KAUNAS UNIVERSITY OF MEDICINE
Arūnas Vertelis
FACTORS INFLUENCING TREATMENT
RESULTS OF FEMORAL NECK FRACTURES
Summary of the Doctoral Dissertation Biomedical Sciences, Medicine (07 B)
The doctoral dissertation was prepared at Kaunas University of Medicine in 2004-2008.
Scientific supervisor
Prof. Dr. Habil. Ţilvinas Padaiga (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Dissertation will be defended at the Medical Research Council of Kaunas University of Medicine:
Chairperson
Assoc. Prof. Dr. Algimantas Tamelis (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Members:
Assoc. Prof. Dr. Rimtautas Gudas (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Assoc. Prof. Dr. Alfredas Smailys (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Prof. Dr. Antanas Sederevičius (Lithuanian Veterinary Academy, Biomedical Sciences, Veterinary Medicine – 12 B)
Prof. Dr. Habil. Henrikas Ţilinskas (Lithuanian Veterinary Academy, Biomedical Sciences, Veterinary Medicine – 12 B)
Official opponents:
Assoc. Prof. Dr. Egidijus Kontautas (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Prof. Dr. Linas Daugnora (Lithuanian Veterinary Academy, Biomedical Sciences, Veterinary Medicine – 12 B)
The dissertation will be defended at the open session of the Medical Research Council on 18 December, 2009, at 14:00 in the Big (Conference) Hall of the Hospital of Kaunas University of Medicine.
Address: Eivenių str. 2, LT-50009 Kaunas, Lithuania.
The summary of the doctoral dissertation was distributed on 18 November, 2009. The full text of the doctoral dissertation is available in the library of Kaunas University of Medicine.
KAUNO MEDICINOS UNIVERSITETAS
Arūnas Vertelis
ŠLAUNIKAKLIO KAKLO LŪŢIŲ GYDYMO
REZULTATUS ĮTAKOJANTYS VEIKSNIAI
Daktaro disertacijos santrauka Biomedicinos mokslai, medicina (07 B)
Disertacija rengta 2004–2008 metais Kauno medicinos universitete.
Mokslinis vadovas
prof. habil. dr. Ţilvinas Padaiga (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
Disertacija ginama Kauno medicinos universiteto Medicinos mokslo krypties taryboje:
Pirmininkas
doc. dr. Algimantas Tamelis (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
Nariai:
doc. dr. Rimtautas Gudas (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
doc. dr. Alfredas Smailys (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
prof. dr. Antanas Sederevičius (Lietuvos veterinarijos akademija, biomedicinos mokslai, veterinarinė medicina – 12 B)
prof. habil. dr. Henrikas Ţilinskas (Lietuvos veterinarijos akademija, biomedicinos mokslai, veterinarinė medicina – 12 B)
Oponentai:
doc. dr. Egidijus Kontautas (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
prof. dr. Linas Daugnora (Lietuvos veterinarijos akademija, biomedicinos mokslai, veterinarinė medicina – 12 B)
Disertacija bus ginama viešame Medicinos mokslo krypties tarybos posėdyje 2009 m. gruodţio 18 d. 14 val. Kauno medicinos universiteto klinikų Didţiojoje auditorijoje. Adresas: Eivenių g. 2, LT-50009 Kaunas, Lietuva.
Disertacijos santrauka išsiuntinėta 2009 m. lapkričio 18 d.
Disertaciją galima perţiūrėti Kauno medicinos universiteto bibliotekoje. Adresas: Eivenių g. 6, LT-50161 Kaunas, Lietuva.
ABBREVIATIONS
ADL activities of daily living
ASA American Society of Anaesthesiologists
HOOS Hip Disability and Osteoarthritis Outcome Score
QOL quality of life
1. INTRODUCTION
Femoral neck fractures are one of the most common trauma in the elderly population [Cummings et at., 1990; Cooper et al., 1992; Koval and Zuckerman, 1994]. The incidence of this trauma is increasing with growing number of elderly people [Cummings et at., 1990; Cooper et al., 1992]. It is estimated that by the year 2050, the number of femoral neck fractures occurring each year over the world will rise to 2.26 million [Cooper et al., 1992]. Surgical treatment is a key element in the management of femoral neck fractures. Due to high mortality rate among patients suffering from these fractures [Koike et al., 1999; Su et al., 2003; Beringer et al., 2006] and a wide variety of treatment methods [Casett et al., 2000; Blomfeldt et al., 205; Frihagen et al., 2007], scientists and clinicians are seeking how to optimise the treatment of these traumas [Beringer et al., 2006; Johnell and Kanis, 2006; Sahota and Currie, 2008]. In the literature, two main methods applied in the management of femoral neck fractures are described: internal fixation of fractured femoral neck – osteosynthesis – and replacement of fractured femoral neck and femoral head with endoprosthesis – arthroplasty. Surgeons have not reached any consensus in regard to the methods of surgical treatment for femoral neck fractures [Bhandari et al., 2003; Bhandari et al., 2005; Probe and Word, 2006]. Bhandari et al. surveyed 442 orthopaedic trauma surgeons of the United States and European Union. The investigators examined what surgical treatment method was applied for patients who experienced femoral neck fractures. A majority of surveyed respondents reported that patients younger than 60 years should undergo osteosynthesis for femoral neck fractures and patients older than 80 years – arthroplasty. However, they disagreed about the optimal approach to the management of 60–80-year-old patients with displaced femoral neck fractures.
