Yaşlılarda İnstabil İntertrokanterik Kırıklarda Cerrahi Sonrası Bir Yıllık Mortaliteyi Belirleyen Çok Değişkenli Etkenler

Abstract

Amaç: Yaşlı erişkinlerde instabil intertrokanterik femur kırıkları sonrası bir yıllık mortalite halen yüksektir; komorbidite yükü, perioperatif faktörler ve inflamatuvar belirteçleri birlikte değerlendiren bütüncül prognostik modeller ise sınırlıdır. Materyal ve metod: Bu retrospektif tek merkezli kohort çalışmasında, AO/OTA 31A2–31A3 kırığı olan ve 2017–2020 yılları arasında antirotator proksimal femoral çivi (A-PFN) veya çimentosuz bipolar hemiartroplasti (HA) uygulanan ≥65 yaşındaki 141 hasta değerlendirildi. Birincil sonlanım noktası ameliyat sonrası bir yıllık mortaliteydi. Başlangıç demografik veriler, Charlson Komorbidite İndeksi (CCI), ameliyata kadar geçen süre, hastanede kalış süresi, transfüzyon ünite sayısı ve başvuru anındaki inflamatuvar belirteçler (NLR, PLR, MLR, SII) analiz edildi. Tek değişkenli ilişkiler Spearman korelasyonu ve ki-kare/Fisher testleri ile değerlendirildi; ardından kolinerlik tanıları ve adım adım azaltma (step-down) yaklaşımı ile çok değişkenli lojistik regresyon uygulandı.
Bulgular: Bir yıllık mortalite %35,5 (50/141) olarak saptandı. Tek değişkenli analizlerde mortalite; ameliyata kadar geçen süre, hastanede kalış süresi, CCI, NLR, PLR, MLR ve SII ile ilişkiliydi (tümü p<0,05). Tam çok değişkenli modelde yalnızca CCI (OR 2,807, %95 GA 1,619–4,860; p<0,001), MLR (OR 2,034, %95 GA 1,133–3,647; p=0,017) ve SII (OR 3,007, %95 GA 1,010–8,953; p=0,048) bağımsız belirleyiciler olarak kaldı. Model indirgeme sonrası da bu ilişkiler korundu: CCI (OR 2,71, %95 GA 1,63–4,50; p<0,001), MLR (OR 1,69, %95 GA 1,05–2,72; p=0,030) ve SII (OR 1,73, %95 GA 1,03–2,91; p=0,037). Cerrahi teknik (A-PFN’ye karşı HA) mortalite ile bağımsız olarak ilişkili değildi.
Sonuç: Yaşlı instabil intertrokanterik kırık hastalarında komorbidite yükü (CCI) ve inflamatuvar durum (MLR, SII) bir yıllık mortaliteyi bağımsız olarak öngörürken, cerrahi yöntem bağımsız bir belirleyici değildir. Ameliyat öncesi klinik-inflamatuvar birleşik değerlendirme risk sınıflamasını geliştirebilir; bulguların dış doğrulama ile desteklenmesi gereklidir.

Keywords

• İntertrokanterik Femur Kırığı
• Bir Yıllık Mortalite
• Charlson Komorbidite İndeksi
• Monosit/Lenfosit Oranı
• Sistemik İmmün-İnflamasyon İndeks
• Geriatrik Kalça Kırığı

Supporting Institution

Herhangi bir fon, hibe veya başka bir destek alınmamıştır.

Ethical Statement

Ethical approval was obtained from the Clinical Research Ethics Committee of Sağlık Bilimleri University Kanuni Sultan Süleyman Training and Research Hospital (approval no: 112, date: August 9, 2023).

Thanks

: The authors thank all individuals who contributed to the study but did not meet the authorship criteria.

