Predictors for Adverse Outcome in Patients Aged 80 Years and Older Undergoing Emergent Hip Surgery

doi:10.4236/ss.2011.210102

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Surgical Science, 2011, 2, 463-467

doi:10.4236/ss.2011.210102 Published Online December 2011 (http://www.SciRP.org/journal/ss)

Predictors for Adverse Outcome in Patients Aged 80 Years

and Older Undergoing Emergent Hip Surgery

Eli Peled1, Michal Barak2, Yaniv Keren3, Michael Soudry3, Doron Norman1

1Departments of Orthopedic Surgery B, Rambam Health Care Campus and the Bruce Rappaport Faculty

of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

2Departments of Anesthesia, Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine,

Technion-Israel Institute of Technology, Haifa, Israel

3Departments of Orthopedic Surgery A, Rambam Health Care Campus and the Bruce Rappaport Faculty

of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

E-mail: [email protected]

Received June 10, 2011; revised September 14, 2011; accepted October 14, 2011

Abstract

Background: Increased life expectancy results in aging of the population. One of the leading medical pro-

blems of elderly patients is hip fracture. We studied demographic, surgical and anesthetic parameters of eld-

erly patients who underwent surgery due to osteoporotic hip fracture, to find predictors for peri-operative

morbidity and mortality. Methods: This is a retrospective review of prospectively collected data of patients

aged 80 years and older who underwent emergent surgery due to osteoporotic femoral neck, subcapital or

pertrochanteric fractures. Data was collected on age, gender, co-morbidities, American Society of Anesthesi-

ologists Class, number of regular medications, whether the patient was bedridden or not before the surgery,

hemoglobin on admission and on discharge, type of surgery and anesthesia, duration of surgery, duration of

hospitalization, post-operative morbidity and mortality. The demographic and peri-operative parameters were

analyzed and matched to the post-operative complications and mortality to find predictors for adverse out-

come. Results: One hundred and nine patients were included in the study, of whom 22 (20%) had post-ope-

rative complications and 10 (9.1%) died. We found an increased complication rate in patients who had chr-

onic obstructive pulmonary disease and in patients who underwent general anesthesia. Patients who were

bedridden before the surgery had increased mortality rates. No significant correlation was found between

outcome and any other factors. Conclusion: Our results suggest favoring regional anesthesia in elderly pa-

tients undergoing emergent femoral neck surgery and acknowledging a higher risk in chronic pulmonary

disease or bedridden patients.

Keywords: Femoral Fracture, Surgery, Orthopedics, Anesthesia, Spinal, Complications, Postoperative

1. Introduction

Osteoporotic hip fracture is a major health problem world-

wide [1]. Its incidence has been rising steadily, mainly

due to increased life expectancy [1,2], and this trend is

expected to continue in the future. There were 1.6 mil-

lion osteoporotic hip fractures throughout the world in

2000 [1] and it has been estimated that the number of hip

fractures in 2025 will be 2.6 million and in 2050 will be

4.5 million [3]. The age of the patients has been increas-

ing as well. Although age is recognized as a significant

risk factor for complications and mortality [4,5], there is

no recommendation to avoid surgery at any age [6,7]. In

this study we focused on the elderly population, patients

aged 80 years or more, in order to isolate age from other

risk factors. We believe that patients in this age group

constitute a distinct entity, with typical physiology and

unique medical characteristics and needs. We prospec-

tively followed their management during surgery and

hospital stay to find predictors for adverse outcome, in

the hope that this could lead to better management of

these patients in the future, although it is still uncertain

whether or not their outcome is modifiable [8].

2. Patients and Methods

With the approval of the local Ethics Committee, we

conducted this study, a retrospective review of prospec-

E. PELED ET AL.

464

tively collected data of patients 80 years old or older who

underwent emergent orthopedic surgery for osteoporotic

femoral neck fracture in our institution. The surgery took

place within less than 48 hours from admission to the

emergency room. All the patients were assessed pre-

operatively by an anesthesiologist who determined their

American Society of Anesthesiologists (ASA) class and

planned the type of anesthesia and the level of operative

and post-operative monitoring. The anesthesia of choice

was regional, specifically spinal. Only patients who had

a contraindication for regional anesthesia, such as abnor-

mal coagulation blood tests, had general anesthesia.