The mortality rate during the first years following femoral neck fractures varies from 10% to 40% [Aharonoff et al., 1997; Bhandari et al., 2003; Parker and Johansen, 2006], and the complication rate due to trauma and surgery reaches 10–50% [Bhandari et al., 2003; Frihagen et al., 2007; Heetveld et al, 2005]. These issues are extensively analysed in the literature, and many efforts are being undertaken to identify the factors determining mortality and postoperative complication rate in patients with femoral neck fractures. Zlowodzki et al. surveyed North American and European orthopaedic surgeons treating femoral neck fractures to examine their opinion on predictors of outcome of femoral neck fracture treatment.
The surgeons surveyed identified the following prognostic factors of greatest importance to treatment outcomes: type of femoral neck fracture, presence of comorbidities, dementia and prefracture walking ability. However, the investigators, summarising current evidence in the literature, have concluded that gender, age, the American Society of Anesthesiologists (ASA) score and surgery delay may, in fact, have prognostic importance. This survey has shown that not all prognostic factors of greatest importance identified by surgeons influenced outcome of femoral neck fracture treatment. In our study, we evaluated the influence of patients’ age and gender, number of comorbid diseases, blood test data and ASA score on treatment outcome in patients with femoral neck fractures.
Timing of surgery is an important factor among all other factors influencing mortality and development of complications and impacts these parameters [Bredahl et al., 1992; Franzo et al., 2005; Bottle and Aylin, 2006; Novack et al., 2007; Shiga et al., 2008]. In addition, timing of surgery may have an influence on functional status and quality of life of patients [Jain et al., 2002; Orosz et al., 2004]. Previous studies have yielded conflicting results on the influence of timing of surgery on patients’ mortality. Some of these studies reported that preoperative period to surgery did not have any significant influence on mortality rates in the management of femoral neck fractures [Orosz et al., 2004; Franzo et al., 2005; Holt et al., 2008; Hommel et al., 2008], while others have found significant associations between timing of surgery and patients’ mortality [Bredahl et al., 1992; Bottle and Aylin, 2006; Novack et al., 2007; Shiga et al., 208].
In the literature, there is a lack of data on the optimal timing of surgery when it is possible to patients with femoral neck fractures surgically without any additional complications and not determining mortality. According to the findings of many studies, this period from hospital admission to operative treatment varies from 6 hours to 5 days [Franzo et al., 2005; Bottle A, Aylin, 2006; Holt et al., 2008; Hommel et al., 2008; Sebestyen et al., 2008; Shiga et al., 2008; Smektala et al., 2008]. Majority of studies carried out with the aim to assess the timing of surgery usually evaluated the period from hospital admission to surgery [Franzo et al., 2005; Bottle A, Aylin, 2006; Holt et al., 2008; Hommel et al., 2008; Sebestyen et al., 2008; Shiga et al., 2008; Smektala et al., 2008]. However, we did not succeed in finding any data on the influence of time from
trauma to hospital admission on patients’ mortality and functional outcomes.
Therefore, we aimed at evaluating the influence of various factors including preoperative time on treatment outcome after femoral neck fractures. Preoperative time was divided into two periods: time from trauma to hospital admission and from hospitalization to surgical intervention.
The aim of the study
To determine the factors influencing the results of treatment in patients with displaced femoral neck fractures.
The objectives of the study
1. To determine the influence of age, gender, surgery type and number of comorbid diseases on mortality of patients with femoral neck fractures after one year following trauma;
2. To determine the influence of time from trauma to hospitalization and from hospital admission to surgery on mortality of patients with femoral neck fractures after one year following trauma;
3. To determine the influence of age, gender, surgery type and number of comorbid diseases on functional outcomes of the treatment in patients with femoral neck fractures after two years following trauma;
4. To determine the influence of time from trauma to hospitalization and from hospital admission to surgery on functional outcomes of the treatment in patients with femoral neck fractures after two years following trauma.
2. SCIENTIFIC NOVELTY OF THE STUDY
Treatment of patients with femoral neck fractures is an important issue in an ageing population; therefore, in the scientific literature, there are a lot of publications analysing various aspects of management of this pathology.
Many efforts are being undertaken in searching for optimal treatment methods in the management of femoral neck fractures, determining the best functional outcome and quality of life, and lowest mortality rate. Also, the question of factors, which may influence mortality and functional parameters in patients who sustained femoral neck fractures, has been addressed in many studies [Greatorex IF, Gibbs; 1988; Hannan et al., 2001; Lewis et al., 2006; Holt et al., 2008; Hommel et al., 2008; Maxwell
et al., 2008; Smektala et al., 2008]. One of the risk factors described in the literature, which might influence mortality and functional outcome, is time from trauma to surgical intervention. However, there is no consensus or general algorithm regarding the optimal timing of surgery in this group of patients. Majority of studies, which analysed the optimal timing of surgery, have reported this safe period from hospital admission to surgery raging from 6 hours to 5 days [Cooper et al., 1992; Jain et al., 2002; Klassbo et al., 2003; Dorotka et al., 2004; Siegmeth and Parker, 2006; Sebestyen et al., 2008]. However, while analysing the literature data, it was noted that the time from trauma to hospital admission is not taken into account, and the time is being counted just from that moment, when a patient is already hospitalised. This factor may have a great influence on treatment outcome because the time from trauma to hospital admission can vary significantly among different patient’s groups. Therefore, it was purposeful to carry out a study where exactly this period would be evaluated and its influence on patients’ mortality and functional outcome would be determined.
