ORIGINAL ARTICLE. Keywords Femoral Fractures; Mortality; Retrospective Studies

Similar documents
Effect of age, sex, co morbidities, delay in surgery and complications on outcome in elderly with proximal femur fractures

Geriatric Hip Fractures: Pearls for the Hospitalist. Disclosures. Learning Objectives. Speakers Bureau-Synthes

The Journal of the Korean Society of Fractures Vol.16, No.1, January, 2003

Original Article Intertrochanteric hip fracture surgery in Chinese: risk factors for predicting mortality

EVALUATION OF THE KNOWLEDGE ON COST OF ORTHOPEDIC IMPLANTS AMONG ORTHOPEDIC SURGEONS

Preoperative Cardiac Evaluation of Patients With Acute Hip Fracture

The Lateral Trochanteric Wall A Key Element in the Reconstruction of Unstable Pertrochanteric Hip Fractures

Poor Prognosis in Elderly Patients Receiving Nonoperative Treatment for Hip Fracture: A Study of 224 Cases at Kofu National Hospital

Management of Hip Fractures

Comparison of two modality of fixation in unstable trochantric fractures in elderly patients

Outcome after surgery for fracture of the hip in patients aged over 95 years

Results of Conversion Total Hip Prosthesis Performed Following Painful Hemiarthroplasty

Treatment of Femoral Intertrochanteric Fracture with Proximal Femoral Nail

The choice of internal fixator for fractures around the femoral trochanter depends on area classification

ORIGINAL ARTICLE. INTER TROCHANTERIC # NECK FEMUR FIXATION WITH TFN 250 CASES. Prasad Vijaykumar Joshi, Chandrashekar Yadav.

The Risks of Hip Fracture in Older People from Private Homes and Institutions

Assessment of Prognosis of Patients with Intertrochanteric Fractures Undergoing Treatment with PFN: An Observational Study

The issue of whether early surgery to treat hip fracture is

Hip fracture constitutes a major cause of morbidity. Clinical Predictors of Prolonged Hospitalization in Patients with Hip Fracture.

Is anemia at admission related to short-term outcomes of elderly hip fracture patients?

Morbidity and Mortality in Jeju Residents over 50-Years of Age with Hip Fracture with Mean 6-Year Follow-Up: A Prospective Cohort Study

Outcome of Surgery for Unstable Intertrochanteric Fractures in Octogenarians

NON UNION OF TROCHANTERIC FRACTURES

Costs of internal fixation and arthroplasty for displaced femoral neck fractures: a randomized study of 68 patients.

EVALUATION OF THE MORTALITY RATE ONE YEAR AFTER HIP FRACTURE AND FACTORS RELATING TO DIMINISHED SURVIVAL AMONG ELDERLY PEOPLE

Alcohol Abusing Patients that experience Delirium Tremens during admission for hip fractures experience higher morbidity

A comparative study of 30 cases of trochanteric fracture femur treated with dynamic hip screw and proximal femoral nailing

Osteoporotic hip fractures Three-year followup mortality rate in Malta

Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur *

Bundled Payments in Orthopedic Trauma: How to Succeed

Outcome of Girdlestone s resection arthroplasty following complications of proximal femoral fractures

Hip Fractures. Anatomy. Causes. Symptoms

Title. Lau, TW; Fang, CX; Leung, FKL. Geriatric Orthopaedic Surgery and Rehabilitation, 2013, v. 4 n. 1, p Citation.

Effects of Older Age and Multiple Comorbidities on Functional Outcome After Partial Hip Replacement Surgery for Hip Fractures

Sanjit R. Konda, MD; Hesham Saleh, BS; Jordan Gales, BS; Loveita Raymond, MD; Kenneth A. Egol, MD

Malaysian Orthopaedic Journal 2011 Vol 5 No 1 doi: /MOJ

CIRCUMFERENTIAL PROXIMAL FEMORAL ALLOGRAFTS IN REVISION SURGERY ON TOTAL HIP ARTHROPLASTY: CASE REPORTS WITH A MINIMUM FOLLOW-UP OF 20 YEARS

AOTrauma Course Fragility Fractures and Orthogeriatrics

EUROHOPE: Hip fracture in Europe are slippery regions different?