In the operating room, the patients were monitored and

treated according to their general condition and the se-

quence of the surgery. The senior orthopedic surgeon de-

cided, according to the fracture type, whether to do a par-

tial hip replacement (PHR) or reduction and internal fix-

ation. Displaced sub-capital fractures, Garden III & IV,

were replaced, while nondisplaced sub-capital fractures,

Garden I & II, were stabilized by three 7.3 mm cannu-

lated screws (CS). Femoral and intertrochanteric frac-

tures were reduced by closed or open means and were

stabilized by dynamic hip screw (DHS) or proximal fe-

moral nail (PFN). All the patients were admitted to the

post-anesthesia care unit following surgery, where they

stayed for two hours or more, depending on their general

condition. In cases of hemodynamic instability, respire-

tory problem, or intra-operative complication, the patient

was transferred to the intensive care unit. Patients who

underwent uneventful surgery were transferred 7 - 9 days

later to another institution for rehabilitation. Follow-up

continued during their hospitalization time.

Collected data included age, gender, co-morbidities:

hypertension, ischemic heart disease, diabetes mellitus,

chronic obstructive pulmonary disease (COPD), other

co-morbidity, number of medications that the patient

used regularly before admission to hospital, whether or

not the patient was bedridden before the surgery, ASA

class, hemoglobin on admission and on discharge and the

disparity between them, type of surgery (PHR, DHS, CS

PFN), duration of surgery, type of anesthesia, duration of

hospitalization, 30 day post-operative morbidity, and

mortality within six months of surgery. Morbidity was

defined as a new disease or illness (new diagnosis) that

occurred in the peri-operative peiod, meaning within a

month from surgery. We analyzed the data and studied

correlations between each and every pre- and intra-ope-

rative parameter to post-operative morbidity and morta-

lity, in order to find predictors for adverse outcome.

3. Statistical Analysis

Data was analyzed with a commercial statistical software

(Statistica 6.0, StatSoft, Tulsa OK). Frequencies were

compared using Pearson’s chi square test. Continuous

variables were compared using analysis of variance.

Whenever the homogeneity of variance was violated

(significant Levene’s test), the Mann-Whitney test was

applied instead. Pre-post comparisons used the t-test for

dependent variables. Significance level was set at p <

0.05.

4. Results

One hundred and nine patients were included in the study,

32 (29%) male and 77 (71%) female. Age ranged be-

tween 80 to 98 years (median 85); there was no signifi-

cant age difference between genders. Patients’ co-morbi-

dities are summarized in Table 1.

The type of surgery was PHR in 29 (26.6%) patients

and CS or DHS or PFN in 80 (73.3%) patients. In Table

2 we compared patients who underwent PHR to those

who had CS or DHS or PFN. Spinal anesthesia was used

in 95 (87.2%) patients and general anesthesia in 14

(12.8%) patients.

The contraindication for regional anesthesia in all the

patients who underwent general anesthesia was the use

of anticoagulants or anti-platelet aggregation drugs, other

than acetylsalicylic acid.

Mean length of hospital stay was 7.6 days (SD 3.5

days).

Twenty-two (20%) patients had post-operative com-

plications and 10 (9.1%) patients died. Post-operative

complications are summarized in Table 3.

Predictors for adverse outcome: patients with COPD

had significantly higher rates of post-operative complica-

tions than other patients (p = 0.001). The complication

rate was significantly higher in patients who had general

anesthesia (35%) compared to those who had spinal an-

Table 1. Patient co-morbidities and pre-operative data.

Number of Patients (%)

Hypertension 87 (81%)

Ischemic heart disease 44 (41%)

Diabetes mellitus 26 (24%)

Chronic obstructive pulmonary disease 7 (6.5%)

Other co-morbidities 83 (77.5%)

Patient bedridden 14 (13%)

American Society of Anesthesiology

(ASA) class, Mean (±SD) 2.8 (± 0.7)

Number of regular medications used,

Mean (±SD) 5.3 (± 3.2)

Pre-operative hemoglobin (g%)* Mean

(range) 12.4 (7.1-15.5)

*Normal range is 12.0 - 16.0 g%.

E. PELED ET AL.465

Table 2. Patients who underwent partial hip replacement

(PHR) compared with patients who underwent cannulated

screw (CS), dynamic hip screw (DHS) or proximal femoral

nail (PFN).

PHR

(N = 29,

Mean ± SD)

CS or DHS or

PFN (N = 80,

Mean ± SD)

Significance

Age (years) 85 ± 5.1 86.3 ± 4.3 NS

Duration of surgery

(minutes) 47 ± 8 61 ± 29 p = 0.008*

Hospital stay (days) 7.0 ± 2.7 7.4 ± 3.7 NS

Complications (%) 16% 20% NS

Mortality (%) 15.4% 8.7% NS

Notes: N = number of patients; SD = standard deviation; NS = not signifi-

cant statistically; *Applying the Mann-Whitney test.

Table 3. Postoperative complications.