Similarly as during studies on mortality where the time from trauma to surgery is evaluated and studies where postoperative functional status of a patient is evaluated, the time from trauma to hospital admission has not been examined. While analyzing the scientific literature, we found only one study where the period from hospital admission to surgery and its influence on patients’ functional outcome 6 months after trauma were evaluated [Orosz et al., 2004]. However, the period from trauma to hospital admission was not evaluated, and this could determine the results of treatment.
In our study, we examined the influence of time from trauma to hospital admission and hospitalization to surgery on mortality and functional outcome of patients who sustained femoral neck fractures.
3. MATERIAL AND METHODS
The study was carried out in the Clinic of Traumatology and Orthopaedics from 1 January, 2003, to 31 December, 2005. A total of 265 patients with displaced Garden type III-IV femoral neck fractures, subjected to surgery, were enrolled into the study.
The study consisted of two parts:
Part I. In the first part of study, the influence of patient’s age, gender,
trauma to hospital admission and from hospital admission to surgery on the mortality of patients was evaluated after one year following trauma.
Part II. In the second part of study, we examined the influence of
these factors on functional outcome of patients after two years following trauma.
3.1. Study population Part I. Study of mortality
A total of 265 patients who underwent surgery for femoral neck fractures were enrolled into the study.
Inclusion criteria:
1. Displaced femoral neck fractures (Garden type III-IV); 2. Patients living independently before trauma;
3. Patients who agreed to participate in the study. Exclusion criteria:
1. Undisplaced femoral neck fractures;
2. Femoral neck fractures in patients who sustained multiple fractures.
The exact time from trauma to hospital admission and from admission to surgery was recorded for each patient with femoral neck fractures. Analysing medical literature, we did not succeed in finding the indications when a surgery is considered as early and when as delayed. To our knowledge, no study has reported the time period from trauma to hospital admission, which might be a crucial factor in determining postoperative mortality of patients. Thus, it was decided to divide the patients to the groups considering the median time from trauma to hospital admission and from admission to surgery: the median from trauma to hospital admission was 6 hours and the median from admission to surgery was 7 hours. Thus, four groups were made, and these groups were compared while evaluating the influence of certain factors on mortality after 1 year following femoral neck fractures.
A total of 119 patients who underwent osteosynthesis with the Ullevaal hip screws after displaced femoral neck fractures were enrolled into this study.
Inclusion criteria:
1. Age more than 60 years;
2. Patients who experienced displaced femoral neck fractures (Garden type III-IV);
3. Patients who underwent osteosynthesis of the femoral neck by the Ullevaal method;
4. Patients who agreed to participate in the study. Exclusion criteria:
1. Patients who underwent revision surgery for hip joint following osteosynthesis;
2. Patients who died within two years after surgery; 3. Patients lost to follow-up;
4. Patients who were not able to complete the Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire.
All patients were divided according to the period from trauma to hospital admission and from hospitalization to surgery. According the recommendations of the Royal College of Physicians [Shiga et al., 2008], surgery should be performed within 24 hours after hospital admission for patients with femoral neck fractures. Based on data in the literature, our patients were grouped into four groups: patients who were admitted to hospital within 12 hours after trauma, those who were admitted later than 12 hours from trauma, patients who underwent surgery within 12 hours from hospital admission and those who received surgical treatment later than 12 hours from admission. This 12-hour period was chosen as most suitable according to the recommendations by Jain et al. [Jain et al., 2002]. The 12-hour period dividing surgeries to early and delayed was employed by other investigators too [Bredahl et al. 1992; Heetveld et al., 2005; Sebestyen et al., 2008].
3.2. Methods
Preoperative patient’s examination and data collection
A standardised case report form for collecting data was completed for all patients enrolled into the study. Information was obtained about demographical characteristics (gender, age, etc.), comorbidities, medical
history. The exact time was recorded based on patient’s report and it was confirmed by persons accompanying a patient and data of ambulance personnel. The time of hospital admission was registered after arrival to emergency room.
Blood tests were performed in all patients, and haemoglobin, urea and potassium levels in blood were registered. All patients before the surgery had an anaesthesiologist consultation. The patient’s physical status was documented and it was categorised using the American Society of Anaesthesiologists classification [Allgower M et al., 1988].
Surgery
All patients immediately after arrival to hospital underwent roentgenologic examination of injured hip joint. Roentgenograms were evaluated by a radiologist and orthopaedist traumatologist. In the evaluation of roentgenograms, the displacement of fractures was evaluated. The extent of displacement conditioned the type of fracture according to the Garden classification [Garden, 1961]. All patients who sustained type III-IV Garden fractures received operative treatment. Two types of surgery were done in the patients: femoral neck osteosynthesis or total hip arthroplasty (THA).
