour, G., 1999. The ageing surgical patient-an update. Rev. Clin. Gerontol. 9, 211–233. Stoddart, J., Horne, G., Devane, P., 2002. Influence of pre-operative medical status and delay to surgery on death following a hip fracture. ANZ J. Surg. 72, 405–407. Todd, C.J., Freeman, C.J., Camilleri-Ferrante, C., Palmer, C.R., Hyder, A., Laxton, C.E., Parker, M.J., Payne, B.V., Rushton, N., 1995. Differences in mortality after fracture of hip: The East Anglian audit. Br. Med. J. 310, 904–908. Villar, R.N., Allen, S.M., Barnes, S.J., 1986. Hip fractures in healthy patients: operative delay versus prognosis. Br. Med. J. (Clin. Res. Ed.) 293, 1203–1204. Zuckerman, J.D., 1996. Hip fracture. N. Engl. J. Med. 334, 1519–1525. Zuckerman, J.D., Skovron, M.L., Koval, K.J., Aharonoff, G., Frankel, V.H., 1995. Post-operative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J. Bone Joint Surg. Am. 77, 1551–1556.
The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly Hüseyin Doruk a,∗ , M. Refik Mas a , Cemil Yıldız b , Alper Sonmez c , Vecihi Kýrdemir b a
Department of Geriatric Medicine, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey b Department of Orthopedics, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey c Department of Internal Medicine, Gülhane Military Medical Academy, Etlik Ankara 06018, Turkey Received 1 October 2003; received in revised form 19 February 2004; accepted 17 March 2004 Available online 2 June 2004
Abstract The optimal time for the operation of hip fractures in elderly is not clear. Most of the data indicate that early operation is associated with better prognosis and improved health quality. We aimed to investigate the effect of timing of surgical intervention on the frequency of post-operative complications, recovery of weight bearing ability, total hospitalization time and activities of daily living (ADL) scores. Sixty five patients subjected to surgical repair were followed up. All were evaluated for their ADL before fracture, post-operative 1st, 3rd, 6th and 12th month. The patients operated within 5 days after hospitalization constituted the early group (n = 38, 24 females, 14 males; mean age = 76.16±7.08 years), and the patients operated after the fifth day served as the late group (n = 27, 18 females, 9 males; mean age = 75.81 ± 7.50). Time of recovery of weight bearing ability and total hospitalization time were significantly higher in the late group (P < 0.05). ADL scores in 1st, 3rd and 6th month after surgery were significantly lower (P < 0.05), and death rates on post-operative 1st and 12th month were significantly higher in the late group (P < 0.05). Elderly, operated within 5 days of the hip fracture have increased survival time and better life quality than those operated after the fifth day of the admission. The data supports the previous reports which indicate the necessity of the early operation of elderly hip fractures. © 2004 Published by Elsevier Ireland Ltd. Keywords: Hip fracture; Surgical timing; Life quality; Activity of daily living
∗
Corresponding author. Tel.: +90-312-3043231; fax: +90-312-3094761. E-mail address: [email protected] (H. Doruk).
