title: Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort.
abstract: Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline.
  
  
  
  Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs.
  
  
  
  This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs.
  
  
  
  Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014).
  
  
  
  Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss.
  
  
  
  Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs.
  
  
  
  III, prospective case-control study.
authors.affiliation: Hôpital Pierre-Paul-Riquet, CHU de Toulouse, rue Jean-Dausset, 31000 Toulouse, France.
authors.forename: N
authors.initials: N
authors.lastname: Reina
authors.affiliation: Hôpital Pierre-Paul-Riquet, CHU de Toulouse, rue Jean-Dausset, 31000 Toulouse, France.
authors.forename: P
authors.initials: P
authors.lastname: Bonnevialle
authors.affiliation: Hôpital Sud, CHU de Grenoble, avenue de Kimberley, 38130 Échirolles, France.
authors.forename: B
authors.initials: B
authors.lastname: Rubens Duval
authors.affiliation: CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France.
authors.forename: P
authors.initials: P
authors.lastname: Adam
authors.affiliation: Centre hospitalier intercommunal de Toulon, 54, avenue Henri-Sainte-Claire-Deville, La Seyne-sur-Mer, 83100 Toulon, France.
authors.forename: F
authors.initials: F
authors.lastname: Loubignac
authors.affiliation: Clinique Toutes Aures, 393, avenue des Savels, 04100 Manosque, France.
authors.forename: T
authors.initials: T
authors.lastname: Favier
authors.affiliation: Hôpitaux universitaires Paris Nord Val-de-Seine, 100, boulevard du Général-Leclerc, 92110 Clichy, France; EA 7334 REMES (Recherche Clinique Coordonnée Ville-Hôpital, Méthodologie et Société) Université Paris-Diderot, Sorbonne Paris Cité, 75010 Paris, France. Electronic address: phmassin@gmail.com.
authors.forename: P
authors.initials: P
authors.lastname: Massin
authors.affiliation: SOFCOT, 56, rue Boissonade, 75014 Paris, France.
mesh_terms: D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000401:mortality*; D016063:Blood Loss, Surgical; D016022:Case-Control Studies; D005260:Female; D005265:Femoral Neck Fractures / Q000097:blood / Q000601:surgery*; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000401:mortality*; D015577:Geriatric Assessment; D006400:Hematocrit; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011446:Prospective Studies; D012307:Risk Factors; D012737:Sex Factors; D013530:Surgical Wound Infection / Q000209:etiology
keywords: Aging; Autonomy; Femoral neck fracture; Nutritional status