Spinal anaesthesia was used in all patients. In patients who underwent osteosynthesis, closed reduction was performed under biplanar fluoroscopic control, and the fracture was fixed with the 3 Ullevaal hip screws (Orthovita, Norway) [Lykke et al., 2003]. The patients scheduled for THA were operated on via a posterior approach, and both components were cemented.
All patients received the same infection prophylaxis with cefuroxime and thrombosis prophylaxis with low-molecular-weight heparin. For osteosynthesis patients, partial weight bearing was allowed on the first day, and full weight bearing 6 weeks postoperatively. The THA patients were mobilized the next day after surgery. Otherwise the same rehabilitation program was used.
Evaluation of functional status in patients
After two years following trauma, functional status of all 119 patients enrolled into the study was evaluated using the HOOS questionnaire. Evaluation was done by the investigator, orthopaedist traumatologist. Patients who underwent osteosynthesis with the Ullevaal hip screws were
invited for follow-up visit at 2 years after femoral neck fractures. Eighty-five patients completed the HOOS questionnaire during their follow-up visit at hospital, 23 patients who gave their verbal consent were observed and examined at home and 11 patients filled out the HOOS questionnaire at home and sent it by post.
The HOOS questionnaire was developed to assess the patients’ opinion about function of their hip joint in case of arthrosis and other diseases or traumas. It is meant to be used for short- or long-term evaluation of hip joint function. This questionnaire is easy to understand, and it takes about 10 min to fill it out.
The HOOS questionnaire consists of 5 subscales: 1. Pain.
2. Symptoms.
3. Function in daily living (ADL). 4. Function in sport and recreation. 5. Hip-related quality of life (QOL).
Standardised answer options are given (five Likert boxes), and each question gets a score from 0 to 4. A score of 100 indicates normal function (no symptoms), and a score of 0 indicates extreme symptoms or poor quality of life. The HOOS was translated to Lithuanian language, and the Lithuanian version was validated.
Treatment results of all patients enrolled into the study were assessed using four subscales of the HOOS questionnaire (except function in sport and recreation). Patients were asked to evaluate function of their hip joint taking into consideration the last week when answering the questions. The obtained data were analysed.
Statistical analysis
Kaplan-Meier methodology was used to estimate survival of the patients. The log-rank test was used to compare mortality between groups. In addition, Cox regression analysis was performed, and two groups were compared, i.e. patients who arrived within 6 hours and those who arrived later, and patients who underwent surgery within 7 hours after hospital admission and those operated on later (these variables were considered as categorical). Gender and age were entered into the Cox regression analysis. The ASA grade and blood test values were not included into the Cox regression analysis due to possible interrelationships between these
variables. Also, all these above-mentioned variables can have associations with patients’ age and time of arrival to hospital or surgery.
For evaluation of differences in the mean values of numeric variables, t test for independent samples and Mann-Whitney U test were used. Chi-square test was used to compare the proportions between categorical variables. Multiple linear regression was employed to analyse the influence of all factors (haemoglobin, potassium, urea, ASA grade, age, gender, time of hospital admission/surgery and comorbid diseases) on functional outcome (HOOS subscales).
The level of significance was set at 0.05. Difference or relationship between variables was considered significant if P was <0.05. SPSS version 17.0 (SP .SS Inc, Chicago, IL) was used for statistical analysis of the data.
4. RESULTS
4.1. Part I. Mortality studyThere were 86 (32.45%) men and 179 (67.55%) women enrolled into this study. The mean age of men and women was 75 years (SD 14) and 77 years (SD 7), respectively. The mean age of the general study population was 75.3 years (SD 11), and it ranged from 24 to 99 years. Osteosynthesis was performed in 204 patients and THA in 61 patients.
The mean time from trauma to arrival to the hospital was 50 hours (SD 122) while the median was 6 hours.
The mean time from hospital admission to surgery for patients who underwent osteosynthesis was 18 hours (SD 40) and for those who underwent total hip arthroplasty (THA) – 144 hours (SD 122). The difference in the mean time was significant between those groups (P=0.001).
Patients’ groups were compared in regard to age, ASA class, haemoglobin, potassium and urea levels. Patients admitted to hospital within 6 hours from trauma had higher haemoglobin levels and lower urea levels than those who arrived later than 6 hours from trauma Age, ASA class, potassium level were similar in both groups (Table 4.1.1).
Table 4.1.1. Demographic and clinical characteristics of the patients admitted to hospital within 6 hours from trauma and later
Variable Admitted before 6 hours, n=132 Admitted later than 6 hours, n=133 P value
Age, years, mean (SD) 75 (11) 76 (11) 0.5
ASA score, mean (SD) 2.3 (0.6) 2.4 (0.6 0.13
Haemoglobin, g/L, mean (SD) 131 (17) 124 (21) 0.004 Potassium, mg/L, mean (SD) 4.2 (0.5) 4.2 (0.5) 0.9
Urea, mg/L, mean (SD) 7.0 (2.4) 8.2 (3.5) 0.002
Haemoglobin level was also higher in patients who underwent surgery within 7 hours from hospital admission as compared to those who were operated on later than 7 hours from admission, but the difference in urea level between the groups was not significant (P=0.07) (Table 4.1.2).
