Surgical Science, 2011, 2, 463-467
doi:10.4236/ss.2011.210102 Published Online December 2011 (
Copyright © 2011 SciRes. SS
Predictors for Adverse Outcome in Patients Aged 80 Years
and Older Undergoing Emergent Hip Surgery
Eli Peled1, Michal Barak2, Yaniv Keren3, Michael Soudry3, Doron Norman1
1Departments of Orthopedic Surgery B, Rambam Health Care Campus and the Bruce Rappaport Faculty
of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
2Departments of Anesthesia, Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine,
Technion-Israel Institute of Technology, Haifa, Israel
3Departments of Orthopedic Surgery A, Rambam Health Care Campus and the Bruce Rappaport Faculty
of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
Received June 10, 2011; revised September 14, 2011; accepted October 14, 2011
Background: Increased life expectancy results in aging of the population. One of the leading medical pro-
blems of elderly patients is hip fracture. We studied demographic, surgical and anesthetic parameters of eld-
erly patients who underwent surgery due to osteoporotic hip fracture, to find predictors for peri-operative
morbidity and mortality. Methods: This is a retrospective review of prospectively collected data of patients
aged 80 years and older who underwent emergent surgery due to osteoporotic femoral neck, subcapital or
pertrochanteric fractures. Data was collected on age, gender, co-morbidities, American Society of Anesthesi-
ologists Class, number of regular medications, whether the patient was bedridden or not before the surgery,
hemoglobin on admission and on discharge, type of surgery and anesthesia, duration of surgery, duration of
hospitalization, post-operative morbidity and mortality. The demographic and peri-operative parameters were
analyzed and matched to the post-operative complications and mortality to find predictors for adverse out-
come. Results: One hundred and nine patients were included in the study, of whom 22 (20%) had post-ope-
rative complications and 10 (9.1%) died. We found an increased complication rate in patients who had chr-
onic obstructive pulmonary disease and in patients who underwent general anesthesia. Patients who were
bedridden before the surgery had increased mortality rates. No significant correlation was found between
outcome and any other factors. Conclusion: Our results suggest favoring regional anesthesia in elderly pa-
tients undergoing emergent femoral neck surgery and acknowledging a higher risk in chronic pulmonary
disease or bedridden patients.
Keywords: Femoral Fracture, Surgery, Orthopedics, Anesthesia, Spinal, Complications, Postoperative
1. Introduction
Osteoporotic hip fracture is a major health problem world-
wide [1]. Its incidence has been rising steadily, mainly
due to increased life expectancy [1,2], and this trend is
expected to continue in the future. There were 1.6 mil-
lion osteoporotic hip fractures throughout the world in
2000 [1] and it has been estimated that the number of hip
fractures in 2025 will be 2.6 million and in 2050 will be
4.5 million [3]. The age of the patients has been increas-
ing as well. Although age is recognized as a significant
risk factor for complications and mortality [4,5], there is
no recommendation to avoid surgery at any age [6,7]. In
this study we focused on the elderly population, patients
aged 80 years or more, in order to isolate age from other
risk factors. We believe that patients in this age group
constitute a distinct entity, with typical physiology and
unique medical characteristics and needs. We prospec-
tively followed their management during surgery and
hospital stay to find predictors for adverse outcome, in
the hope that this could lead to better management of
these patients in the future, although it is still uncertain
whether or not their outcome is modifiable [8].
2. Patients and Methods
With the approval of the local Ethics Committee, we
conducted this study, a retrospective review of prospec-
tively collected data of patients 80 years old or older who
underwent emergent orthopedic surgery for osteoporotic
femoral neck fracture in our institution. The surgery took
place within less than 48 hours from admission to the
emergency room. All the patients were assessed pre-
operatively by an anesthesiologist who determined their
American Society of Anesthesiologists (ASA) class and
planned the type of anesthesia and the level of operative
and post-operative monitoring. The anesthesia of choice
was regional, specifically spinal. Only patients who had
a contraindication for regional anesthesia, such as abnor-
mal coagulation blood tests, had general anesthesia.