PRIMARY BIPOLAR ARTHROPLASTY IN TREATMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES IN ELDERLY PATIENTS

The Result of the treatment in osteoporotic ankle fractures with small fragment using claw plate in elderly

Predictors of hip fracture mortality at a general hospital in South Brazil: an unacceptable surgical delay

ISSUES FROM AN ORTHOPEDIC PERSPECTIVE

Cover Page. The handle holds various files of this Leiden University dissertation.

PROSPECTIVE AND RANDOMIZED STUDY OF PATIENTS WITH OPEN FRACTURES OF THE FEMORAL SHAFT, TREATED WITH PLATE OR OPEN INTRAMEDULLARY LOCKED NAIL

AO Debate Controversies in Management

Outcomes of Cephalomedullary Nailing in Basicervical Fracture

Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore

Clinical outcomes and hospital length of stay in 2,756 elderly patients with hip fractures: a comparison of surgical and non-surgical management

Original Article Effects of Hardinge versus Moore approach on postoperative outcomes in elderly patients with hip fracture

Predicting Short Term Morbidity following Revision Hip and Knee Arthroplasty

)1( COPYRIGHT 2014 BY THE ARCHIVES OF BONE AND JOINT SURGERY. Prediction of Mortality in Hip Fracture Patients: Role of Routine Blood Tests

Review of Proximal Nail Antirotation (PFNA) and PFNA-2 Our Local Experience

Functional Recovery Following Pertrochanteric Hip Fractures Fixated with the Dynamic Hip Screw vs. the Percutaneous Compression Plate

Risk factors affecting inhospital mortality after hip fracture: retrospective analysis using the Japanese Diagnosis Procedure Combination Database

National Registration of Hip Fractures in Sweden

The Experience in Exeter with. hip fracture care. Data For Change

Use Of A Long Femoral Stem In The Treatment Of Proximal Femoral Fractures: A Report Of Four Cases

Treatment of Periprosthetic Femoral Fractures Following Hip Arthroplasty

AOTrauma Course Fragility Fractures and Orthogeriatrics

Fractures of the tibia shaft treated with locked intramedullary nail Retrospective clinical and radiographic assesment

J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 4/ Issue 22/ Mar 16, 2015 Page 3785

Case Report Bilateral Distal Femoral Nailing in a Rare Symmetrical Periprosthetic Knee Fracture

Journal of American Science 2014;10(10)

Misdiagnosis of occult hip fracture is more likely in patients with poor mobility and cognitive impairment

HOW TO CITE THIS ARTICLE:

PFN in trochanteric fractures: Clinico radiological outcome study

Development and Initial Validation of a Risk Score for Predicting In-Hospital and 1-Year Mortality in Patients With Hip Fractures

Clinical Results of Internal Fixation of Subcapital Femoral Neck Fractures

Anaemia impedes functional mobility after hip fracture surgery

The Long-term Prognosis of Delirium

Outcome of Cloverleaf Locking Plate Fixation for Femoral Neck Fractures in Young Adults

DAFTAR PUSTAKA. Anwar R, Tuson K dan Khan S. Intertrochanteric Fracture. Classification ST dan

More than half of hip fracture patients do not regain mobility in the first postoperative yearggi_

MRIMS Journal of Health Sciences 2016;4(1) pissn: , eissn:

Optimizing Patient Outcomes Following Orthopedic Surgery: The Role of Albumin and the Case For Fast- Track

1 Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, UK.

Medical Care of the Hip Fracture Patient

Similar mortality rates in hip fracture patients over the past 31 years

Effect of surgical approach on the early outcome of total hip replacement for femoral neck fractures

Femoral Fractures in Adolescents: A Comparison of Four Methods of Fixation

Page Proof 1 of 5. Fig. E1-A The INTERTAN nail was short or long.