Table 4.1.2. Demographic and clinical characteristics of the patients operated on within 7 hours from hospital admission and later
Variable Operated on
within 7 hours after admission, n=132
Operated on later than 7 hours after admission,
n=133
P value
Age, years, mean (SD) 76 (11) 75 (12) 0.2
ASA score, mean (SD) 2.3 (0.6) 2.4 (0.6 0.63
Haemoglobin, g/L, mean (SD) 130 (17) 125 (20) 0.03 Potassium, mg/L, mean (SD) 4.2 (0.5) 4.2 (0.5) 0.9
Urea, mg/L, mean (SD) 7.3 (2.6) 7.9 (3.4) 0.07
No patient died before surgery. Thirty-eight patients (14%) died during the first year after surgery. Twelve patients died in the group of patients who were admitted within 6 hours after trauma, and 26 patients died in the group of patients who arrived to hospital later than 6 hours. Survival probability of the patients considering the time of arrival to hospital is shown in Fig. 4.1.1.
Figure 4.1.1. Kaplan-Meier curves for the survival of patients considering the time from trauma to hospital admission
The survival of patients who were admitted to hospital within 6 hours from trauma was 11.3 months (95% CI, 10.9–11.7), and the survival of patients who arrived to hospital later than 6 hours after trauma was 10.5 months (95% CI, 9.9–11.1). Comparing Kaplan-Meier curves for the survival up to 12 months, a significant difference was revealed (log-rank 6.010, P=0.014).
Evaluation of the survival of patients who were underwent surgery within 7 hours from admission to hospital or later showed that death occurred in 19 patients in each group. Survival probability of the patients considering the time from hospital admission to surgery is shown in Fig. 4.1.2.
Figure 4.1.2. Kaplan-Meier curves for the survival of patients considering the time from hospital admission to surgery
The survival of patients who underwent surgery within 7 hours from hospital admission was 11.0 months (95% CI, 10.5–11.5), and the survival of patients who were operated on later than 7 hours after hospital admission was 10.8 months (95% CI, 10.3–11.3). However, comparing Kaplan-Meier curves for the survival up to 12 months, no significant difference was observed (log-rank 0.001, P=0.998).
Comorbidity was evaluated too in all study groups. It was determined that patients having more comorbid conditions arrived to hospital later than 6 hours from trauma. Moreover, patients who underwent the surgery later than 7 hours from admission to hospital had more comorbid conditions.
Cox regression analysis revealed that arrival to hospital within 6 hours after Garden III-IV type femoral neck fractures was associated with a 60% decreased mortality risk (RR=0.4, 95% CI, 0.2–0.8; P=0.01) during the first year following trauma. As it was expected, age had an effect on
mortality (RR=1.1, 95% CI, 1.0–1.1; P=0.001). Women were more likely to have a decreased mortality risk (RR=0.5, 95% CI, 0.3–1.0), but the difference was insignificant (P=0.06). The mortality risk was similar in patients who underwent surgery with 7 hours from hospitalization or later; the type of surgery did not have a significant influence on mortality risk too (Table 4.1.3).
Table 4.1.3. Association between patients’ characteristics, type of treatment in 265 patients with displaced femoral neck fractures
Variable RR 95% CI P value
Sex
(males are the reference)
0.5 0.3–1.0 0.06 Age
(change in risk for each year in increased age)
1.1 1.0–1.1 <0.001 Arrival within 6 hours
(arrival later than 6 hours is the reference)
0.4 0.2–0.8 0.01 Surgery within 7 hours of arrival
(surgery more than 7 hours later is the reference)
0.7 0.4–1.5 0.9 Surgery type (osteosynthesis compared to THA)
(THA is the reference)
1.4 0.6–3.0 0.4
Additionally Cox regression was performed where comorbidity was included. It was found that the number of comorbid diseases had a significant influence on mortality (P=0.02), but arrival to hospital later than within 6 hours has remained the factor significantly influencing mortality (P=0.03).
4.2. Part II. Functional outcomes of treatment
In this part of the study, functional status of the hip joint in 119 patients was evaluated with the help of HOOS questionnaire.
There were 32 (26.9%) men and 87 (73.1%) women. The mean age of the patients was 77 (SD 8). The age and gender distribution of patients by trauma-admission and admission-surgery periods is presented in Table 4.2.1. There were no significant age and gender differences comparing the groups.
Table 4.2.1. Patients’ distribution in respect to age and gender Group Variable ≤12 hours from trauma to admission, n=90 >12 hours from trauma to admission, n=29 ≤12 hours from admission to surgery, n=98 >12 hours from admission to surgery, n=21
Age, years, mean (SD) 78.1 (8) 78.9 (8) 76 (8) 78 (7.4)
Sex, n, M/W 25/65 7/ 22 29/69 3/18
M – men, W – women.
The mean time from trauma to hospital admission was 20 hours and 32 min and it raged from 1 hour to 336 hours. The mean time from hospital admission to surgery was 16 hours 7 min (SD 32 hours 51 min) and varied from 1 hour to 168 hours.
Blood test results and ASA score were evaluated between patients’ groups. No significant differences in haemoglobin, potassium, urea levels and ASA score comparing patients who arrived within 12 hours from trauma with those who arrived later than 12 hours. Meanwhile, patients who underwent surgery later than 12 hours from hospital admission had higher haemoglobin level that those who were operated within 12 hours from hospital admission to surgery (P=0.03).
