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PREDICTIVE SIGNIFICANCE OF COMORBID STATUS IN DEVELOPMENT OF COMPLICATIONS IN SURGICAL TREATMENT OF PATIENTS WITH INJURIES TO THE PROXIMAL FEMORAL BONE
Milyukov A.Yu., Ustyantsev D.D., Gilev Ya.Kh., Mazeev D.V.
Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
Comorbidity
influences on the prediction of life and increases the possibility of lethal
outcome. The presence of comorbid disease promotes the increasing amount of
bed-days, disability and prevents the conduction of rehabilitation, increases
the number of postsurgical complications and causes the increase in probability
of fallings in older patients [1, 2, 3].
Comorbid
pathology makes the multifactorial and individual influence on the clinical
manifestations, diagnostics and treatment of many diseases. The interaction of
diseases, age and drug therapy significantly changes the clinical picture of
the main nosology, characteristics and severity of complications, worsens the
quality of life, limits or impedes the medical and diagnostic process [5. 6].
As
the last works show, the problem of comorbidity is quite common for
traumatologists-orthopedists during formation of a diagnostic and medical
concept with consideration of potential risks for a patient and his/her remote
prognosis [3, 7, 8].
The
presence of comorbidity should be considered when selecting a diagnostic
algorithm or a scheme of surgical treatment in locomotor system injuries [9,
10].
However
in most conducted randomized clinical studies the authors include patients with
separate traumatological pathology and present comorbidity as an exclusion
criterion [3, 8, 10]. For this category of patients it is necessary to confirm
a degree of functional disorders and the morphological status for all
identified nosological forms.
Currently,
the significance of comorbidity does not raise any doubts. There are 12 uniform
techniques for measuring comorbidity [1, 2, 11, 12]. But how it can be measured
in an individual patient? Each day any clinician meets such difficulties regardless
of clinical experience and medical knowledge.
Absence
of a uniform complex approach to estimation of comorbidity causes some gaps in
clinical practice of a traumatologist-orthopedist [2, 12]. The main blocks on
the way to implementation of comorbidity estimation systems into a many-sided
medical and diagnostic process is their inconsistency and narrow directionality
despite of variety of techniques for comorbidity estimation [2, 10].
After
analyzing a comorbidity status in a certain patient with use of the most common
international scales for comorbidity estimation, one can receive the essentially
different results.
So,
a recent study by Lakomkin N. et al. showed a statistically significant
relationship between the increasing Charlson Comorbidity Index (CCI) and
duration of postsurgical hospital stay for patients with single fractures of
the lower extremities as compared to patients with hip joint injuries and
pelvic fractures [13].
Min
L., Burruss S., Morley E. et al. (2013) published the retrospective analysis of
concurrent pathology in 280,000 trauma patients according to the data from US
National Bank of Trauma Data including the trauma centers of the levels 1-3
[10]. The authors identified a close relationship between the age and
complications in patients with three or more concurrent diseases. The risk of
mortality increased in patients at the age > 45 [10].
The
use of primary data acquired at the moment of admission (age, gender, chronic
diseases and simple calculation of comorbidity categories) was successfully
used for development of a nomogram of estimation of risk of complications and
mortality in older trauma patients [10].
As
result, the potentially wider use of such approach can be useful for
stratifying the risk of complications, mortality with consideration of a
comorbidity status for development of more efficient approaches in complex
surgical treatment of patients with injuries and multiple chronic concurrent
diseases.
The
development of nomograms can be a starting point for estimating the risk of
possible complications and for timely use of intensive prevention of infections
in surgical treatment of some categories of patients with traumatic
musculoskeletal injuries.
The objective of the study – to analyze and separate the values (age, gender, Injury Severity
Score, length of hospital stay after surgery, complications) of the comorbid
status and to develop a simple nomographic chart for clinical estimation of the
risk of complications in patients with the proximal femoral bone injuries.
MATERIALS AND METHODS
The
study is based on the analysis of the results of the complex examination and
the surgical treatment of 161 patients with injuries to the proximal femoral
bone. The patients received the treatment in the traumatology and orthopedics
unit No.2, Regional Clinical Center of Miners’ Health Protection in 2013-2016.
The study data was obtained from the computer basis of the Medical Information
System (MIS) of Regional Clinical Center of Miners’ Health Protection.
The
inclusion criteria for the patients with the proximal femoral bone injuries
were the age ≥ 18, Injury Severity Score (ISS) ≤ 15 [14]. The increase in the
amount of points corresponded to the increasing severity of injury since ISS is
a continuous variable and can vary from 0 to 75 points [14]. The study excluded
the cases when the patients were transferred to other hospital or a lethal
outcome was registered during 24 hours after admission.