HEMIARTHROPLASTY IN THE TREATMENT FRACTURES OF THE FEMORAL NECK

Primary total hip arthroplasty after acetabular fracture using intra-acetabular bended plates

Comparison between Conventional and Minimally Invasive Dynamic Hip Screws for Fixation of Intertrochanteric Fractures of the Femur

Perso An. Geri-O. Objectives: fragility fracture. AL SUPPORT. presentation.

TREATMENT OF SUBTROCHANTERIC FEMUR FRACTURES WITH PROXIMAL FEMORAL NAILS: A PROSPECTIVE STUDY

Dynamization Versus Static Antegrade Intramedullary Interlocking Nail In Femoral Shaft Fractures

Technique Guide. DHS Blade. For osteoporotic bone.

ISSN X (Print) Original Research Article. Hospital, Begrajpur, Muzaffarnagar, UP, India

Yoshihisa Fujita 1*, Kumi Shimada 1, Tomohiko Sato 1, Masahiko Akatsu 1, Koichi Nishikawa 2, Atsuko Kanno 3 and Toshitake Aizawa 3

My hip fracture care: 12 questions to ask A guide for patients, their families and carers

Peritroch Hip Fractures. Robert M Harris MD. Hip Fractures. Factors Influencing Construct Strength: Uncontrolled factors 4/28/2016

Increased mortality after fracture of the surgical neck of the humerus: a case-control study of 253 patients with a 12-year follow-up.

Saman Arbabi M.D., M.P.H., F.A.C.S. Kathleen O'Connell M.D. Bryce Robinson M.D., M.S., F.A.C.S., F.C.C.M

DISCLOSURE FNFX ORIF OR ARTHROPLASTY? 11/21/2016 FEMORAL NECK FRACTURES: ORIF OR ARTHROPLASTY? ROYALTIES DEPUY, BIOMET

Results of tibia nailing with Angular Stable Locking Screws (ASLS); A retrospective study of 107 patients with distal tibia fracture.

Femoral Neck Fractures- Gold standards and breaking news. Anna Ekman, MD, PhD Stockholm South hospital Sweden

Intertrochanteric Femur Fractures. Alan Afsari, MD March 2014

Transcription:

ORIGINAL ARTICLE CORRELATION BETWEEN TIME UNTIL SURGICAL TREATMENT AND MORTALITY AMONG ELDERLY PATIENTS WITH FRACTURES AT THE PROXIMAL END OF THE FEMUR Gustavo Gonçalves Arliani 1, Diego da Costa Astur 2, Glauber Kazuo Linhares 3, Daniel Balbachevsky 4, Hélio Jorge Alvachian Fernandes 5, Fernando Baldy dos Reis 6 ABSTRACT Objective: The primary aim of this study was to analyze the possible association between delay in receiving surgical treatment and mortality among elderly patients with fractures at the proximal end of the femur. Methods: 269 patients with fractures at the proximal end of the femur (femur neck and intertrochanteric fractures) who were treated surgically at Hospital São Paulo, UNIFESP, São Paulo, between January 2003 and December 2007, were studied. The following attributes were analyzed and compared with the literature relating to this subject: sex, age, type of fracture, classification of the fracture, affected side, synthesis used, trauma mechanism, length of hospitalization, waiting time for surgery, associated comorbidities, hemogram on admission, type of anesthesia, need for blood transfusion, day of the week and season of the year of the fracture. Results: The study showed that higher mortality correlated with higher numbers of clinical comorbidities, longer hospitalization and use of general anesthesia during the surgery. Conclusion: There was no association between the time spent waiting for surgery and mortality. Keywords Femoral Fractures; Mortality; Retrospective Studies INTRODUCTION The incidence of fractures at the proximal end of the femur has increased significantly in recent decades. It is believed that this increase is closely related to the increasing geriatric population in our society, since this disease occurs predominantly in elderly patients and its incidence progressively increases with advanced age (1-6). In the United States, between 1999 and 2002, the cost of treating these patients reached three billion dollars a year. It is estimated that the number of hip fractures will increase by 310% in men and 240% in women by the year 2025 (7). The trauma is generally low-energy and is related to the factors responsible for the increase in its incidence, such as osteoporosis, malnutrition, impaired activities of daily living, decreased visual acuity and reflexes, and weakened muscles (1,8-12). This type of fracture is responsible for mortality and 1 Junior Resident of the Sports Traumatology Center (CETE) Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. 2 Junior Resident of the Sports Traumatology Center (CETE) Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. 3 Resident Doctor of the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. 4 Assistant Doctor and Master of the Discipline of Traumatology of the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. 5 Affiliate Professor and Head of the Trauma Sector of the Traumatology Discipline of the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. 6 Livre-Docente Professor of the Traumatology Discipline of the Department of Orthopedics and Traumatology, Universidade Federal de São Paulo/EPM. Work carried out at the Department of Orthopedics and Traumatology of the Universidade Federal de São Paulo, SP Brazil (DOT-Unifesp/EPM). Correspondence: Rua Borges Lagoa, 783 5 o andar Vila Clementino 04038-032 São Paulo, SP. E-mail: ggarliani@hotmail.com Work received for publication: April 19, 2010; accepted for publication: October 5, 2010. The authors declare that they did not have any conflict of interests in producing this article

