Top

Clinical Orthopaedics and Related Research®

Published in:

01-04-2011 | Clinical Research

Mortality After Distal Femur Fractures in Elderly Patients

Authors: Philipp N. Streubel, MD, William M. Ricci, MD, Ambrose Wong, BS, Michael J. Gardner, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 4/2011

Abstract

Background

Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.

Questions/purposes

We evaluated the mortality of elderly patients after distal femur fractures; determined predictors for mortality; analyzed the effect of surgical delay; and compared survivorship of elderly patients with distal femur fractures with subjects in a matched hip fracture group.

Patients and Methods

We included 92 consecutive patients older than 60 years with low-energy supracondylar femur fractures treated between 1999 and 2009. Patient, fracture, and treatment characteristics were extracted from operative records, charts, and radiographs. Data regarding mortality were obtained from the Social Security Death Index.

Results

Age-adjusted Charlson Comorbidity Index and a previous TKA were independent predictors for decreased survival. Congestive heart failure, dementia, renal disease, and history of malignant tumor led to shorter survival times. Patients who underwent surgery more than 4 days versus 48 hours after admission had greater 6-month and 1-year mortality risks. No differences in mortality were found comparing patients with native distal femur fractures with patients in a hip fracture control group.

Conclusions

Periprosthetic fractures and fractures in patients with dementia, heart failure, advanced renal disease, and metastasis lead to reduced survival. The age-adjusted Charlson Comorbidity Index may serve as a useful tool to predict survival after distal femur fractures. Surgical delay greater than 4 days increases the 6-month and 1-year mortality risks. Mortality after native fractures of the distal femur in the geriatric population is high and similar to mortality after hip fractures.

Level of Evidence

Level II, prognostic study. See the guidelines online for a complete description of evidence.

Arneson TJ, Melton LJ 3rd, Lewallen DG, O’Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965–1984. Clin Orthop Relat Res. 1988;234:188–194.PubMed

Baker DM. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1997;79:470.PubMed

Beringer TR. Mortality and morbidity after hip fractures. BMJ. 1994;308:343.PubMed

Bhattacharyya T, Chang D, Meigs JB, Estok DM 2nd, Malchau H. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg Am. 2007;89:2658–2662.PubMedCrossRef

Bhattacharyya T, Iorio R, Healy WL. Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am. 2002;84:562–572.PubMed

Bolhofner BR, Carmen B, Clifford P. The results of open reduction and Internal fixation of distal femur fractures using a biologic (indirect) reduction technique. J Orthop Trauma. 1996;10:372–377.PubMedCrossRef

Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332:947–951.PubMedCrossRef

Boyd AD Jr, Wilber JH. Patterns and complications of femur fractures below the hip in patients over 65 years of age. J Orthop Trauma. 1992;6:167–174.PubMedCrossRef

Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients: operative versus non-operative treatment. J Bone Joint Surg Br. 1996;78:110–114.PubMed

10.

Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245–1251.PubMedCrossRef

11.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.PubMedCrossRef

12.

Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arch Orthop Trauma Surg. 2005;125:73–79.PubMedCrossRef

13.

Clayer MT, Bauze RJ. Morbidity and mortality following fractures of the femoral neck and trochanteric region: analysis of risk factors. J Trauma. 1989;29:1673–1678.PubMedCrossRef

14.

Cornwall R, Gilbert MS, Koval KJ, Strauss E, Siu AL. Functional outcomes and mortality vary among different types of hip fractures: a function of patient characteristics. Clin Orthop Relat Res. 2004;425:64–71.PubMedCrossRef

15.

Cowper DC, Kubal JD, Maynard C, Hynes DM. A primer and comparative review of major US mortality databases. Ann Epidemiol. 2002;12:462–468.PubMedCrossRef

16.

Deakin DE, Boulton C, Moran CG. Mortality and causes of death among patients with isolated limb and pelvic fractures. Injury. 2007;38:312–317.PubMedCrossRef

17.

Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619.PubMedCrossRef

18.

Dunlop DG, Brenkel IJ. The supracondylar intramedullary nail in elderly patients with distal femoral fractures. Injury. 1999;30:475–484.PubMedCrossRef

19.

Elliott J, Beringer T, Kee F, Marsh D, Willis C, Stevenson M. Predicting survival after treatment for fracture of the proximal femur and the effect of delays to surgery. J Clin Epidemiol. 2003;56:788–795.PubMedCrossRef

20.

Fillenbaum GG, Burchett BM, Blazer DG. Identifying a national death index match. Am J Epidemiol. 2009;170:515–518.PubMedCrossRef

21.

Franzo A, Francescutti C, Simon G. Risk factors correlated with post-operative mortality for hip fracture surgery in the elderly: a population-based approach. Eur J Epidemiol. 2005;20:985–991.PubMedCrossRef

22.