Number

Respiratory complications

Pneumonia

Pleural effusion

Respiratory failure

Cardiac complications

Acute MI

Acute atrial fibrillation

Neurological complications

CVA

Delirium

Parasthesia

Infectious complications

Infection

UTI

Sepsis

Renal failure 3

Loosening of prosthesis and re-operation 1

Bleeding

Bleeding in surgical site

Rectal bleeding

Notes: MI = myocardial infarction; CVA = cerebral vascular accident; UTI

= urinary tract infection.

esthesia (16%), p = 0.044. Mortality was higher in gene-

ral anesthesia (14%) than in spinal anesthesia (9%) but

this was not statistically significant (p = 0.5). Death was

significantly higher in the bedridden group of patients

(28.6%) than in ambulant patients (6.45%), p = 0.008.

As expected, hospitalization was significantly longer

in patients with complications than in those without com-

plications. Also, the mortality rate was significantly higher

in the group of patients who had a complication than in

patients who had uneventful surgery (p = 0.016).

5. Discussion

Increased life expectancy is an indicator of improved life

style and good health services. Yet, aging of the popula-

tion establishes a challenge to the medical profession.

Patients 80 year old and more require special manage-

ment, as all body systems undergo physiological dete-

rioration during these years. Cardiovascular, pulmonary

and central nervous systems show considerable decline,

as do liver and kidney functions, and metabolic and en-

docrine systems [9-12]. Progressive osteoporosis and

reduced muscle mass cause frailty [13]; hence, bone fra-

cture is a leading health problem in this age group [14].

Often, these patients are treated with many drugs, suffer

malnutrition and electrolyte disturbances, and a notable

number of them are bedridden [15,16]. Elderly patients

have reduced drug metabolism and elimination [17]. As a

result of all this, anesthesia for elderly patients is com-

plex. Surgery is more complicated as patients age. Oste-

oporotic bones raise technical difficulties with keeping

the fracture reduced and stable enough to allow patients

to ambulate. It is not uncommon to lose reduction and

fixation during the postoperative and rehabilitation peri-

ods due to the bone quality of older patients. Failure of

fixation or weak bone purchase prevents ambulation

which is not easy after such a fracture. Thus, postopera-

tive recovery and rehabilitation is slow and demanding.

In this study, we found a significant higher complica-

tion rate in patients who had general anesthesia com-

pared with spinal anesthesia. We also found a higher

mortality rate in general anesthesia than in spinal anes-

thesia, although this was not statistically significant. The

issue of general versus regional, specifically spinal, ane-

sthesia was studied in the past, although the literature is

not unanimous. In a large retrospective study of 9425

patients who underwent hip surgery in 1983-1993, the

30-day mortality rate in the general anesthesia group was

4.4%, compared with 5.4% in the regional anesthesia

group [18]. Contradicting results were found in a meta-

analysis of 15 trials comparing general to regional anes-

thesia, where regional anesthesia was associated with

decreased mortality at one month, yet the statistical sig-

nificance was borderline [19]. In an early prospective

study of 578 patients aged 50 and more who underwent

hip surgery, the difference in postoperative mortality

after spinal versus general anesthesia was statistically

insignificant [20]. Koval et al. conducted a prospective

randomized study of 749 patients undergoing hip surgery

and found no significant difference in inpatient morbidity

and mortality between patients receiving general or spi-

nal anesthesia [21]. Based on our results, we suggest that

E. PELED ET AL.

466

general anesthesia carried an increased complication risk

compared with spinal anesthesia in the selected group of

patients aged 80 years or more.

In addition, we found that COPD significantly in-

creased the risk of postoperative complications in this

group of elderly patients. The causative association be-

tween COPD and hip fracture is well known since COPD

patients who are treated with systemic corticosteroids are

at a higher risk for osteoporotic fractures [22]. However,

their higher risk for poor outcome was only recently ac-

knowledged. In 2002, Eisler et al. found that only COPD

significantly affected functional recovery at three months

after hip surgery [23]. Later, de Luise et al found that

patients with COPD had a 60% - 70% higher risk of

death following hip fracture than those without COPD

[24]. These authors suggested that certain diseases are

more strongly associated with mortality than others,

since they profoundly affect the maintenance of normal

physiology, as does the cardiopulmonary system.

In summary, elderly patients are more vulnerable than

younger patients, and their recovery ability is damaged.

Every single complication may deteriorate the patient

gravely. This is supported by our finding that the morta-

lity rate was significantly higher in the group of patients

who had a complication than in patients who had an un-

eventful procedure. Thus, prompt and intensive reaction

to a change in patient status is required. The recognition

of elderly patients as a distinct group with certain medi-

cal and surgical characteristics and needs is essential for

future improvement of care.

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