In concordance with ICD-10, the proximal femoral bone injuries were
verified on the basis of complaints, the results of physical examination and
X-ray examination of the hip joint in two standard planes.
119
patients (74 %) had the medial fractures of the proximal femoral bone, with the
basal, medial and subcapital fractures of the femoral neck in 34, 50 and 35
patients correspondingly. 42 cases (26 %) were associated with the lateral
fractures of the proximal femoral bone. The transtrochanteric and subtrochanteric
fractures were identified in 28 and 14 patients with the injuries according to
the classification by A.V. Kaplan (1967).
The
study was conducted in concordance with the ethical principles of World Medical
Association Declaration of Helsinki – Ethical Principles for Medical Research Involving
Human Subjects, 2013 and the Rules for Clinical Practice in the Russian
Federation (the Order No.266 by RF Health Ministry, June 19, 2003) after
receiving the written consent from a patient and approval from the local
ethical committee of the center.
The age of the patients was selected
as a stratified variable: the age of 18-64 was considered as young one, ≥ 65 –
as older age (the table 1). Initially, the values were analyzed and separated
(age, gender, injury mechanism, injury type, ISS, duration of hospital stay
after surgery). The comorbidity status was estimated with the amount of
concurrent diseases (among 16 possible diseases) (the table 1).
Table 1. The characteristics of patients with proximal femoral bone injuries in the examined age groups
|
Values |
|
Young age (18–64 years) (n = 39) |
Older age (65+ years) (n = 122) |
p-value |
|
Men, % |
|
65 |
43 |
< 0.001 |
|
Injury mechanism, % |
Road traffic accidents |
46.2 |
9.0 |
< 0.001 |
|
|
Falling from height* |
23.0 |
83.6 |
< 0.001 |
|
|
Others (home injury, diving) |
30.8 |
7.4 |
< 0.001 |
|
Injury Severity Score (ISS), mean |
|
15 (10.0) |
13 (8.2) |
|
|
Hospital stay, mean (SD), days |
|
11.2 (16.0) |
16.5 (19.3) |
< 0.001 |
|
Comorbidity (concurrent diseases before injury), %1 |
No concurrent diseases (0) |
12.8 |
5.7 |
< 0.001 |
|
|
1-2 and more concurrent diseases |
53.8 |
54.1 |
< 0.001 |
|
|
3+ concurrent diseases |
33.3 |
40.2 |
< 0.001 |
|
|
Hypertension |
28.2 |
70.5 |
< 0.001 |
|
|
Coronary heart disease |
25.6 |
59.0 |
< 0.001 |
|
|
Coagulopathy and anticoagulant therapy |
30.8 |
69.7 |
< 0.001 |
|
|
Chronic pulmonary diseases including obstructive pulmonary disease and asthma |
12.8 |
24.6 |
< 0.001 |
|
|
Previous cardiosurgical operations |
2.6 |
9.0 |
< 0.001 |
|
|
Arrhythmia (also installed cardiac stimulators) |
12.8 |
26.2 |
< 0.001 |
|
|
Deep venous thrombosis, lymphostasis |
23.1 |
23.0 |
0.563 |
|
|
Diabetes mellitus |
19.7 |
23.1 |
< 0.001 |
|
|
Obesity (degrees 3-4) |
11.5 |
28.2 |
< 0.001 |
|
|
Neurological diseases (including hemiparesis, stroke, chronic demyelinating diseases) |
1.6 |
5.5 |
< 0.001 |
|
|
Chronic renal insufficiency (including hemodialysis, urinary tract infections) |
5.1 |
9.0 |
< 0.001 |
|
|
Systemic diseases (RA, SLE) |
2.6 |
7.4 |
< 0.001 |
|
|
Senile dementia |
0.3 |
5.0 |
< 0.001 |
|
|
Bed sores |
2.6 |
4.9 |
< 0.001 |
|
|
Oncological diseases |
2.6 |
4.1 |
< 0.001 |
|
|
Alcoholism |
30.8 |
7.4 |
< 0.001 |
|
|
Hepatitis, HIV |
23.1 |
14.8 |
< 0.001 |
|
|
Drug addiction, toxicomania (smoking) |
43.6 |
19.7 |
< 0.001 |
Note: p – value in comparison with the groups of young and older age (χ2 – for the qualitative signs, t-test for the quantitative signs); * – falling from low height – falling from low furniture (a chair, a bed, an arm-chair, curbs, stairs); 1 – percentage ratio for each item of comorbidity has been calculated with consideration of all patients with at least one concurrent disease.