In the operating room, the patients were monitored and
treated according to their general condition and the se-
quence of the surgery. The senior orthopedic surgeon de-
cided, according to the fracture type, whether to do a par-
tial hip replacement (PHR) or reduction and internal fix-
ation. Displaced sub-capital fractures, Garden III & IV,
were replaced, while nondisplaced sub-capital fractures,
Garden I & II, were stabilized by three 7.3 mm cannu-
lated screws (CS). Femoral and intertrochanteric frac-
tures were reduced by closed or open means and were
stabilized by dynamic hip screw (DHS) or proximal fe-
moral nail (PFN). All the patients were admitted to the
post-anesthesia care unit following surgery, where they
stayed for two hours or more, depending on their general
condition. In cases of hemodynamic instability, respire-
tory problem, or intra-operative complication, the patient
was transferred to the intensive care unit. Patients who
underwent uneventful surgery were transferred 7 - 9 days
later to another institution for rehabilitation. Follow-up
continued during their hospitalization time.
Collected data included age, gender, co-morbidities:
hypertension, ischemic heart disease, diabetes mellitus,
chronic obstructive pulmonary disease (COPD), other
co-morbidity, number of medications that the patient
used regularly before admission to hospital, whether or
not the patient was bedridden before the surgery, ASA
class, hemoglobin on admission and on discharge and the
disparity between them, type of surgery (PHR, DHS, CS
PFN), duration of surgery, type of anesthesia, duration of
hospitalization, 30 day post-operative morbidity, and
mortality within six months of surgery. Morbidity was
defined as a new disease or illness (new diagnosis) that
occurred in the peri-operative peiod, meaning within a
month from surgery. We analyzed the data and studied
correlations between each and every pre- and intra-ope-
rative parameter to post-operative morbidity and morta-
lity, in order to find predictors for adverse outcome.
3. Statistical Analysis
Data was analyzed with a commercial statistical software
(Statistica 6.0, StatSoft, Tulsa OK). Frequencies were
compared using Pearson’s chi square test. Continuous
variables were compared using analysis of variance.
Whenever the homogeneity of variance was violated
(significant Levene’s test), the Mann-Whitney test was
applied instead. Pre-post comparisons used the t-test for
dependent variables. Significance level was set at p <
4. Results
One hundred and nine patients were included in the study,
32 (29%) male and 77 (71%) female. Age ranged be-
tween 80 to 98 years (median 85); there was no signifi-
cant age difference between genders. Patients’ co-morbi-
dities are summarized in Table 1.
The type of surgery was PHR in 29 (26.6%) patients
and CS or DHS or PFN in 80 (73.3%) patients. In Table
2 we compared patients who underwent PHR to those
who had CS or DHS or PFN. Spinal anesthesia was used
in 95 (87.2%) patients and general anesthesia in 14
(12.8%) patients.
The contraindication for regional anesthesia in all the
patients who underwent general anesthesia was the use
of anticoagulants or anti-platelet aggregation drugs, other
than acetylsalicylic acid.
Mean length of hospital stay was 7.6 days (SD 3.5
Twenty-two (20%) patients had post-operative com-
plications and 10 (9.1%) patients died. Post-operative
complications are summarized in Table 3.
Predictors for adverse outcome: patients with COPD
had significantly higher rates of post-operative complica-
tions than other patients (p = 0.001). The complication
rate was significantly higher in patients who had general
anesthesia (35%) compared to those who had spinal an-
Table 1. Patient co-morbidities and pre-operative data.
Number of Patients (%)
Hypertension 87 (81%)
Ischemic heart disease 44 (41%)
Diabetes mellitus 26 (24%)
Chronic obstructive pulmonary disease 7 (6.5%)
Other co-morbidities 83 (77.5%)
Patient bedridden 14 (13%)
American Society of Anesthesiology
(ASA) class, Mean (±SD) 2.8 (± 0.7)
Number of regular medications used,
Mean (±SD) 5.3 (± 3.2)
Pre-operative hemoglobin (g%)* Mean
(range) 12.4 (7.1-15.5)
*Normal range is 12.0 - 16.0 g%.
Copyright © 2011 SciRes. SS
Table 2. Patients who underwent partial hip replacement
(PHR) compared with patients who underwent cannulated
screw (CS), dynamic hip screw (DHS) or proximal femoral
nail (PFN).
(N = 29,
Mean ± SD)
CS or DHS or
PFN (N = 80,
Mean ± SD)
Age (years) 85 ± 5.1 86.3 ± 4.3 NS
Duration of surgery
(minutes) 47 ± 8 61 ± 29 p = 0.008*
Hospital stay (days) 7.0 ± 2.7 7.4 ± 3.7 NS
Complications (%) 16% 20% NS
Mortality (%) 15.4% 8.7% NS
Notes: N = number of patients; SD = standard deviation; NS = not signifi-
cant statistically; *Applying the Mann-Whitney test.
Table 3. Postoperative complications.