Table 4.2.2. Blood test results and ASA score by groups Group Variable ≤12 hours from trauma to admission, n=90 >12 hours from trauma to admission, n=29 P value ≤12 hours from admission to surgery, n=98 >12 hours from admission to surgery, n=21 P value ASA, score 2.3 (0.5) 2.3 (0.5) 0.7 2.3 (0.5) 2.4 (0.5) 0.3 Haemoglobin, mg/L 131 (14) 133 (16) 0.241 130 (15) 138 (10)* 0.03 Potassium mg/L 4.2 (0.5) 4.2 (0.5) 0.323 4.2 (0.5) 4.2 (0.5) 0.9 Urea, mg/L 7.1 (2.4) 8.5 (4.0) 0.987 7.3 (2.3) 8.5 (4.6) 0.7 Values are means (standard deviation).
The number of comorbid diseases in patients was evaluated between groups. Analysis revealed that patients who arrived to hospital within 12 hours from trauma had more comorbid diseases (P=0.036). No significant difference in the number of comorbid diseases was seen comparing patients who underwent surgery within 12 hours from hospital admission
with those who were surgically treated later than 12 hours from hospitalization (Table 4.2.3).
Table 4.2.3. Distribution of patients in regard to the number of comorbid diseases, and time from trauma to hospital admission and from hospital admission to surgery
Number of
comorbid diseases
Time from trauma to hospital admission*
Total Time from hospital admission to surgery**
Total
≤12 hours >12 hours ≤12 hours >12 hours
0 11 (12.2) 4 (13.8) 15 (12.6) 13 (13.3) 2 (9.5) 15 (12.6) 1 42 (46.7) 6 (20.7) 48 (40.3) 43 (43.9) 5 (23.8) 48 (40.3) 2 23 (25.6) 15 (51.7) 38 (31.9) 27 (27.6) 11 (52.4) 38 (31.9) 3 14 (15.6) 4 (13.8) 18 (15.1) 15 (15.3) 3 (14.3) 18 (15.1) Values are number (%) of patients.
*Fisher exact criterion 8.402, P=0.036. **Fisher exact criterion 4.916, P=0.17.
Pain in the hip joint, symptoms, function and quality of life in patients with femoral neck fractures were evaluated using the HOOS questionnaire. Patients who arrived to hospital within 12 hours from trauma reported lower pain intensity, better function of the hip joint and better quality of life. Meanwhile, no significant differences in pain intensity, symptoms, function and quality of life were found comparing patients who were operated on within 12 hours from hospital admission with those who underwent surgery later than 12 hours from hospitalization (Table 4.2.4). Table 4.2.4. Data of HOOS questionnaire
Group Variable ≤12 hours from trauma to admission, n=90 >12 hours from trauma to admission, n=29 P value ≤12 hours from admission to surgery, n=98 >12 hours from admission to surgery, n=21 P value Pain 76 (21) 65 (25) 0.003 75 (23) 67 (20) 0.134 Symptoms 70 (20) 59 (20) 0.02 69 (22) 61 (20) 0.116 ADL 74 (23) 62 (25) 0.03 72 (25) 66 (19) 0.297 QQL 67 (27) 55 (30) 0.05 66 (28) 56 (26) 0.129
Values are means (standard deviation).
Aiming at identifying the overall effect of other factors (number of comorbid diseases, gender, age, time, blood test results, ASA grade) on functional outcome and quality of life, a multiple stepwise regression
analysis was performed. It was determined that time from trauma to hospital admission within 12 hours and patient’s gender and age had a significant influence on functional outcome, but the time from hospitalization to surgical intervention had no influence on treatment results (Table 4.2.5)
Table 4.2.5. Coefficients of multiple stepwise regression HOOS
subscale Factor β* 95% CI P
Pain hospitalization (≥12 hours) Time from trauma to –9.578 –19.190; –1.300 0.025 Number of comorbid diseases –6.383 –10.685; –2.082 0.004 Gender –9.446 –18.109; –0.784 0.033 Symptoms hospitalization (≥12 hours) Time from trauma to –10.245 –17.605; –1.551 0.020 Number of comorbid diseases –5.037 –9.048; –1.026 0.014 Gender –12.698 –20.511; –4.884 0.002 Age –0.542 –1.016; –0.067 0.026 Function in
daily activities
Time from trauma to
hospitalization (≥12 hours) –10.653 –20.168; –1.139 0.029 Number of comorbid diseases –6.064 –10.809; –1.319 0.013 Gender –0.558 –1.118; 0.002 0.051 Quality of life hospitalization (≥12 hours) Time from trauma to –11.989 –23.221; –0.757 0.037
Age –1.021 –1.658; –0.384 0.002
*evaluating the time from trauma to hospitalization, the time from hospitalization to surgery, number of comorbid diseases, ASA grade, gender, age, haemoglobin, potassium, urea levels.
5. CONCLUSIONS
1. Older age and higher number of comorbid diseases was associated with higher mortality rate after 1 year following femoral neck fractures whereas the type of surgery and gender did not have any influence on the mortality rate;
2. The period of less than 6 hours from trauma to hospital admission was related to lower mortality rate among patients, meanwhile the period from hospital admission to surgery did not have any significant influence on mortality;
3. Older age, higher number of comorbid diseases and male gender were associated with more intense pain in the hip joint and worse function whereas ASA grade, blood test results had no significant influence on patients’ functional outcome after 2 years following trauma;
4. The period of 12 hours and more from trauma to hospital admission was related poorer functional outcome in patients with femoral neck fractures, meanwhile the period from hospital admission to surgery did not impact significantly the function of the hip joint after two years following trauma.
