With the increasing aging of the population worldwide, the incidence and age of hip fractures have increased significantly, and hip fractures in the elderly pose a serious challenge to people’s health and quality of life, and are associated with a high rate of disability and mortality. Most of the domestic literature focuses on the follow-up of long-term functional status after hip fracture surgery, but there are few studies on the early outcome observation of elderly patients. In this retrospective study, 196 cases of hip fractures in elderly patients who were treated surgically for trauma in our department between August 1995 and June 2006 were selected to evaluate and analyze the early outcome of hip fractures in elderly patients after surgery and the related influencing factors.
I. Materials and methods
1. Case data There were 196 cases in this group, 60 males and 136 females, aged 65?100 years, including 61 cases aged 65?75 years, 90 cases aged 76?85 years and 45 cases aged >86 years; the average age was (78.3±18.7) years, including males (74.0±17.5) years and females (80.2±16.3) years. There were 88 cases of femoral neck fractures, 27 males and 61 females, including 26 cases of subtrochanteric type, 42 cases of transcranial type, and 20 cases of basal type; 108 cases of intertrochanteric fractures, 33 males and 75 females, according to Evans’ typing, 16 cases of type I, 21 cases of type II, 47 cases of type III, 18 cases of type IV, and 6 cases of type V. The surgical treatment of femoral neck fracture included closed reduction hollow screw internal fixation, artificial hemi- or total hip replacement; the surgical treatment of intertrochanteric fracture included closed reduction external fixation frame fixation or internal fixation, and some ultra-advanced patients underwent artificial hemi-acetabular arthroplasty.
2. Preoperative assessment of systemic functional status There were 157 cases of coexisting diseases before the fracture, accounting for about 80.1%. There were 61 cases of hypertension, 48 cases of cardiovascular disease, 44 cases of diabetes, 38 cases of respiratory disease, 35 cases of cerebrovascular accident sequelae, 24 cases of liver and kidney insufficiency, 21 cases of senile dementia, and 22 cases of other systemic diseases (including urinary tract infection, peptic ulcer, biliary tract disease, Parkinson’s disease, etc.); 42 cases of two diseases, 37 cases of three or more diseases The maximum number of patients with a combination of 6 diseases increased with age. The systemic functional status of elderly patients was assessed according to their preoperative mobility, self-care ability and coexisting diseases [1], including 21 cases in the high-risk group, 68 cases in the moderate-risk group and 107 cases in the relatively safe group.
3. Surgical complications In the early postoperative follow-up, there were 6 cases of death. Systemic complications mainly included pulmonary infection in 32 cases, cardiac events in 27 cases, cognitive dysfunction or exacerbation in 16 cases, urinary tract infection in 16 cases, cerebrovascular accident in 11 cases, deep vein embolism in the lower extremities (confirmed by Doppler ultrasound) in 9 cases, renal insufficiency in 6 cases, gastrointestinal stress ulcer in 5 cases, and pulmonary embolism in 2 cases. As a comprehensive assessment index, the main complications to be observed in this study include: acute myocardial infarction or unstable angina, acute heart failure or arrhythmia, pneumonia, respiratory insufficiency, cerebrovascular accident, pulmonary embolism, deep vein thrombosis or renal insufficiency.
4. Clinical efficacy assessment The outpatient or telephone follow-up is used, and the time boundary of the follow-up is 3 months after the patient’s operation, and the patient’s condition at the time of discharge is combined with the comprehensive analysis. According to the degree of postoperative recovery, patients can be classified into 4 grades [2]: Grade A, the general condition is satisfactorily recovered, and patients can walk slowly on the ground by themselves or with the assistance of a walker; Grade B, the general condition is gradually improved, and patients can get out of bed and stand with assistance, but further strengthening of functional exercise is needed; Grade C, the complications are initially controlled, but the general condition of patients is still poor, and they are unable to get out of bed or have poor cognitive function; Grade D, the general Grade D, poor general condition, unsatisfactory control of systemic complications, easy to combine multi-organ organ failure or even death.
5. Statistical analysis For different subgroups, the preoperative age, gender, injury site, nutritional status, general condition, hospitalization time and mortality rate were recorded and counted to further analyze the efficacy of hip fracture surgery and the influencing factors. The percentage of each sample size was calculated. The differences of the clinical observation indexes of each group were compared and studied, and the t-test of the mean of the completely randomized design data was used for off statistical analysis, and the rank sum test was used for the analysis of multiple samples with different levels of data.
II. Results
Excluding fatal cases, patients were hospitalized for 12?78 d, with a mean of (21.0±15.9) d. Postoperative follow-up focused on the presence of local and systemic complications, the degree of recovery of hip function, and whether the patients were combined with cognitive impairment.
The pre-injury and perioperative clinical observations of 196 elderly patients are shown in Table 1. 68.9% of elderly hip fractures were in patients aged 76 years or older, of which 69.3% were in female patients, and 54.6% were in relatively safe preoperative assessment of systemic functional status. 82.7% of the cases were operated within 1 week after injury, and 34.2% had systemic complications after surgery, while 64.8% of the cases were hospitalized for less than 3 The hospital stay was less than 3 weeks in 64.8% of cases.