190 functional loss, mainly due to the fact that it affects patients with significant comorbidities and at high risk of postoperative complications. In general, 30% of elderly patients end up dying one year after the occurrence of the injury (1,13-15), making this disease the leading cause of death from trauma in people over 75 years of age (2). As in several developed countries, like the USA and the UK, the social and economic costs of this type of femur fracture are increasing every year in Brazil too (14). The causes of the high mortality in elderly patients with fracture at the proximal end of the femur have been thoroughly investigated in developed countries. However, little is known about this subject in developing countries (7). There is a great controversy in the literature as to whether there is an association between waiting time for surgery after the occurrence of fracture at the proximal end of the femur among the elderly and mortality (16-18). The primary objective of this study is to analyze the possible association between delayed surgical treatment and mortality in elderly patients with fracture at the proximal end of the femur. The secondary objective is to assess the correlation between the number of clinical comorbidities, hospitalization time, and the type of anesthesia used in surgeries where mortality was the outcome. Material and Methods The research project was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (Unifesp/Hospital São Paulo). This is a study with a retrospective cohort design which evaluated 314 patients with fractures at the proximal end of the femur who underwent surgery at the Hospital São Paulo (Department of Orthopedics and Traumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina) from January 2003 to December 2007. The minimum and maximum follow-up periods were six months and five years, respectively. Of this total of patients, the present study included 269 patients. The criteria for exclusion was patients aged 60 years or under. Therefore, all the patients were considered elderly (aged above 60 years), according to the Brazilian Senior Citizen Statute, in order to make the study population more homogeneous. Through descriptive analysis of medical records, data from the surgical department of Hospital São Paulo and previous protocol, we collected data on gender, age, type of fracture, fracture classification, affected side, type of surgical procedure, trauma mechanism, length of hospitalization, waiting time for surgery, hemogram on admission, type of anesthesia used in the surgery, need for blood transfusion during hospitalization, day of the week and season when the study participants suffered the fracture. Seeking to reduce potential biases in this study due to the retrospective nature of the assessments, we sought to perform this analysis by comparing all the means of information available (medical records, data from the surgical department, protocol from the orthopedics department, and contact with patients or their family members). Telephone contacts and outpatient care were used for follow-up and to verify patient deaths and comorbidities. Regarding clinical comorbidity, we opted to divide the diseases into groups such as cardiovascular, pulmonary, metabolic, musculoskeletal, central nervous system, gastrointestinal, genitourinary and neoplasms. From this division, the total number of comorbidities for each patient was counted individually. Femoral neck fractures and intertrochanteric fractures were counted as fractures at the proximal end of the femur. The Garden classification was adopted for femoral neck fractures, and the Tronzo classification for intertrochanteric fractures. The trauma mechanisms that led to the injury were divided into the following categories: falls, being run over, sports, car accidents, seizures and aggression. For statistical purposes, we considered two categories: falls and others (including all other mechanisms of injury except falls). A descriptive analysis of the variables involved in the study was initially performed, to characterize the sample. In order to assess the association of the variable mortality with other variables, we used the Chi-square test and Fisher s exact test. A level of significance of 5% was adopted throughout the analysis.