0167-4943/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.archger.2004.03.004
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1. Introduction Hip fractures are among the major causes of morbidity and mortality in geriatric population. The elderly, falls more frequently and most hip fractures result from relatively minor traumas, such as falls out of bed or from a standing height or lower (Hagino et al., 2004). The reflexes are weaker to cushion the impact of a fall and bones weakened by osteoporosis require less mechanical force to break (Melton et al., 1997). These factors act together to make elderly more susceptible to hip fractures. An estimated 1.3 million such fractures occurred globally in 1990, and the annual rate of hip fracture worldwide is expected to rise considerably as life expectancy and age-specific rates of hip fracture increase (Gullberg et al., 1997). The main goals of management of hip fractures are restoring the anatomic arrangement and bringing back the function of the limb, and rehabilitating the patient effectively. The incidence of post-operative complications is high, and rehabilitation is difficult and long-lasting. Largely as a result of diminished mobility and independence, patients with hip fracture experience a rapid and major deterioration in health-related quality of life. One in five people die in the first year after a hip fracture and one in four elderly requires a higher level of long term care after a fracture (Schurch et al., 1996). Treatment of patients with hip fracture accounts for most of the healthcare spending associated with osteoporosis (about US$ 14 billion annually in the United States) (Ray et al., 1997). Many factors are reported to affect the post-operative mortality and quality of life. Comorbid conditions, age, mental status, operation type and early mobilization are among these factors (Nather et al., 1995; Poor et al., 1995). Some reports indicate that the post-operative quality of life and mortality is related with the early surgical time (Schurch et al., 1996). Surgery is advised as soon as the medical condition of the patient allows, provided that appropriate staffing and facilities are available (Bredahl et al., 1992; Holt et al., 1994; Hamlet et al., 1997). However, there is also data which indicate that there is no association with the early repair and mortality (Grimes et al., 2002; Stoddart et al., 2002). Again it has been reported that surgical repair may be delayed up to 7 days from the fracture episode with no adverse effect on outcome (Kenzora et al., 1984). Most of these controversial data are from the retrospective analyses, performed through databases. Thus, the delayed operations due to poor health conditions were possibly involved in these investigation groups. Preexisting medical problems in the elderly is the most important cause of post-operative complications (Seymour, 1999). In order to prevent any bias between the early and late surgical operation groups, a prospective follow up study was designed by recruiting elderly people with similar health statuses on early and late surgical groups. The aim of this study was to investigate the relation between the frequency of post-operative complications, mortality, quality of life and the timing of surgical repair.
2. Patients and methods The consecutive admissions for hip fractures to the Orthopedics and Traumatology Department of Gülhane Military Medical Academy were prospectively screened from August 2000 to May 2002.
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181
Sixty five patients (42 females, 23 males, mean age = 76.02 ± 7.20 years) who met the criteria were enrolled in the study. The admission criteria of the patients were as follows: (1) patients older than 65 years; (2) hip fractures were not pathological (i.e. not secondary to metastasis); and (3) ambulatory patients with or without assistive devices. All the patients were examined and followed by geriatricians and orthopedists for metabolic and psychological stabilization both pre-operative and post-operative periods. The baseline characteristics of the patients and the activities of daily living (ADL) scale were assessed for all patients before fracture, and 1, 3, 6 and 12 months after surgery (ADL 0, 1, 3, 6, 12, respectively) (Katz et al., 1970). The ADL 0 was judged after the admission to hospital with an interview about the patients’ daily activities before fracture. The comorbid conditions of the patients were reported as hypertension, heart failure, coronary artery disease, cerebrovascular diseases, rheumatic diseases, dementia, Parkinson’s disease, diabetes mellitus and chronic obstructive lung disease. The patients who had poor control of chronic diseases, inappropriate intake