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The key issue of outcome after hip fracture repair lays in the early perioperative period
- Anne Le Noel, [Guillaume De Saint Maurice], [Sylvain Ausset], and [Bernard Lenoir] (1 September 2009)
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Anne Le Noel Department of Anesthesiology and Intensive Care, Percy Military Hospital, Paris, France, [Guillaume De Saint Maurice], [Sylvain Ausset], and [Bernard Lenoir]
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We read with interest the article of Oscarsson et al. on the incidence of NT- proBNP rise in high-risk patients undergoing hip fracture repair (HFR) and its correlation with late cardiac outcome¹. We fully agree with their conclusion when they say that the incidence of postoperative myocardial damage (PMD) after HFR is high and strongly correlated with both perioperative elevation of NT-proBNP and cardiac complication (CC). But, beyond the predictive value of biomarkers for adverse outcome, this study also confirms that PMD with troponin release are significant events in the course of patients care, with a strong impact on outcome. This was well described after vascular surgery ²ˉ⁵, but less studied in the orthopaedic surgery setting although HFR seems associated with a high cardiac risk. Indeed, in the Escort study, Rosencher et al, founded that CC were the most frequent causes of death (270/1006= 26,8%) in their 6860 patients cohort⁶. In medical literature, CC occur in 15 to 32% of the patients, and the incidence of PMD, diagnosed by troponin elevation, ranges between 22 and 53% ⁷ˉ¹⁰. Furthermore, recent works have demonstrated the association between troponin rise after HFR and cardiac outcome ⁷ˉ¹⁰. The onset of CC after HFR seems to appear early in the course of hip fracture, eventualy preoperatively, as shown by Matot et al who, in their sample of 68 hip fracture patients, founded seven (10,3%) preoperative CC and six (9,4%) postoperative CC in the 64 patients who survived to the surgery ¹¹. This study of Oscarsson et al confirms the early onset of PMD: 58% of the troponin elevation already existed before surgery. Moreover, this association between early PMD and late CC allows us a new look on the Escort study: If the majority of late deaths after HFR was of cardiac origin, now we can wonder if the genesis of the death toll is in perioperative period. This hypothesis is consistent with the study of Foss et al who show that the 30 days mortality after HFR varies according to immediate postoperative cares ¹² and with recent data who indicate that in-hospital complications are correlated with late mortality ¹³ˉ¹⁵ Thus we think that the study of Oscarsson perfectly features the clinical problem of outcome after HFR: A high mortality rate, 6 months to one year after surgery, mainly due to the consequences of early PMD. This study seems to select a high-risk population since the patients were all selected with an ASA physical status classification III or IV. But studies on HFR find 37.5 - 73% of ASA III or more. ⁶, ⁶ˉ¹⁹. Thus, because of the ageing of the population, associated with a growing incidence of hip fracture, Oscarsson et al describe a key issue of a major health burden who will tremendously grows in years to come. 1 Oscarsson A, Fredrikson M, Sorliden M, Anskar S, Eintrei C. N- terminal fragment of pro-B-type natriuretic peptide is a predictor of cardiac events in high-risk patients undergoing acute hip fracture surgery. Br J Anaesth 2009; 103: 206-12 2 Barbagallo M, Casati A, Spadini E, et al. Early increases in cardiac troponin levels after major vascular surgery is associated with an increased frequency of delayed cardiac complications. J Clin Anesth 2006; 18: 280-5 3 Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 2003; 42: 1547-54 4 Kim LJ, Martinez EA, Faraday N, et al. Cardiac troponin I predicts short- term mortality in vascular surgery patients. Circulation 2002; 106: 2366- 71 5 Kertai MD, Boersma E, Klein J, Van Urk H, Bax JJ, Poldermans D. Long- term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery. Eur J Vasc Endovasc Surg 2004; 28: 59- 66 6 Rosencher N, Vielpeau C, Emmerich J, Fagnani F, Samama CM. Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study. J Thromb Haemost 2005; 3: 2006-14 7 Ausset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol 2008; 25: 158-64 8 Dawson-Bowling S, Chettiar K, Cottam H, et al. Troponin T as a predictive marker of morbidity in patients with fractured neck of femur. Injury 2008; 39: 775-80 9 Chong CP, Lam QT, Ryan JE, Sinnappu RN, Lim WK. Incidence of post- operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age Ageing 2009; 38: 168-74 10 Fisher AA, Southcott EN, Goh SL, et al. Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance. Arch Orthop Trauma Surg 2008; 128: 1073-9 11 Matot I, Oppenheim-Eden A, Ratrot R, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003; 98: 156-63 12 Foss NB, Kehlet H. Short-term mortality in hip fracture patients admitted during weekends and holidays. Br J Anaesth 2006; 96: 450-4 13 Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242: 326-41; 14 Halm EA, Magaziner J, Hannan EL, et al. Frequency and impact of active clinical issues and new impairments on hospital discharge in patients with hip fracture. Arch Intern Med 2003; 163: 108-13 15 Manku K, Bacchetti P, Leung JM. Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival. Anesthesia and analgesia 2003; 96: 583-9 16 Foss NB, Kehlet H. Mortality analysis in hip fracture patients: implications for design of future outcome trials. Br J Anaesth 2005; 94: 24-9 17 Ausset S, Minville V, Marquis C, et al. Postoperative myocardial damages after hip fracture repair are frequent and associated with a poor cardiac outcome: a three-hospital study. Age and ageing 2009; 38: 473-6 18 Fisher AA, Southcott EN, Goh SL, et al. Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance. Arch Orthop Trauma Surg 2008 19 Soderqvist A, Ekstrom W, Ponzer S, et al. Prediction of Mortality in Elderly Patients with Hip Fractures: A Two-Year Prospective Study of 1,944 Patients. Gerontology 2009 Conflict of Interest:None declared |
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