Influence of surgical quality (according to postoperative radiography) on mortality, complications and recovery of walking ability in 1425 hip fracture patients.

Abstract

To evaluate the influence of surgical quality (as evaluated in the post-surgical radiographic control) on mortality, complications and recovery of walking ability in patients older than 64 years with hip fracture. Retrospective observational study of a single-center, consecutive cohort of 1425 patients operated from December/2012 to March/2018. Average age was 85.66±7.13 (65-108) years and 966 (67.86%) were female. Extracapsular fractures (811 cases, 56.91%) were fixed with trochanteric nails (Affixus-DePuy / PFNA-Synthes) (795 cases) or sliding-hip-screw-plates (Biomet) (16 patients). Intracapsular fractures (614, 43.09%) were treated with cannulated screws (Smith-Nephew) (134 cases) or with arthroplasty (472 bipolar and 8 total hip, Furlong-JRI or Exeter-Stryker). Postoperative radiographs were used to determine surgical quality (reduction, compression, screw position, tip-apex, stem position, Voss, intraoperative fracture). Patients were followed clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months. Bivariate analysis (Pearson, Fischer, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Relative Risks (RR) were calculated. 196 patients (13.75%) died along follow-up, and poor reduction was found to be a risk factor for mortality both in trochanteric nail group (p=0.0495) (RR 1.510, 1.01-2.26) and in cannulated screw group (p=0.0023) (RR 6.48, 2.40-17.53); this is a previously non-published risk factor. Surgical complications included 33 infections (2.36%), 12 non-unions (1.27%), 12 cut-outs (1.47%), 7 broken nails (0.86%), 21 hemiarthroplasty dislocations (4.37%), and 8 ischemic necrosis of the femoral head (5.97%). The significant risk factors were: poor reduction for trochanteric nail breakage (p=0.041) (RR 4.47, 1.13-17.67), poor reduction for non-union in cannulated screws (p=0.035) (RR 10.91, 1.70-70.09), as well as "tip-apex distance" over 25mm in trochanteric fractures for "cut-out" type of fixation failure (p=0.0159) (RR 3.84, 1.19-12.40). Previous walking ability was restored in 564 patients (39.58%) and worsened in 581 (40.77%), but statistical relationships were not found, although follow-up data were inadequate in 212 cases (14.88%). Appropriate reduction of hip fractures is a significant step to reduce mortality, nail breakage and non-union. Adequate position of sliding screw (avoiding tip-apex distances over 25mm) is important to reduce "cut-out" in trochanteric fractures.