Statistical analysis
Choice of predictive parameters
The
preliminary analysis demonstrated 21 values, which are presented in the table 1
and could be used as the predictive parameters for estimating the risk of
complications in patients with the proximal femoral bone injuries. We considered
each value (total of 21) as a dichotomized variable in relation to the variants
– gender, ISS, the amount of concurrent diseases (among 16 possible diseases).
The statistical analysis of the results was conducted with
IBM SPSS Statistics 20. Student’s test and Mann-Whitney U-test were used for
estimating the reliability of intergroup differences in dependence of the type
of distribution of the variables.
The
quantitative variables were presented as mean arithmetic values (M) and quadratic
deviation of mean arithmetic values (SD) in the amplitude of the ordered sample
as Me (LQ-UQ), where Me – is the median, (LQ-UQ) is interquartile range (LQ –
25 %, UQ – 75 %).
The
extensive coefficients (%) describing the relationship between members and the
integral were measured during the process of statistical analysis. The qualitative
signs were presented as absolute and relative (%) values. Fisher’s exact test
and χ2 (chi-square) test were used for
estimating the significance of differences of frequency of observation of the
studied values in the study groups. The critical level of significance (p) was less
0.05 during testing the statistical hypotheses.
The
randomized heterogeneous combined sample was used as a way of formation of the sampling
population. The relationships were identified with multiple logistic regression
for each concurrent disease, distinct from 0, with consideration of gender, ISS
and amount of concurrent diseases.
The risk of complications was
estimated with the comorbidity parameters, when the incidence of a concurrent
disease was 2-3 times higher than the similar value in the young patients.
The model for development of a nomogram of clinical risk of complications
Multiple
logistic regression was used for creation of a nomogram for predictive
estimation of clinical risk of development of complications. First of all, we
used three variables received at the moment of admission (age, gender,
concurrent pathology). The variability was controlled with estimating the
severity of injuries with use of ISS. The concurrent pathology was considered
as a variable consisting of three categories: healthy persons (0 – absence of
concurrent diseases), mean chronic state (1-2 and more concurrent diseases),
multiple morbidity (3+ concurrent diseases). All types of interaction of the
variables were analyzed (mutual influence between age, gender and the
concurrent pathology). The statistically significant values (p < 0.05) were
included into the final multivariate model.
We used the ISS = 15 (mean severity
of an injury) for predictive estimation of risk of complications. Then we
estimated the predictive risk of complications in relation to increasing age
and categories of comorbidity for men and women. The analytic sample predicting
the risk of complications was limited by at least three various preexisting
states (Fig. 1).
Figure 1. The nomographic chart for calculation of risk of
development of complications after surgical
treatment of the patients with the proximal femoral bone fractures with
consideration of the age, gender and the concurrent diseases. The complications included the infectious (wound
infection, periprosthetic infection, urinary tract infection, pneumonia) and
non-infectious complications (metal construct instability, thrombosis in the
femoral artery and lower extremity veins, thrombophlebitis, thromboembolism,
infarction, cerebral perfusion, sciatic nerve neuritis, renal insufficiency,
contact dermatitis).
The nomographic chart is presented separately for the
men and the women. The potential risk of complications in the coordinate axis
(Y) is presented in concordance with the age (in the axis of abscissas (X) and
comorbidity categories (0 – absent concurrent diseases, 1-2 concurrent
disease, 3+ concurrent diseases).
The horizontal direct line (30 %)
risk demonstrates the use of the nomographic chart for calculating the
potential risk of complications. So, all values, which are higher than the
values of the direct line of 30 % risk show the high risks of
complications with consideration of gender and the age of the patients with
injuries. For example, the men at the age of 50 with more than 3 concurrent
diseases show 30 % risk of complications, as well as the men at the age of
55 with at least 2 concurrent diseases and the men at the age of 70 and
older. The predictor risk with is presented in the similar manner with
consideration of the age and concurrent pathology in the women (55 years
and 3 concurrent disease; 60 years and 1-2 concurrent diseases;
the women older than 75).
The nomographic chart for calculation of risk of
development of complications after surgical
treatment of the patients with the proximal femoral bone fractures with
consideration of the age, gender and the concurrent diseases.
The complications included the infectious (wound
infection, periprosthetic infection, urinary tract infection, pneumonia) and
non-infectious complications (metal construct instability, thrombosis in the
femoral artery and lower extremity veins, thrombophlebitis, thromboembolism,
infarction, cerebral perfusion, sciatic nerve neuritis, renal insufficiency,
contact dermatitis).