6. PRACTICAL RECOMMENDATIONS
Summarising the findings of our study and in the literature, it is strongly recommended to deliver a patient who sustained femoral neck fractures to a hospital as soon as possible and to start preoperative readiness. It is advisable to prepare the teaching material on diagnostics of femoral neck fractures and treatment strategy for ambulance personnel and family doctors. This could improve early diagnostics of femoral neck fractures and would allow shortening the time from trauma to hospital admission, which is of crucial importance in survival prognosis and functional treatment outcome of a patient. After admitting a patient to the hospital, it is recommended to prepare the patient for surgery thoroughly as this period from admission to surgery has no significant influence on patients’ mortality and functional outcome.
7. PUBLICATIONS
Publications in peer-reviewed journals
1. Vertelis, Arūnas; Tarasevičius, Šarūnas; Robertsson, Otto; Wingstrand, Hans. Delayed hospitalization increases mortality in displaced femoral neck fracture patients. Acta Orthopaedica. In press.
2. Vertelis, Arūnas; Tarasevičius, Šarūnas; Wingstrand, Hans. Ikioperacinio laiko įtaka pasislinkusių šlaunikaulio kaklo lūţių gydymo rezultatams (Delay to surgery and functional outcome in displaced femoral neck fracture.) Lietuvos bendrosios praktikos gydytojas 2009; 13(4):223-7.
Other publications
1. Vertelis, Arūnas; Indrulionis, Tomas; Vertelis, Linas. Ikioperacinio laiko įtaka dislokuotų šlaunikaulio kaklo lūţimų gydymo rezultatams // 9-asis Lietuvos ortopedų traumatologų suvaţiavimas “Nauji metodai ir technologijos vaikų ir suaugusių ortopedijoje traumatologijoje”: 2008 m. balandţio 25-26 d., Klaipėda.
2. Vertelis, Arūnas; Vertelis, Linas; Tarasevičius, Šarūnas. Trial femoral head loss in to the soft tissues of pelvis during primary total hip replacement: a case report. Cases Journal 2008; 1:151.
SUMMARY IN LITHUANIAN
Šlaunikaulio kaklo lūţiai – viena daţniausių vyresniojo amţiaus ţmonių traumų [Cummings ir kt., 1990; Cooper ir kt., 1992; Koval ir Zuckerman, 1994]. Šių traumų nepaliaujamai daugėja, didėjant vyresniojo amţiaus ţmonių skaičiui [Cummings ir kt., 1990; Cooperir kt., 1992]. Prognozuojama, kad 2050 metais ŠK lūţių skaičius pasieks 6,26 milijono [Cooper ir kt., 1992].
Šiuo metu literatūroje yra ieškoma tinkamiausių šlaunikaulio kaklo lūţių gydymo metodikų, laiduojančių geriausius funkcinius ir gyvenimo kokybės rezultatus bei maţiausiai lemiančius mirštamumą. Taip pat ieškoma rizikos veiksnių, galbūt lemiančių pacientų, patyrusių šlaunikaulio kaklo lūţius, mirštamumą bei funkcinius rodiklius [Greatorex IF, Gibbs, 1988; Hanan ir kt., 2001; Gruson ir kt., 2002; Holt ir kt., 2008; Hommel ir kt., 2008; Lewis ir kt., 2006; Maxwell ir kt., 2008; Sebestyen ir kt., 2008; Smektala ir kt., 2008]. Literatūroje nevienareikšmiškai vertinama paciento lyties, operacinio gydymo metodo, sergamumo gretutinėmis ligomis ir kraujo tyrimų įtaka šlaunikaulio kaklo lūţių gydymo rezultatams. Šių veiksnių reikšmę pacientų mirštamumui ir judumui bei gyvenimo kokybei mes įvertinome savo atliktame tyrime. Vienas iš aprašomų literatūroje svarbių rizikos veiksnių, galbūt lemiančių mirštamumą ir pacientų funkciją, yra laiko trukmė nuo traumos iki operacinio gydymo pradţios. Tačiau nėra suformuotos bendros nuomonės ar algoritmo, kada saugiausia operuoti šios grupės pacientus. Daugumoje publikacijų apie atliktus tyrimus šis saugus laikotarpis nuo patekimo į ligoninę iki operacinio gydymo pradţios svyruoja nuo 6 val. iki 5 parų [Cooper ir kt., 1992; Jain ir kt., 2002; Klassbo ir kt., 2003; Dorotka ir kt., 2004; Sebestyen ir kt., 2008; Siegmeth ir kt., 2006]. Tačiau analizuojant literatūros duomenis pastebima, kad nėra išskiriamas laikas nuo traumos iki patekimo į ligoninę, o laikas pradedamas skaičiuoti tik nuo tada, kada pacientas jau stacionarizuotas. Šis veiksnys gali turėti didelės įtakos galutiniams gydymo rezultatams, nes laikotarpio nuo traumos iki patekimo į stacionarą trukmė gali labai svyruoti tarp įvairių pacientų grupių.