Multivariate Determinants of One-Year Mortality Post-Surgery for Unstable Intertrochanteric Fractures in the Elderly

Abstract

Background: One-year mortality after unstable intertrochanteric femur fractures in older adults remains high, and integrated prognostic models that combine comorbidity burden, perioperative factors, and inflammatory indices are limited.
Materials and Methods: In this retrospective single-center cohort, 141 patients aged ≥65 years with AO/OTA 31A2–31A3 fractures (2017–2020) underwent antirotator proximal femoral nailing (A-PFN) or cementless bipolar hemiarthroplasty (HA). The primary endpoint was one-year postoperative mortality. Baseline demographics, Charlson Comorbidity Index (CCI), time to surgery, length of stay, transfusion units, and admission inflammatory markers (NLR, PLR, MLR, SII) were analyzed. Univariable associations were assessed using Spearman correlation and chi-square/Fisher tests, followed by multivariable logistic regression with collinearity diagnostics and step-down model reduction. Results: One-year mortality was 35.5% (50/141). In univariable analyses, mortality was associated with time to surgery, hospital stay, CCI, NLR, PLR, MLR, and SII (all p<0.05). In the full multivariable model, only CCI (OR 2.807, 95% CI 1.619–4.860; p<0.001), MLR (OR 2.034, 95% CI 1.133–3.647; p=0.017), and SII (OR 3.007, 95% CI 1.010–8.953; p=0.048) remained independent predictors. After model reduction, these associations persisted: CCI (OR 2.71, 95% CI 1.63–4.50; p<0.001), MLR (OR 1.69, 95% CI 1.05–2.72; p=0.030), and SII (OR 1.73, 95% CI 1.03–2.91; p=0.037). Surgical technique (A-PFN vs HA) was not independently associated with mortality.
Conclusions: In elderly patients with unstable intertrochanteric fractures, comorbidity burden (CCI) and inflammatory status (MLR, SII) independently predicted one-year mortality, whereas surgical method did not. Combined preoperative clinical-inflammatory assessment may improve risk stratification; external validation is warranted.

Keywords

• Intertrochanteric Femur Fracture
• One-Year Mortality
• Charlson Comorbidity Index
• Monocyte-To-Lymphocyte Ratio
• Systemic Immune-Inflammation Index
• Geriatric Hip Fracture

Supporting Institution

No funds, grants, or other support was received.

Ethical Statement

Ethical approval was obtained from the Clinical Research Ethics Committee of Sağlık Bilimleri University Kanuni Sultan Süleyman Training and Research Hospital (approval no: 112, date: August 9, 2023).

Thanks

The authors thank all individuals who contributed to the study but did not meet the authorship criteria.

References

1. 1. Baghdadi S, Kiyani M, Kalantar SH, Shiri S, Sohrabi O, Beheshti Fard S, et al. Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors. BMC Musculoskelet Disord. 2023;24(1):693.
2. 2. Canbeyli İ D, Çırpar M, Oktaş B, Çoban M. Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture. Acta Orthop Traumatol Turc. 2021;55(1):16-21.
3. 3. Kumar P, Rajnish RK, Sharma S, Dhillon MS. Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis. Int Orthop. 2020;44(4):623-33.
4. 4. Bingol O, Ozdemir G, Kulakoglu B, Keskin OH, Korkmaz I, Kilic E. Admission neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio to predict 30-day and 1-year mortality in geriatric hip fractures. Injury. 2020;51(11):2663-7.
5. 5. Moldovan F, Ivanescu AD, Fodor P, Moldovan L, Bataga T. Correlation between Inflammatory Systemic Biomarkers and Surgical Trauma in Elderly Patients with Hip Fractures. J Clin Med. 2023;12(15).
6. 6. Liu ZJ, Li GH, Wang JX, Mo ZH, Yang KY, Shen CL, et al. Prognostic value of the systemic immune-inflammation index in critically ill elderly patients with hip fracture: evidence from MIMIC (2008-2019). Front Med (Lausanne). 2024;11:1408371.
7. 7. Tekin SB, Bozgeyik B, Mert A. Relationship between admission neutrophil/lymphocyte, thrombocyte/lymphocyte, and monocyte/lymphocyte ratios and 1-year mortality in geriatric hip fractures: Triple comparison. Ulus Travma Acil Cerrahi Derg. 2022;28(11):1634-40.
8. 8. Dülgeroğlu TC, Kurt M, Üzümcigil AO, Yilmaz S, Karaaslan F. Multivariate analysis of blood parameters for predicting mortality in patients with hip fractures. Exp Ther Med. 2024;28(5):414.

