Functional outcome and mortality in geriatric distal femoral fractures

doi:10.1016/j.injury.2012.02.014

Injury

Volume 43, Issue 7, July 2012, Pages 1096-1101

https://doi.org/10.1016/j.injury.2012.02.014 Get rights and content

Abstract

Background

Fragility fractures are a major health care problem worldwide. Due to the ageing population an increase of distal femoral fractures is to be expected. We studied the long-term functional outcome and their influencing factors in geriatric patients with LISS-plated distal femoral fractures.

Patients and methods

A cohort study with functional long-term follow up examination was carried out in a level one trauma centre on distal femoral fracture patients 65 years and older. Of 53 consecutive patients who were treated in our hospital, 43 patients with a mean age of 80 years met our inclusion criteria. 48.8% died within the study period of 5.3 years. On the remaining patients the residential status, the Barthel index and the Parker score were assessed.

Results

The mean Barthel index was 47.7 and the mean Parker score was 3.5. 23% were found to be totally housebound and 26% were not able to perform any social activity. Only 18% were able to walk unaided. Patients with any medical complication had significantly higher mortality rates. Patients with extraarticular fractures had better mobility scores. Nursing home residents showed higher mortality rates but compared to patients coming from their own home the difference regarding Barthel and Parker scores remained non-significant.

Conclusion

This study documents the poor functional long-term outcome of geriatric patients with distal femoral fractures. In comparison to other fragility fracture patients it seems that this population is at higher risk to die in-hospital during their perioperative course. Medical complications have to be avoided as they were found to be associated with worse functional outcome and higher mortality rates. An osteoporosis therapy may be associated with reduced mortality rates also in these patients.

Introduction

Fragility fractures are a major health problem in many countries. Predictions of the demographic development of the world population point out – with some regional differences – that the proportion of the geriatric population will increase continuously over the coming decades.¹

Distal femoral fractures account for about 6% of all femoral fractures² and the incidence is likely to increase in our ageing population.3, 4 Most of these fractures in the elderly occur after a low-energy trauma in osteoporotic bone.2, 4, 5

Elderly patients are predisposed for falls by cardiovascular diseases, neurological disorders, visual impairment and multiple other indispositions. Falls in osteoporotic patients are at high risk to lead to a fracture even if they are only from standing height. A higher endostal resorption, osteoporosis-related changes in the microarchitecture of the cancellous bone and a loss of cancellous and cortical bone are increasing the risk of a fragility fracture.⁶ Furthermore, elderly patients are also at higher risk to develop complications such as infection, delirium or iatrogenic problems.7, 8

According to the type of fracture and the orthopaedics preferences there are several ways to stabilise distal femoral fractures in the elderly. Locked plating was proven to achieve good results and is the accepted standard in the treatment of these fractures.2, 5, 9

In the literature there are some reports about long-term outcome of geriatric hip fractures¹⁰ but there is only little known about this issue in distal femoral fractures. Our study closes the gap and shows long-term data of mortality, functional outcome and influencing factors in geriatric distal femoral fracture patients treated with a LISS plate.

Section snippets

Patients and methods

In this cohort study all distal femoral fracture patients aged 65 years and older treated within our level-1 trauma centre between the years 2000 and 2008 were included. Patients with pathological fractures, multiple fractures, patients who underwent any organ transplantation and non-residents were excluded from this study. Preexisting comorbidities and perioperative complications were validated through chart review.

Data collection was performed by two of the authors (CK and PR) by chart

Results

Overall we identified 53 patients, of which 10 (19%) met our exclusion criteria (eight were travellers and 2 sustained a pathological fracture). Therefore a total of 43 (81%) patients were included and 19 of the surviving 21 patients were available for the follow-up examination.