of medicine, and inadequate pre-hospital care were stabilized before the operation. The pre-operative physiological statuses of the patients were graded with simplified acute physiologic score (SAPS) (Le Gall et al., 1984). The patients were arranged into two groups according to the operation time: 38 patients (mean age = 76.2 ± 7.1 years; M/F ratio = 24/14) were in the early group and 27 patients (mean age = 75.8 ± 7.5 years; M/F ratio = 18/9) in the late group. The early group was operated within 5 days after hospitalization, while the late group was undertaken for surgery after the fifth day of admission. Both groups received anticoagulant therapy with low molecular weight heparin after hospitalization. Intra and post-operative antibiotic prophylaxis with Cefazolin (1000 mg, i.v. bid.) was also done. All patients received partial hip prosthesis. The surgical procedures were based on patients’ clinical situation and did not conform to any pre-established protocol. During the post-operative follow-up, physiotherapists and diet consultants were also included to give a better quality of medical support. Post-operative rehabilitation usually began within 24 h after surgery, with mobilization out of bed to a chair and progression to ambulation training. Weight bearing status was determined by the clinical assessment of the surgeon and physiotherapists. The post-operative follow up was monitored by the orthopedic surgeon and geriatcian and was assisted by the clinical resident staff. 2.1. Statistical analysis Statistical analysis was performed using commercially available statistical software (SPSS 10.0, SPSS Inc., Chicago USA). All the results were reported as mean ± standard deviation. Continuous variables were compared using Mann–Whitney U test. Comparisons between the death rates of two groups were made by Chi-square test. Differences were accepted as statistically significant if calculated P value was found below 0.05. 3. Results The mean age and gender distribution of the patient groups were not different. The weight bearing times after the operation and the total hospitalization periods were significantly
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Table 1 Baseline characteristics of the patients
Mean age (years) Gender (F/M) Intertrochanteric fracture Collum femoris fracture Admission time (days) Pre-operative period (days) Weight bearing (days) Total hospitalization period (days) SAPS
Early group (n = 38)
Late group (n = 27)
Total patients (n = 65)
76.2 ± 7.3 24/14 22 16 0.95 ± 1.4 3.5 ± 1 a 4.8 ± 3 c 24.9 ± 13 e 14.3 ± 3.2
75.8 ± 8.4 18/9 14 13 1.48 ± 1.40 11.7 ± 7 b 7.8 ± 6 d 40.4 ± 25 f 16.2 ± 4.2
76.0 ± 7.5 42/23 36 29 1.17 ± 1.41 6.90 ± 5.83 5.94 ± 4.18 30.58 ± 19.87 15.2 ± 3.8
Mann–Whitney U test. P < 0.05 for a vs. b, c vs. d and e vs. f. Table 2 The ADL scores of the patients Early group ADL 0 ADL 1 ADL 3 ADL 6 ADL 12 a
10.8 ± 1.8 (n = 38) 8.55 ± 2.5 (n = 38) 9.7 ± 2.4 (n = 37) 10.35 ± 2.05 (n = 34) 10.07 ± 1.9 (n = 33)
Late group
Pa
10.9 ± 1.35 (n = 27) 7.15 ± 2.3 (n = 22) 8.2 ± 2.2 (n = 20) 8.8 ± 2.15 (n = 19) 10.3 ± 1.95 (n = 17)
NS <0.05 <0.05 <0.05 NS
Mann–Whitney U test.
longer in the late group (P < 0.05 for both). The baseline characteristics of the patients are shown in Table 1. The ADL scores before the fracture and on the 12th month of the operation were not different between the two groups. The ADL scores on the 1st, 3rd and 6th month were significantly lower in the late group (P < 0.05 for each). The ADL scores of both groups are shown in Table 2. Within the post-operative first month, five patients died in the late group. The causes of death of the patients are as follows: (1) cerebral embolism and acute renal failure (ARF), (2) right total atelectasis and upper gastrointestinal bleeding, (3) pulmonary embolism, (4) stroke, (5) ARF and bronchopneumonia. Between post-operative 1st and 3rd month, two patients of the late group and one from the early group died. The cause of death of the patient of the early group was acute myocardial infarction (MI). The causes of death in the late group were stroke, MI and ARF. Between post-operative 3rd and 6th month, three patients
Table 3 The mortality rates of the early and late subgroups Post-operative mortality
Early group (n = 38)
Late group (n = 27)
Pa
1st month 12th month
0 (0%) 5 (13.2%)
5 (18.5%) 10 (37%)
<0.05 <0.05
a
Chi-square test.
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in the early group (two from MI and one from pneumonia), and one patient in the late group (stroke) died. Between 6th and 12th month, one death from ARF in the early group, and two deaths (one of which from stroke and the other from coronary artery disease) in the late group were observed. Mortality rates are shown in Table 3.