CORRELATION BETWEEN TIME UNTIL SURGICAL TREATMENT AND MORTALITY AMONG ELDERLY PATIENTS WITH FRACTURES AT THE PROXIMAL END OF THE FEMUR 191 Data were analyzed using the application SPSS for Windows version 16.0. To establish the cut-off number of comorbidities and length of hospitalization in days that would best indicate the relationship with the patient s death, we used the ROC curve. RESULTS The patients ages ranged from 61 to 100 years. The average age was 79.9 (± 8.7) years. There was a slight prevalence of femoral neck fractures (50.1%) over intertrochanteric fractures (49.9%) (Table 1). The patients diagnosed with femoral neck fracture were predominantly aged 70 to 89 years, while those diagnosed with intertrochanteric fracture were 80 years or older. A prevalence of these fractures was observed in female patients (74.7%). The ratio between the genders for this type of fracture was 2.95 women to one man (Table 1). Table 1 - Sample description (quantitative variables). Variable Frequency (%) Mortality Non-fatal 38.7 Fatal 32.7 Not found 28.6 Gender Male 25.3 Female 74.7 Day of the week when the fracture occurred Sunday 14.9 Monday 10 Tuesday 11.5 Wednesday 16 Thursday 14.1 Friday 14.5 Saturday 19 Fracture Femoral neck 50.2 Intertrochanter 49.9 The distribution of femoral neck fractures according to the Garden classification was: type I (12.5%), type II (8.82%), type III (29.41%) and type IV (49.26%). Intertrochanteric fractures, according to Tronzo classification, were: type I (9.77%), type II (24.06%), type III (45.11%), type IV (12.03%) and type V (9.02%). In our study, we observed a prevalence of unstable fractures, considering these as the ones classified as III and IV (78.67%) under the Garden classification and III, IV and V (66.16%) under the Tronzo classification. The involvement of the left and right sides was similar (51.7% and 48.3%, respectively). The predominant cause of fractures was falls (94.4%). All patients underwent surgery, with 16.4% being submitted to total hip arthroplasty, 22.7% to partial hip arthroplasty, 6.7% to percutaneous pinning, 19.7% to intramedullary nail with cephalomedullary interlocked nail and 34.2% with plate and dynamic screw. The length of hospitalization ranged from one to 101 days, with an average of 10.7 days. 53.2% of patients in this study stayed in hospital for a period of more than seven days (Table 2). Table 2 - Sample description (quantitative variables). Variable Frequency (%) Affected side Right 48.4 Left 51.7 Osteosynthesis PHA 22.7 THA 16.4 DHS 34.2 PFN 19.7 Pinning 6.7 Season Spring 23.4 Summer 22.7 Fall 24.9 Winter 29 Received blood during hospitalization Yes 42.8 No 57.2 Type of anesthesia General 23.8 Epidural 76.2 Length of hospitalization 1 to 7 days 46.8 More than 7 days 53.2 Comorbidity None 7.8 From 1 to 4 81.4 More than 4 10.8