The mean age at time of the fracture was 80 years (65–102) and the mean time to follow up was 5.3 years (±3). 25.6% of all patients had at least 2 comorbidities whereas hypertension (62.8%) and coronary heart disease

Discussion

The aim of this study on 43 subsequent geriatric patients with distal femoral fractures was to accurately assess their long-term outcome and influencing factors. The treatment of these patients is complicated by their frequent coincidence with preexisting implants around the hip or knee and – as pointed out in some reports – due to often multiple medical comorbidities.⁹ The influence of these conditions is already widely known in hip fracture patients and nowadays interdisciplinary concepts are

Conclusion

This study documents the poor functional long-term outcome of geriatric patients suffering from a distal femoral fracture. In comparison to hip fracture patients it seems that this population is at higher risk to die in-hospital during their first stay. Medical complications have to be avoided as they were found to be associated with worse functional outcome and higher mortality rates whereas an osteoporosis therapy may reduce mortality.

Conflict of interest

None of the authors has a conflict of interest regarding the topics discussed in this study.

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Distal femur fractures (DFF) account for 6% of all femoral fractures and predominate in females. The current 1-year mortality of DFF is currently reported to be between 10 and 38%, a wide margin, and confounded by multiple factors including age, high energy mechanisms, pathological and periprosthetic fractures. The purpose of this study was to assess and determine all-cause mortality following geriatric native distal femur fractures at 30 days, six months and one year.
– The databases Cochrane CENTRAL, MEDLINE, EMBASE and NHS NICE Healthcare Databases Advanced Search Interface were searched in accordance with PRISMA guidelines. Original research articles relevant to mortality outcomes in native geriatric distal femur fractures following low energy trauma were included. A time-to-event data meta-analysis model was used to estimate pooled 30-day, six month and one-year mortality. A random effects meta-regression model was performed to assess potential sources of heterogeneity when studies reported on factors affecting the mortality observed in patients with geriatric distal femur fractures.
– Thirteen studies were included in the meta-analysis with a mean age of 79.6 years. Eight studies reported the 30-day mortality of distal femur fractures in patients as a pooled estimate of 8.14%. Pooled estimate for 6-month mortality reported was 19.5% and the one-year mortality reported by ten studies was 26.10%. Time-to-event modelling showed that risk of mortality at one year in elderly patients with distal femur fractures was significantly higher HR = 4.31 (p < 0.001). When evaluating prognostic predictors, age and Type C fracture were predictive of highest mortality rates.
– This study is the first meta-analysis to evaluate the early and long-term mortality observed in elderly patients presenting with native distal femoral fractures. Through our results we have shown the quantifiable impact patient age and fracture configuration has on one-year mortality in this patient cohort.
Single-stage surgery of distal femoral type B fracture combined with posterior cruciate ligament injury
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An analytical model of lateral condylar plate working length
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The locking plate is a common device to treat distal femur fractures. Healing is affected by construct stiffness, thus many surgeon-controlled variables such as working length have been examined for their effects on strain at the fracture. No convenient analytical model which aids surgeons in determining working length has yet been described. We propose an analytical model and compare it to finite element analysis and cadaveric biomechanical testing.
First, an analytical model based on a cantilever beam equation was derived. Next, a finite element model was developed based on a CT scan of a “fresh-frozen” cadaveric femur. Third, biomechanical testing in single-leg stance loading was performed on the cadaver. In all methods, strain at the fracture was recorded. An ANCOVA test was conducted to compare the strains.
In all models, as the working length increased so did strain. For strain at the fracture, the shortest working length (35 mm) had a strain of 8% in the analytical model, 9% in the finite element model, and 7% for the cadaver. The longest working length (140 mm) demonstrated strain of 15% in the analytical model, and the finite element and biomechanical tests both demonstrated strain of 14%.
The strain predicted by the analytical model was consistent with the strain observed in both the finite element and biomechanical models. As demonstrated in existing literature, increasing the working length increases strain at the fracture site. Additional work is required to refine and establish validity and reliability of the analytical model.
Current standard of care for distal femur fractures in Germany and Switzerland