4. Discussion Hip fractures cause significant mortality in the elderly as compared with normal population (Poor et al., 1995). The intractable pain, loss of mobility and independent life are the most important problems meaning to exhaustion or death for the elderly patient (Lyons, 1997). The optimal timing of the surgery is said to be essential in order to prevent mortality and morbidity of the hip fractures. The reports indicate that 4 week mortality rate decreases from 12 to 8% when the operation is done in 12 h after hospitalization (Davis et al., 1987) while mortality rate increases if the operation is delayed more than 48 h (Todd et al., 1995). As well as causing distress to the patient, a delay of more than 24 h in operative fixation is associated with increased morbidity and mortality, and with reduced chance of successful internal fixation and rehabilitation (Villar et al., 1986; Davis et al., 1988). Current guidelines indicate that patients be operated on as soon as possible (within 24 h), during standard daytime working hours, including weekends, if their medical conditions allows (Scottish Intercollegiate Network Guidelines, 2002). The evidence indicates that early operations reduce the risk of deep vein thrombosis (Hefley et al., 1996) and of fatal pulmonary embolism after hip fracture (Perez et al., 1995). Delay in surgery however will result in a postponement of full weight bearing status, leading to delayed functional recovery (Zuckerman et al., 1995). Prolonged bed rest may increase the risk of medical complications such as deep venous thrombosis, pulmonary complications, urinary tract infection, and skin breakdown (Bredahl et al., 1992; Zuckerman, 1996). Among the causes of the operational delays are the insufficient control of chronic diseases, inappropriate intake of medicine, dementia and inadequate pre-hospital care of the patients. Failure to stabilize coexisting medical conditions prior to surgery may increase the risk of post-operative complications (Zuckerman, 1996). Although the current evidence is in favor of early surgery, most of the data about the timing of the surgery are obtained from the retrospective analyses of the cases. Preexisting medical problems in the geriatric population play the most important role both in quality of daily life and success of rehabilitation (Nather et al., 1995; Poor et al., 1995). Thus it is possible that the patients, who were operated later because of poor health conditions, contributed to increased mortality and morbidity and caused a bias towards early operation. Several reports indicate that there is no association with the early repair and mortality (Stoddart et al., 2002). There is also substantial data supporting delayed operations. Lorhan and Shelby (1964) reported increased mortality if the surgery is done in the first 12 h after hospitalization. Kenzora et al. (1984) reported 1 year mortality as 34% if the surgery had been done in the first 24 h and 6% between second and fifth day. They concluded that, side effects are decreased if the operation is postponed up to 7 days after the medical stabilization of the patients. It has also been demonstrated that surgical treatment conducted as night-time emergency increases mortality (Lunn et al., 1993). Finally, a large study on hip fractures
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indicate that patients who had surgery more than 96 h after admission do not have increased mortality compared with patients who had surgery 24–48 h after admission (Grimes et al., 2002). The later study reported that the comorbidities but not the mortality rates increase because of the delay in surgery. In the present study the aim was to stabilize patients before the operation and provide optimal pre-operative physical statuses. Because of the stabilization of the patients the pre-operative SAPS and the ADL scores of the early group were not different from the late operation group. Therefore poor physiological statuses of the patients were not indicators for the consequences of the study. However, according to the results, the post-operative complications and mortality is significantly increased in patients who were operated in the late group. On the other hand, recovery of weight bearing occurred in a shorter time, duration of total hospitalization and ADL were regained in 6 months in the early operation group. The ADL scores indicate that the early intervention group also has a good quality of life after the operation. The lack of difference of the ADL scores 1 year after the operation between the two groups was attributed to the death of the patients in the late group who already had poor conditions. In conclusion, the results of the present study indicate that operation within 5 days of the fracture is associated with increased survival time and better life quality than the operation after the fifth day of the admission among the elderly hip fractures with similar ADL and SAPS. These data support the previous reports which indicate the necessity of the early operation of the hip fractures in the elderly.
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