192 In terms of the relationship between the length of hospitalization and mortality, a significant difference was observed. The patients who were hospitalized for more than seven days had a higher mortality rate, compared to patients hospitalized for less than seven days (p < 0.001) (Table 3). Table 3 - Correlations between variables and mortality. Non-fatal N(%) Fatal N(%) Gender Female 75 (72.1) 67 (76.1) Male 29 (27.9) 21 (23.9) Waiting time for surgery Less than 1 day 8 (7.7) 13 (14.8) From 1 to 2 days 22 (21.2) 11 (12.5) More than 2 days 74 (71.2) 64 (72.7) Type of anesthesia General 20 (19.2) 33 (37.5) Epidural 84 (80.8) 55 (62.5) Length of hospitalization 1 to 7 days 64 (61.5) 25 (28.4) More than 7 days 40 (38.5) 63 (71.6) Comorbidity From 0 to 4 101 (97.1) 72 (81.8) More than 4 3 (2.9) 16 (18.1) p 0.62 0.11 0.006* < 0.001* < 0.001* Regarding the number of comorbidities, most patients (81.4%) presented between one and four clinical comorbidities. A significant difference was observed between the number of comorbidities and mortality. The patients who died had a higher number of comorbidities (p = 0.002) (Table 3). The patients, hemoglobin and hematocrit levels on admission were, on average, 11.6 (± 1.8) mg/dl and 35.3 (± 8.4)%, respectively. The presence of anemia (Hb < 11) on admission was associated in some studies with increased mortality (20,21). Regarding the need for blood transfusion, 57.2% of the patients did not receive any blood during hospitalization. However, 61.3% of the patients that received red blood cell concentrates during hospitalization died during the follow-up period. There was a slight prevalence of fractures during winter, with 29.0% occurring in this season, 24.9% occurring in fall, 22.7% in summer and 23.4% in spring (Table 2). Regarding the day of the week in which the fracture occurred, we observed a slight prevalence of fractures occurring on Saturday (19.0%), followed by Wednesday (16.0%) and Sunday (14.9%) (Table 1). The type of anesthesia most frequently used in the surgeries was epidural anesthesia (76.2%). A positive association was observed between the use of general anesthesia with an increase in mortality in these patients (p = 0.006) (Table 2). In relation to mortality, 32.7% of the patients in the sample died during the follow-up period. No statistical correlation was observed between gender and mortality (p > 0.05). The waiting time for surgery was, on average, 5.8 days. Some patients underwent surgery on the day of admission, while the longest waiting time for surgery procedure was 60 days. In this sample, 13.01% of the patients underwent surgery within 24 hours of the occurrence of the fracture, 17.1% between 24 and 48 hours, and 69.89% more than 48 hours after the occurrence of the injury. No association was observed in this study between waiting time for surgery and mortality (p > 0.05) (Table 3). DISCUSSION The prevalence of patients aged 80 to 100 years, with fractures at the proximal end of the femur, was consistent with the literature (21,22). These fractures are caused by low-energy traumas, particularly in osteoporotic bones. Global life expectancy, particularly in Brazil, is increasing, and an increase in incidence of these fractures is also expected (7). In our study, there was a higher incidence of fractures in female patients, with a female to male ratio of 2.95:1. These data are consistent with several other studies that showed a prevalence of female patients ranging from between two and eight women to each man (7,10,21). The involvement of the left and right sides was similar. An alternation of prevalence between right and left sides is seen in the literature, but it is always very close to 50% for each side (7,23). Some authors have found a correlation between season and higher incidence of this type of fracture. However, in most cases, this relationship was observed in regions of cold weather, because, during summer, the