Table 1 Pre-injury and perioperative clinical observation of 196 elderly hip fracture patients
Clinical observation index n (%)
Age ≥ 76 years 135 (68.9)
Female 136 (69.3)
Relatively safe group in terms of overall health 107 (54.6)
Basic self-care of life before injury 175 (89.3)
Malnutrition (hematocrit <80g/L, or albumin <22g/L) 41 (20.9)
Pre-operative with comorbidities 157 (80.1)
Surgery within 1 week after injury 162 (82.7)
Type of fracture
Femoral neck fracture 88 (44.9)
Intertrochanteric fracture 108 (55.1)
Major postoperative complications 67 (34.2)
Length of postoperative hospital stay <3 weeks 127 (64.8)
Grouping by the degree of preoperative assessment of general functional status showed no gender differences and a tendency for patients’ health status to deteriorate with increasing age; there were significant correlations between preoperative general functional status and postoperative complication rates, mortality at follow-up within 30 d after surgery, and degree of clinical recovery; and mean hospital stay statistics showed that the high-risk group was significantly longer than the moderate-risk and relatively safe groups. See Table 2.
Table 2 Preoperative systemic functional status of patients and clinically relevant indexes
Clinical observation indexes Preoperative systemic functional status
High-risk group Moderate-risk group Relatively safe group
Number of cases 21 68 107
Male? 8 15 37
Female? 13 53 70
Mean age (years)* 84.4±12.1 80.1±17.2 75.9±18.9
Major postoperative complications* 11 24 32
Postoperative cognitive impairment or exacerbation* 5 5 6
Death within 30 d after surgery* 2 3 1
Mean number of postoperative hospital days (d)** 29.1±18.6 21.5±16.6 19.3±14.0
Postoperative recovery grade A or B* 5 48 95
Note: All indicators are expressed as the number of cases, except for the labeled unit indicators, which are expressed as the mean ± standard deviation.? indicates that there is no statistical difference in the distribution of the observed indicators in each functional status group (P>0.05); * indicates that there is a statistical difference in the distribution of the observed indicators in each functional status group or between the values (P<0.05); ** indicates that there is a statistical difference between the values of the underlined group and the other two groups (P<0.05).
The patients were grouped by the degree of clinical recovery after surgery, with 65 cases of grade A, 83 cases of grade B, 33 cases of grade C, and 15 cases of grade D. The excellent rate (grade A and B) reached 75.5%. There were no significant correlations between gender and fracture site and efficacy, and no significant differences in patient age between groups; there were significant differences in preoperative hematocrit and albumin measurements, major comorbidities, and cognitive impairment concomitant rates between A and B grade and C and D grade rehabilitation groups, while there were no significant differences between single groups comparing A/B or C/D; post-injury to surgery time statistics showed that there were no significant differences between A, B, and C grade rehabilitation groups There was no significant difference in the time from injury to surgery among the A, B, and C level rehabilitation groups, while the D level rehabilitation group had a relatively longer waiting time for surgery. See Table 3.
Table 3 Postoperative rehabilitation degree of patients and clinical related indexes
Clinical observation indexes Postoperative rehabilitation degree
Grade A Grade B Grade C Grade D
Number of cases 65 83 33 15
Male? 17 27 10 6
Female? 48 56 23 9
Mean age (years)? 77.8±19.8 78.3±20.1 78.6±16.5 79.8±14.2
Preoperative hematocrit (g/L)* 113.6±26.9 108±28.4 86.6±17.3 83. 2±21.6
Preoperative albumin (g/L)* 34.1±13.0 35.8±16.5 27. 4±12.5 25.6±11.1
Preoperative comorbid cognitive impairment* 4 6 7 4
Major preoperative coexisting conditions* 48 66 29 14
Femoral neck fracture# 31 38 14 5
Intertrochanteric fracture# 34 45 19 10
Time to surgery after injury (d)** 5.8±2.7 5.0±3.3 5.5±4.6 8.1±6.3
Note: All indicators are expressed as the number of cases, except for the labeled unit indicators, which are expressed as the mean ± standard deviation.? indicates that there is no statistical difference between the distribution or values of the observed indicators in each functional status group (P>0.05); * indicates that there is a statistical difference between the distribution or values between the underlined and non-underlined groups (P<0.05).
III. Discussion
1. To explore the significance of early efficacy
For hip fractures, previous studies have focused more on the functional status and rehabilitation survival of patients in long-term follow-up, while for elderly patients, the assessment of early efficacy is also of great value. As reported in the literature [3], hip fractures have a high incidence of complications within 3 months after surgery, and the mortality rate is higher within 30 d after surgery, so short-term follow-up can directly assess the appropriateness of the surgical indication, timing and method; short-term postoperative functional status prediction can help to communicate with patients and their families in a timely manner, formulate a more detailed postoperative rehabilitation plan, and eliminate patients’ concerns. On the other hand, because the postoperative rehabilitation conditions of elderly hip fractures are closely related to functional recovery, and under the current conditions where home care rehabilitation is still the main focus in China, the family environment in which patients live varies greatly, so the interfering factors of long-term follow-up are uncertain; at the same time, for elderly patients, early follow-up eliminates the influence of factors such as natural illness or death in the same age group to the maximum extent [4]. Of course, there is also a significant correlation between the general condition of patients in the early postoperative period and their long-term survival status [3, 5].