Respiratory complications
Pleural effusion
Respiratory failure
Cardiac complications
Acute MI
Acute atrial fibrillation
Neurological complications
Infectious complications
Renal failure 3
Loosening of prosthesis and re-operation 1
Bleeding in surgical site
Rectal bleeding
Notes: MI = myocardial infarction; CVA = cerebral vascular accident; UTI
= urinary tract infection.
esthesia (16%), p = 0.044. Mortality was higher in gene-
ral anesthesia (14%) than in spinal anesthesia (9%) but
this was not statistically significant (p = 0.5). Death was
significantly higher in the bedridden group of patients
(28.6%) than in ambulant patients (6.45%), p = 0.008.
As expected, hospitalization was significantly longer
in patients with complications than in those without com-
plications. Also, the mortality rate was significantly higher
in the group of patients who had a complication than in
patients who had uneventful surgery (p = 0.016).
5. Discussion
Increased life expectancy is an indicator of improved life
style and good health services. Yet, aging of the popula-
tion establishes a challenge to the medical profession.
Patients 80 year old and more require special manage-
ment, as all body systems undergo physiological dete-
rioration during these years. Cardiovascular, pulmonary
and central nervous systems show considerable decline,
as do liver and kidney functions, and metabolic and en-
docrine systems [9-12]. Progressive osteoporosis and
reduced muscle mass cause frailty [13]; hence, bone fra-
cture is a leading health problem in this age group [14].
Often, these patients are treated with many drugs, suffer
malnutrition and electrolyte disturbances, and a notable
number of them are bedridden [15,16]. Elderly patients
have reduced drug metabolism and elimination [17]. As a
result of all this, anesthesia for elderly patients is com-
plex. Surgery is more complicated as patients age. Oste-
oporotic bones raise technical difficulties with keeping
the fracture reduced and stable enough to allow patients
to ambulate. It is not uncommon to lose reduction and
fixation during the postoperative and rehabilitation peri-
ods due to the bone quality of older patients. Failure of
fixation or weak bone purchase prevents ambulation
which is not easy after such a fracture. Thus, postopera-
tive recovery and rehabilitation is slow and demanding.
In this study, we found a significant higher complica-
tion rate in patients who had general anesthesia com-
pared with spinal anesthesia. We also found a higher
mortality rate in general anesthesia than in spinal anes-
thesia, although this was not statistically significant. The
issue of general versus regional, specifically spinal, ane-
sthesia was studied in the past, although the literature is
not unanimous. In a large retrospective study of 9425
patients who underwent hip surgery in 1983-1993, the
30-day mortality rate in the general anesthesia group was
4.4%, compared with 5.4% in the regional anesthesia
group [18]. Contradicting results were found in a meta-
analysis of 15 trials comparing general to regional anes-
thesia, where regional anesthesia was associated with
decreased mortality at one month, yet the statistical sig-
nificance was borderline [19]. In an early prospective
study of 578 patients aged 50 and more who underwent
hip surgery, the difference in postoperative mortality
after spinal versus general anesthesia was statistically
insignificant [20]. Koval et al. conducted a prospective
randomized study of 749 patients undergoing hip surgery
and found no significant difference in inpatient morbidity
and mortality between patients receiving general or spi-
nal anesthesia [21]. Based on our results, we suggest that
Copyright © 2011 SciRes. SS
general anesthesia carried an increased complication risk
compared with spinal anesthesia in the selected group of
patients aged 80 years or more.
In addition, we found that COPD significantly in-
creased the risk of postoperative complications in this
group of elderly patients. The causative association be-
tween COPD and hip fracture is well known since COPD
patients who are treated with systemic corticosteroids are
at a higher risk for osteoporotic fractures [22]. However,
their higher risk for poor outcome was only recently ac-
knowledged. In 2002, Eisler et al. found that only COPD
significantly affected functional recovery at three months
after hip surgery [23]. Later, de Luise et al found that
patients with COPD had a 60% - 70% higher risk of
death following hip fracture than those without COPD
[24]. These authors suggested that certain diseases are
more strongly associated with mortality than others,
since they profoundly affect the maintenance of normal
physiology, as does the cardiopulmonary system.
In summary, elderly patients are more vulnerable than
younger patients, and their recovery ability is damaged.
Every single complication may deteriorate the patient
gravely. This is supported by our finding that the morta-
lity rate was significantly higher in the group of patients
who had a complication than in patients who had an un-
eventful procedure. Thus, prompt and intensive reaction
to a change in patient status is required. The recognition
of elderly patients as a distinct group with certain medi-
cal and surgical characteristics and needs is essential for
future improvement of care.
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