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Distal femur fractures occur with an incidence of 4.5/100,000 and show a prevalence of 0.4%. Causes include low-impact trauma in older patients and high-impact trauma in younger patients without pre-existing medical conditions. The aim of this study was to perform a comprehensive evaluation of trauma mechanisms, trauma-promoting factors, comorbidities, medication history and type of surgical care to provide an overview of the causes of injury and the most appropriate therapeutic approach.
In this multicenter cohort study a retrospective analysis of 229 patients who sustained a distal femur fracture between January 2011 and December 2020 was performed. Individual fracture patterns, fracture predisposing factors, concomitant disease profiles, medication history, treatment strategy and associated complications were analyzed.
229 patients were included in the retrospective analysis. A total of 113-type 33 A, 50-type 33 B and 66-type 33 C fractures were diagnosed, of whom 92% received a lateral locking plate osteosynthesis. There was a complication in 14.4% of all cases, of which 6.1% were attributable to infection. Significant risk factors for developing a complication were an increased BMI (29.9 ± 8.5 kg/m2; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008).
In this multicenter retrospective cohort study, lateral locking plate osteosynthesis was the method of choice and was selected in over 90% of cases, regardless of the fracture classification and risk factors. A complication rate of 14.4% emphasizes the necessary analysis of patient- and care-specific risk factors and a resulting adjustment of the therapy strategy. An increased BMI (29.9 ± 8.5 kg/m²; p = 0.04), fracture displacement of over half a shaft width (p < 0.001) and AOC fractures (p < 0,016), specifically C2 fractures (p < 0,008) increase the risk of developing a complication and should prompt an early switch to a treatment strategy that provides more stability.
Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends
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Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.
Predictive factors for mortality after distal femoral fractures in the elderly: A retrospective multicenter (TRON group) study
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Citation Excerpt :
Another study confirmed these results in a retrospective series of 115 fractures comparing retrograde nailing (n = 59) and mini-invasive locking plate use (n = 56) [25]. Several studies also reported no association between time to surgery and mortality after DFFs [9,11]. These results suggest that clinical outcomes after DFFs do not depend on the choice of implant and that it is important for surgeons to plan the surgical techniques carefully and wait until the patient's general condition become acceptable for surgery.
This retrospective multicenter study aimed to assess the 1-year mortality rate in elderly patients with distal femoral fractures (DFFs) and identify potential risk factors for mortality.
We analyzed 321 patients aged 65 years and older with DFFs treated surgically between 2012 and 2019 in 13 hospitals. Patient demographics and surgical characteristics were extracted from medical records and radiographs. We used univariable and multivariable Cox regression analyses to identify the factors affecting mortality.
The mortality rate for DFFs in elderly patients at 1 year was 9.0%. Multivariable Cox regression analysis revealed older age, male sex, underweight (body mass index [BMI] <18.5 kg/m²), bedridden status, and nursing home residency to be independent predictors for mortality (older age: hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.03–1.11, P<0.001; male sex: HR 3.08, 95% CI 1.23–7.71, P=0.015; underweight: HR 1.93, 95% CI 1.01–3.68, P=0.045; bedridden status: HR 4.59, 95% CI 1.61–13.07, P=0.0042; and nursing home residency: HR 2.63, 95% CI 1.18–5.83, P=0.017). None of the factors associated with surgery including types of fixation, time from initial visit to surgery, blood loss during operation, and operation time was an independent predictor for mortality.
The 1-year mortality rate in elderly patients with DFFs was relatively low at 9.0%. Older age, lower BMI, and nursing home residency were associated with mortality after surgery for DFFs. Factors associated with the surgical procedure were not significant predictors.

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Functional outcome and mortality in geriatric distal femoral fractures

Abstract

Background

Patients and methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Conflict of interest

Injury

Injury

J Clin Epidemiol

J Chronic Dis

Bone

Injury

Injury

Hip fractures in the elderly: a world-wide projection

Osteoporos Int

Distal femoral fractures: current concepts

J Am Acad Orthop Surg

The epidemiology of fractures of the distal femur

Injury

Mortality after distal femur fractures in elderly patients

Clin Orthop Relat Res

Treatment strategies for proximal femur fractures in osteoporotic patients

Osteoporos Int

A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics

Ann Intern Med

Hazards of hospitalization of the elderly

Ann Intern Med

Long-term functional outcome in geriatric hip fracture patients

Arch Orthop Trauma Surg

In brief: classifications in brief: Vancouver classification of postoperative periprosthetic femur fractures

Clin Orthop Relat Res