CORRELATION BETWEEN TIME UNTIL SURGICAL TREATMENT AND MORTALITY AMONG ELDERLY PATIENTS WITH FRACTURES AT THE PROXIMAL END OF THE FEMUR 193 elderly population exercises more and consequently, is more exposed to the possibility of fractures (2,23,24). In our study, a slight prevalence of fractures in the winter was observed. As for the day of the week, a prevalence of fractures on weekends was observed. Another study reported no association between the day of the week and the higher incidence of these fractures (23). The length of hospitalization ranged from one to 101 days, with an average of 10.7 days. This average was lower than the majority of services evaluated in different studies (7). This shows the importance given in our department to prompt rehabilitation and discharge of this type of patient, who is so susceptible to complications caused by long periods spend in the hospital bed after surgery. The analysis to correlate length of hospitalization with mortality showed that patients with a length of hospitalization of more than seven days had higher mortality. Therefore, we believe that the length of hospitalization should be reduced to improve the results. Undergoing surgery as soon as possible after the injury proved to reduce the length of hospitalization in these patients, with a possible reduction in mortality (25). The number of comorbidities ranged from zero to seven, with most of the patients presenting between one and four clinical comorbidities, which was consistent with the literature (1,24). We observed that the higher the number of comorbidities in the patient with fracture, the higher the chances of an outcome of death. Like the present study, previous studies have shown that patients with comorbidities are at increased risk of morbimortality after surgery (15,21,26). Therefore, particular attention must be paid, in the preoperative, intraoperative and postoperative care of patients with clinical comorbidities. One study showed that delayed surgery was due, in 80% of cases, to the need for clinical optimization of the patient (27). In this study, a positive association was observed between the use of general anesthesia and increased mortality. This correlation was not observed in another study, in which the type of anesthesia had no effect on increasing the mortality rate in patients undergoing surgery of fractures at the proximal end of the femur (28). No association was observed in this study between waiting time for surgery and mortality. In the literature, there are few studies that defend delaying the intervention in these fractures, concluding that early surgery increases patient mortality (24,29). However, the vast majority of articles found no association between waiting time for surgery and mortality (15,21,26,30,31). Delayed surgery, according to some articles, increases the likelihood of these patients developing pressure ulcers, pneumonia and urinary tract infections (21,27). A systematic review was performed in 2009, analyzing 52 articles involving 291,413 patients. No randomized clinical trials were found in these articles, since this type of trial often encounters ethical issues. Patient randomization would result in some patients being submitted to prolonged periods of pain and discomfort, and greater exposure to possible complications such as decubitus ulcers and pneumonia. This review concluded that there is no association between waiting time for surgery and mortality, but that a delay in performing surgery increases patient morbidity and length of hospitalization. The articles reviewed therefore recommend that surgery be performed as soon as possible if the patient has medical conditions (25). CONCLUSIONS Most patients in this study were aged between 80 and 100 years. The most common cause of fractures was falls (94.4%), predominantly in females (74.7%), and there was no significant difference in relation to the affected side. A correlation was observed between a higher number of clinical comorbidities, longer length of hospitalization, the use of general anesthesia in surgery, and increased mortality. However, no association was found in this study between waiting time for surgery and mortality. References 1. Vilas Boas Junior A, Vercesi AE, Bodachne L, Vialle LR. Estudo epidemiológico de fraturas de fêmur proximal em idosos. Acta Ortop Bras. 1996;4(3):122-6. 2. Rodriguez J, Herrara A, Canales V, Serrano S. Epidemiologic factors, morbidity and mortality after femoral neck fractures in the elderly. A comparative study: internal fixation vs. hemiarthroplasty. Acta Orthop Belg. 1987;53(4):472-9. 3. Zain Elabdien BS, Olerud S, Karlstrom G, Smedby B. Rising incidence of hip fracture in Uppsala, 1965-1980. Acta Orthop Scand. 1984;55(3):284-9. 4. Honton JL, Pascarel H, Dupuy L, Pontailler JR, Colombet P, Nehme B. Etude