Panašiai kaip ir per mirštamumo po šlaunikaulio kaklo lūţių tyrimus, kurių metu buvo vertinama laiko trukmė nuo traumos iki operacijos, taip ir per tyrimus, kai vertinama pooperacinė funkcinė paciento būklė, laiko trukmė nuo traumos iki patekimo į ligoninę tirta nebuvo. Mes, analizduodami literatūrą, radome tik vieną mokslo publikaciją [Orosz ir kt., 2004], kurioje buvo vertinamas laikotarpis nuo patekimo į stacionarą
iki operacinio gydymo pradţios ir jo įtaka pacientų funkcijai praėjus 6 mėnesiams po traumos. Tačiau laikotarpis nuo traumos iki paciento patekimo į ligoninę įvertintas nebuvo. Tai galėjo lemti gydymo rezultatus.
Darbo tikslas
Nustatyti veiksnius darančius įtaką šlaunikaulio kaklo lūţių gydymo rezultatams.
Darbo uţdaviniai
1. Nustatyti amţiaus, lyties, operacijos tipo, gretutinių ligų skaičiaus įtaką, pacientų, patyrusių šlaunikaulio kaklo lūţius, mirštamumui praėjus 1 metams po traumos;
2. Nustatyti laiko trukmės nuo traumos iki patekimo į ligoninę ir laiko trukmės nuo patekimo į ligoninę iki operacijos įtaką pacientų, patyrusių šlaunikaulio kaklo lūţius, mirštamumui praėjus 1 metams po traumos;
3. Nustatyti amţiaus, lyties, ASA laipsnio, gretutinių ligų skaičiaus įtaką, pacientų, patyrusių šlaunikaulio kaklo lūţius, funkciniams gydymo rezultatams, praėjus 2 metams po traumos;
4. Nustatyti laiko trukmės nuo traumos iki patekimo į ligoninę ir laiko trukmės nuo patekimo į ligoninę iki operacijos įtaką pacientų funkciniams gydymo rezultatams, praėjus 2 metams po traumos.
Išvados
5. Vyresnis pacientų amţius, didesnis gretutinių ligų skaičius buvo susijęs su didesniu pacientų mirštamumu praėjus 1 metams po šlaunikaulio kaklo lūţio, tuo tarpu operacijos tipas, lytis mirštamumo neįtakojo;
6. Trumpesnis laiko tarpsnis nei 6 val. nuo traumos iki patekimo į ligoninę buvo susijusi su maţesniu pacientų mirštamumu, tuo tarpu laiko trukmė nuo patekimo į ligoninę iki operacijos reikšmingos įtakos mirštamumui;
7. Vyresnis pacientų amţius, didesnis gretutinių ligų skaičius ir vyriška lytis buvo susijusi su didesniu klubo sąnario skausmu bei blogesne funkcija, tuo tarpu ASA laipsnis, kraujo tyrimų rezultatai neturėjo reikšmingos įtakos pacientų funkciniams rezultatams, praėjus 2 metams po traumos;
8. Laiko tarpsnis ilgesnis nei 12 val. nuo traumos iki patekimo į ligoninę buvo susijęs su blogesniais funkciniais rezultatais, tuo tarpu laiko tarpsnis nuo patekimo į ligoninę iki operacijos klubo sąnario funkcijos reikšmingai neįtakojo, praėjus 2 metams po traumos.
Praktinės rekomendacijos
Įvertinus literatūros duomenis bei mūsų tyrimo duomenis, įvykus šlaunikaulio kaklo lūţiams tikslinga kuo greičiau pacientą pristatyti į gydymo įstaigą, ir pradėti priešoperacinį paruošimą. Tikslinga greitosios medicininės pagalbos medikams bei šeimos gydytojams paruošti mokomają medţiagą apie šlaunikaulio kaklo lūţių diagnostiką ir gydymo taktiką. Tai galėtų pagerinti šlaunikaulio kaklo lūţių ankstyvą diagnostiką bei leistų sutrumpinti laiko nuo traumos iki patekimo į ligoninę trukmę, kas yra labai svarbu paciento išgyvenamumo prognozei bei funkciniams gydymo rezultatams. Pacientui atvykus į ligoninę tikslingas kruopštus ikioperacinis paruošimas neskubant operuoti, kadangi šio laiko trukmė neturi reikšmingos įtakos pooperaciniam pacientų mirštamumui ir funkciniams gydymo rezultatams.
CURRICULUM VITAE
Name, surname: Arūnas Vertelis Date of birth: 1 June, 1960
Address: Kleboniškio 3H,Kaunas, Lithuania
Phone: +370 687 21510
E-mail: arunas.vertelis@gmail.com
Medical education
1978-1984 Studies at the Faculty of Medicine, Kaunas University of Medicine
1984-1985 Internship at the Faculty of Medicine, Kaunas University of Medicine
Current position
Since 2004 the head of unit at the Clinic of Traumatology and Orthopaedics, Hospital of Kaunas University of Medicine
Traineeship
1995 Francis Hospital, Tulsa, USA
1996 St. Joseph-Hospital Duisburg, Germany
2001 Vienna University, Steyr University Hospital, Austria
Knowledge of languages