9. 9. Cher EWL, Allen JC, Howe TS, Koh JSB. Comorbidity as the dominant predictor of mortality after hip fracture surgeries. Osteoporos Int. 2019;30(12):2477-83.
10. 10. Yoo J, Lee JS, Kim S, Kim BS, Choi H, Song DY, et al. Length of hospital stay after hip fracture surgery and 1-year mortality. Osteoporos Int. 2019;30(1):145-53.
11. 11. Çelen ZE, Gazi O. Distal fixation modular stem hemiarthroplasty versus proximal femoral nailing for unstable intertrochanteric fractures: a retrospective cohort study. Acta Orthop Belg. 2022;88(3):599-608.
12. 12. Ekinci Y, Gürbüz K, Batın S, Kahraman M, Doğar F, Kaya Erten Z. A multicenter intertrochanteric fracture study in the elderly: Hemiarthroplasty versus proximal femoral nailing. Jt Dis Relat Surg. 2020;31(2):209-17.
13. 13. Tu DP, Liu Z, Yu YK, Xu C, Shi XL. Internal Fixation versus Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fractures in the Elderly: A Systematic Review and Meta-Analysis. Orthop Surg. 2020;12(4):1053-64.
14. 14. Li X-p, Zhang P, Zhu S-w, Yang M-h, Wu X-b, Jiang X-y. All-cause mortality risk in aged femoral intertrochanteric fracture patients. Journal of Orthopaedic Surgery and Research. 2021;16.
15. 15. Chen Y, Tu C, Liu G, Peng W, Zhang J, Ge Y, et al. Association between admission inflammatory indicators and 3-year mortality risk in geriatric patients after hip fracture surgery: a retrospective cohort study. Front Surg. 2024;11:1440990.
16. 16. Chen YH, Chou CH, Su HH, Tsai YT, Chiang MH, Kuo YJ, et al. Correlation between neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture: a meta-analysis. J Orthop Surg Res. 2021;16(1):681.
17. 17. Wang Z, Wang H, Yang L, Jiang W, Chen X, Liu Y. High platelet-to-lymphocyte ratio predicts poor survival of elderly patients with hip fracture. Int Orthop. 2021;45(1):13-21.
18. 18. Wang ZC, Jiang W, Chen X, Yang L, Wang H, Liu YH. Systemic immune-inflammation index independently predicts poor survival of older adults with hip fracture: a prospective cohort study. BMC Geriatr. 2021;21(1):155.
19. 19. Oh ES, You Z, Nowak KL, Jovanovich AJ. Association of Monocyte Count and Monocyte/Lymphocyte Ratio with the Risk of Cardiovascular Outcomes in Patients with CKD. Kidney360. 2022;3(4):657-65.
20. 20. Patti G, Di Martino G, Ricci F, Renda G, Gallina S, Hamrefors V, et al. Platelet Indices and Risk of Death and Cardiovascular Events: Results from a Large Population-Based Cohort Study. Thromb Haemost. 2019;119(11):1773-84.
21. 21. Penn MS, MacRae C, Goldfaden RF, Choksi RR, Smith S, Wrenn D, et al. Association of chronic neutrophil activation with risk of mortality. PLoS One. 2023;18(7):e0288712.
22. 22. Maheshwari K, Planchard J, You J, Sakr WA, George J, Higuera-Rueda CA, et al. Early Surgery Confers 1-Year Mortality Benefit in Hip-Fracture Patients. J Orthop Trauma. 2018;32(3):105-10.
23. 23. Chu Z, Ng JPH, Chua THI, Ho SWL. Does early surgery within 48 hours improve clinical outcomes in elderly hip fractures? A matched cohort study of 1776 hip fractures. European Journal of Orthopaedic Surgery & Traumatology. 2025;35(1):201.
24. 24. Tan S, Jiang Y, Qin K, Luo Y, Liang D, Xie Y, et al. Systemic immune-inflammation index and 2-year all-cause mortality in elderly patients with hip fracture. Arch Gerontol Geriatr. 2025;129:105695.
25. 25. Zhou YF, Pu LF, Lin QC, Yuan KM, Li J. [Analysis of factors related to one-year mortality in elderly patients following hip fracture surgery]. Zhonghua Yi Xue Za Zhi. 2021;101(17):1269-74.