2. Surgical efficacy of hip fractures in the elderly and prevention of complications
The superiority of surgical treatment over non-surgical treatment for hip fractures has been widely recognized by scholars at home and abroad [6]. With the improvement of people’s demand for quality of life, active surgical treatment of hip fracture in the elderly has become the development trend, which can reduce the time of bed rest, heal the fracture in the shortest possible time, and restore good function [7]. This study shows that age is not a key factor in determining the efficacy of surgery, and most elderly patients can achieve satisfactory results with good preoperative preparation and standardized and enhanced postoperative rehabilitation, with a 75.5% A and B-level recovery rate. Of course, elderly people are characterized by weakness, poor organ function, many pre-fracture coexisting diseases, and high surgical risks, especially in elderly patients with high mortality rate within 30 d after surgery. Early complications of surgery in this group of cases mainly include impairment of organ functions such as heart, brain, lung and kidney, cognitive impairment, deep vein thrombosis and stress ulcers of the gastrointestinal tract, etc. Therefore, we should have a comprehensive understanding of the patient’s general condition before surgery, strictly grasp the indications, and realize that hip surgery in the elderly is only one aspect of treatment, and the patient’s recovery depends on the full cooperation of internal medicine, anesthesiology, rehabilitation and even psychosomatic departments. Specific measures include: detailed preoperative assessment of the patient’s pre-injury living ability and mental status to improve the function of all organs as much as possible; selection of surgical methods as simple and effective as possible to reduce surgical trauma and bleeding; anesthesia methods to minimize the impact on respiration and circulation; strengthening postoperative functional exercises, timely sputum removal, encouraging coughing, and getting off the floor as early as possible.
3. Analysis of factors affecting the efficacy of hip fracture surgery in the elderly
Systemic status and comorbidities: systemic functional status is undoubtedly an important factor in determining prognosis, and more comorbidities, especially cardiovascular system, respiratory system diseases and diabetes mellitus, increase the treatment difficulty and complication rate of elderly hip fracture. Some scholars believe that patients’ preoperative systemic status and risk factor score have clinical value for prognostic assessment [7, 8], and preoperative health status is closely related to postoperative morbidity and mortality, with acute myocardial infarction, cardiac failure, pulmonary embolism, pulmonary infection, and respiratory failure being the main causes of patient death. The clinic should weigh the advantages and disadvantages according to the specific systemic condition of the patient and choose the appropriate treatment method in order to achieve satisfactory results. For this study, it is suggested that patients in the high risk group have significantly increased complications, mortality and hospitalization days, and the satisfactory rate of clinical recovery is low, so surgery should be carefully selected; for patients in the moderate risk group, surgery should be selected as much as possible with active treatment of comorbidities; for patients in the relatively safe group, surgery should be performed as soon as possible.
Age, gender and fracture site: Although the results showed a significant correlation between age and the systemic status of elderly patients, there was no direct relationship between surgical efficacy and age in this study, and the reason for this difference was that the scale of grasp of surgical indications was not determined by age. In addition, although older women tend to have osteoporosis and have a relatively high incidence of fracture age and intertrochanteric fractures, gender and fracture site were not prognostic factors. Comparing age and gender factors, Takeda, et al [9] concluded that language, cognitive ability and trunk and social function play a more important role in the rehabilitation of hip fractures in the elderly.
Preoperative nutritional status: The nutritional status of elderly patients is generally poor, and fracture weakens the reserve and compensatory capacity of important organs. In our data, severe malnutrition accounted for 1/5 of the total number of cases, and there is a correlation between hematocrit and albumin content and the degree of postoperative recovery. Anemia, hypoproteinemia, and negative nitrogen balance due to low diet can affect cellular-humoral immunity and increase the incidence of postoperative pulmonary infections, as well as affect local wound healing.
Cognitive impairment: The incidence of preoperative combined or postoperative psychiatric abnormalities in elderly patients is high, which is harmful to the elderly and easily overlooked by health care professionals. Patients with combined cognitive impairment are unable to cooperate with rehabilitation after surgery and often fail to achieve the desired goals of surgery due to bed rest, communication difficulties and inadequate care.
Time factor: Long-term bed rest after fracture in the elderly is currently considered to be a fatal threat, and treatment should minimize the time spent in bed and strive to get out of bed early. Clinical studies have shown that preoperative delay in surgery for more than 3 days will increase the mortality rate of patients by a factor of 1. Most of the cases in this data were operated within 1 week after surgery, so there was no significant difference in the time from injury to surgery in the A, B, and C rehabilitation groups, while the time in the D rehabilitation group was significantly longer than the previous three groups, suggesting that the extension of a certain time may be one of the factors affecting the prognosis. However, the reasons for the delay in surgery are more complicated, mostly due to the poor general condition of the patient, and the clinical practice does not allow blind surgery before adequate improvement, so the influence factor should be comprehensively analyzed and evaluated.