Gdalevich M, Cohen D, Yosef D, Tauber C. Morbidity and mortality after hip fracture: the impact of operative delay. Arch Orthop Trauma Surg. 2004;124:334–340.PubMedCrossRef

23.

Giles JB, DeLee JC, Heckman JD, Keever JE. Supracondylar-intercondylar fractures of the femur treated with a supracondylar plate and lag screw. J Bone Joint Surg Am. 1982;64:864–870.PubMed

24.

Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112:702–709.PubMedCrossRef

25.

Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 1987;10:1781–1788.PubMed

26.

Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742–746.PubMedCrossRef

27.

Haidukewych G, Sems SA, Huebner D, Horwitz D, Levy B. Results of polyaxial locked-plate fixation of periarticular fractures of the knee. J Bone Joint Surg Am. 2007;89:614–620.PubMedCrossRef

28.

Henry SL. Supracondylar femur fractures treated percutaneously. Clin Orthop Relat Res. 2000;375:51–59.PubMedCrossRef

29.

Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18:509–520.PubMedCrossRef

30.

Majumdar SR, Beaupre LA, Johnston DW, Dick DA, Cinats JG, Jiang HX. Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study. Med Care. 2006;44:552–559.PubMedCrossRef

31.

Markmiller M, Konrad G, Sudkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004;426:252–257.PubMedCrossRef

32.

Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audige L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1–S133.PubMedCrossRef

33.

Martinet O, Cordey J, Harder Y, Maier A, Buhler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000;31(suppl 3):C62–C63.PubMedCrossRef

34.

McGuire KJ, Bernstein J, Polsky D, Silber JH. The 2004 Marshall Urist Award: Delays until surgery after hip fracture increases mortality. Clin Orthop Relat Res. 2004;428:294–301.PubMedCrossRef

35.

Melton LJ 3rd, Crowson CS, O’Fallon WM. Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int. 1999;9:29–37.PubMedCrossRef

36.

Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, Cosman F. Fragility fractures of the hip and femur: incidence and patient characteristics. Osteoporos Int. 2010;21:399–408.PubMedCrossRef

37.

Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19:170–176.PubMedCrossRef

38.

Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006;20:190–196.PubMedCrossRef

39.

Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005;331:1374.PubMedCrossRef

40.

Schutz M, Muller M, Krettek C, Hontzsch D, Regazzoni P, Ganz R, Haas N. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury. 2001;32(suppl 3):SC48–SC54.

41.

Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55:146–154.PubMedCrossRef

42.

Shih J. Shih/SIZE. 2009. Johns Hopkins School of Public Health. Available at: http://cct.jhsph.edu/javamarc/Shih/powerpropv2.htm. Accessed December 2, 2009.

43.

Social Security Death Index. 2009. Social Security Administration. Available at: http://ssdi.rootsweb.ancestry.com. Accessed October 10, 2009.

44.

Streubel PN, Gardner MJ, Morshed S, Collinge CA, Gallagher B, Ricci WM. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joint Surg Br. 2010;92:527–534.PubMed

45.

Streubel PN, Gardner MJ, Ricci WM. Intracapsular femoral neck fractures in elderly patients. Minerva Ortop Traumatol. 2009;60:541–554.

46.

Streubel PN, Ricci WM, Gardner MJ. Fragility fractures: preoperative, perioperative, and postoperative management. Curr Orthop Pract. 2009;20:482–489.CrossRef

47.

Sund R, Liski A. Quality effects of operative delay on mortality in hip fracture treatment. Qual Saf Health Care. 2005;14:371–377.PubMedCrossRef

48.

Thomson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing. Orthopedics. 2008;31:748–750.PubMedCrossRef

49.

Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma. 2006;20:366–371.PubMedCrossRef

50.

Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77:1551–1556.PubMed

Title: Mortality After Distal Femur Fractures in Elderly Patients
Authors: Philipp N. Streubel, MD
William M. Ricci, MD
Ambrose Wong, BS
Michael J. Gardner, MD
Publication date: 01-04-2011
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 4/2011
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-010-1530-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Mortality After Distal Femur Fractures in Elderly Patients

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 4/2011

Biographical Sketch: William S. Baer (1872–1931)

Can This Prosthesis Be Saved?: Implant Salvage Attempts in Infected Primary TKA

The Sensitivity and Specificity of Ultrasound for the Diagnosis of Carpal Tunnel Syndrome: A Meta-analysis

Can the Change in Center-edge Angle During Pincer Trimming Be Reliably Predicted?

Skeletal Muscle Abnormalities and Genetic Factors Related to Vertical Talus

What Is the Best Femoral Fixation of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction?: A Meta-analysis