194 epidemiologique dês fractures transcervicales. Rev Chir Orthop Reparatrice Appar Mot. 1986;72(1):6-13. 5. Johnell O, Nilsson B, Obrant K, Sernbo I. Age and sex patterns of hip fracturechanges in 30 years. Acta Orthop Scand. 1984;55(3):290-2. 6. Swanson AJ, Murdoch G. Fractured neck of femur. Pattern of incidence and implications. Acta Orthop Scand. 1983;54(3):348-55. 7. Pereira SR, Puts MT, Portela MC, Sayeg MA. The impact of prefracture and hip fracture characteristics on mortality in older persons in Brazil. Clin Orthop Relat Res. 1993;468(7):1869-83. 8. Broos PL, Van Haaften KI, Stappaerts KH, Gruwez JA. Hip fractures in the elderly. Mortality, functional results and social readaptation. Int Surg. 1989;74(3):191-4. 9. Greenspan SL, Myers ER, Maitland LA, Resnick NM, Hayes WC. Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA. 1994;271(2):128-33. 10. Hinton RY, Smith GS. The association of age, race, and sex with the location of proximal femoral fractures in the elderly. J Bone Joint Surg Am. 1993;75(5):752-9. 11. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrocantheric hip fractures. A retrospective and prospective study. J Bone Joint Surg Am. 1979;61(2):216-21. 12. Kyle RF, Cabanela ME, Russell TA, Swiontkowski MF, Winquist RA, Zuckerman JD, et al. Fractures of the proximal part of the femur. Instr Course Lect. 1995;44:227-53. 13. Sakaki MH, Oliveira AR, Coleho FF, Garcez-Leme LE, Suzuki I, Amatuzzi MM. Estudo da mortalidade na fratura do fêmur proximal em idosos. Acta Ortop Bras. 2004;12(4):242-9. 14. Beals RK. Survival following hip fracture. Long follow-up of 607 patients. J Chronic Dis. 1972;25(4):235-44. 15. Verbeek DO, Ponsen KJ, Goslings JC, Heetveld MJ. Effect of surgical delay on outcome in hip fracture patients: a retrospective multivariate analysis of 192 patients. Int Orthop. 2008;32(1):13-8. 16. Casaletto JA, Gatt R. Post-operative mortality related to waiting time for hip fracture surgery. Injury. 2004;35(2):114-20. 17. Clague JE, Craddock E, Andrew G, Horan MA, Pendleton N. Predictors of outcome following hip fracture. Admission time predicts length of stay and inhospital mortality. Injury. 2002;33(1):1-6. 18. Dorotka R, Schoechtner H, Buchinger W. The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life. Operation within six hours of the fracture versus later than six hours. J Bone Joint Surg Br. 2003;85(8):1107-13. 19. Ho CA, Li CY, Hsieh KS, Chen HF. Factors determining the 1-year survival after operated hip fracture: a hospital-based analysis. J Orthop Sci. 2010;15(1):30-7. 20. Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma. 2002;16(1):39-44. 21. Smektala R, Endres HG, Dasch B, Maier C, Trampisch HJ, Bonnaire F, et al. The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures. BMC Musculoskelet Disord. 2008;9:171. 22. Rocha M, Carvalho W, Zanqueta C, Lemos S. Estudo Epidemiológico retrospectivo das fraturas do fêmur proximal tratados no Hospital Escola da Faculdade de Medicina do Triangulo Mineiro. Rev Bras Ortop. 2001;36(8):311-6. 23. Holmberg S, Thorngren KG. Statistical analysis of femoral neck fractures based on 3053 cases. Clin Orthop Relat Res. 1987;(218):32-41. 24. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res. 1984;(186):45-56. 25. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-7. 26. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889-91. 27. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of timeto-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112(9):702-9. 28. Dzupa V, Bartonicek J, Skala-Rosenbaum J, Prikazsky V. [Mortality in patients with proximal femoral fractures during the first year after the injury]. Acta Chir Orthop Traumatol Cech. 2002;69(1):39-44. 29. Mullen JO, Mullen NL. Hip fracture mortality. A prospective, multifactorial study to predict and minimize death risk. Clin Orthop Relat Res. 1992;(280):214-22. 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(6):552-9. 31. Williams A, Jester R. Delayed surgical fixation of fractured hips in older people: impact on mortality. J Adv Nurs. 2005;52(1):63-9.