The nomographic chart is presented separately for the
men and the women. The potential risk of complications in the coordinate axis
(Y) is presented in concordance with the age (in the axis of abscissas (X) and
comorbidity categories (0 – absent concurrent diseases, 1-2 concurrent
disease, 3+ concurrent diseases).
The horizontal direct line (30 %)
risk demonstrates the use of the nomographic chart for calculating the
potential risk of complications. So, all values, which are higher than the
values of the direct line of 30 % risk show the high risks of
complications with consideration of gender and the age of the patients with
injuries. For example, the men at the age of 50 with more than 3 concurrent
diseases show 30 % risk of complications, as well as the men at the age of
55 with at least 2 concurrent diseases and the men at the age of 70 and
older. The predictor risk with is presented in the similar manner with
consideration of the age and concurrent pathology in the women (55 years
and 3 concurrent disease; 60 years and 1-2 concurrent diseases;
the women older than 75).
RESULTS AND DISCUSSION
Results
161
patients with the proximal femoral bone injuries who were admitted to the
traumatology unit No.2, Regional Clinical Center o Miners’ Health Protection,
were included into the study in compliance with the criteria (ISS ≤ 15, age ≥
18, absence of transfer to other hospitals, duration of stay in the clinic ≥ 24
hours). The general mortality was absent in the patients included into the
study.
The
table 1 demonstrates the characteristics of the young and older patients with
the proximal femoral bone injuries.
The
amount of the men was higher (65 %) among the young patients. The mean age was
48.9 ± 1, ISS (SD) ≤ 15 (10.0). The main causes of the injuries were road
traffic accidents (46.2 %), falling from low height (30.8 %), home injuries and
diving (23 %) (the table 1).
Amongthe older patients, the amount of the men was lower (43 % vs. 65 %, p >
0.001), whereas the presence of at least one concurrent disease was more common
for the older patients than the young ones (94.3 % vs. 87.2 %, p < 0.001).
Falling from low height was more common for the older patients (83.6 % vs. 23
%, p < 0.001). The severity of the injuries was evidently lower in the older
patients than in the young ones (ISS = 13 vs. ISS = 15, p < 0.001).
The
types of operations and their amount in the patients with the proximal femoral
bone injuries are presented in the table 2.
Table 2. Types and amount of performed surgeries in the patients of the examined groups with proximal femoral bone injuries
|
Groups of patients |
Young patients (18-64 years) |
Older patients (65+ years) |
||||
|
Proximal femoral bone fractures |
Medial |
Lateral |
n |
Medial |
Lateral |
n |
|
Вид операции / Surgery type: |
||||||
|
Total hip joint replacement |
6 |
1 |
7 |
83 |
7 |
90 |
|
Fixation with cannulated screws |
13 |
1 |
14 |
10 |
1 |
11 |
|
PFN fixation |
1 |
17 |
18 |
6 |
15 |
21 |
|
Amount of operations, abs. |
20 |
19 |
39 |
99 |
23 |
122 |
The
table shows that the young patients (age of 18-64) with the medial and lateral
injuries to the proximal femoral bone received 7 procedures of primary total
hip joint replacement, 14 patients received the femoral bone fixation with the
cannulated screws, 18 patients – the femoral bone osteosynthesis with PFN (18
%, 36 % and 46 % of operations in this group correspondingly).
The
older patients (≥ 65 years) received the hip joint replacement in 74 % of the
cases (the table 2). The feature of these operations included 2 cases of the
acetabular defect replaced with bone automass from the resected and blenderized
femoral head, 1 case of a supporting ring fixed to the pelvic bone according to
Bursh-Schneider, 1 case of a prosthesis cup fixed with bone cement (Fig. 2).
Figure 2. The surgical techniques for the patients with the proximal femoral bone fractures: a) fixation with the cannulated screws; b) total hip joint replacement; c) PFN fixation
The postsurgical complications included the infectious (wound infection, periprosthetic infection, urinary tract infection, pneumonia) and non-infectious (instable metal constructs, thrombosis, thromboembolism, infarction, cerebral perfusion disorders, sciatic nerve neuritis, renal insufficiency, contact dermatitis) complications (the table 3).
Table 3. The predictive factors of risk of infectious and non-infectious complications in patients with proximal femoral bone injuries after surgery and multiple logistic regression analysis (OR – odds ratio, CI – confidence interval)
|
Comorbidity categories Values |
Absence of concurrent diseases |
All concurrent diseases |
1-2 and more concurrent diseases |
3+ concurrent diseases |
|||||
|
OR (95 % CI) |
p |
OR (95 % CI) |
p |
OR (95 % CI) |
p |
OR (95 % CI) |
p |
||
|
Age a |
1.01 (0.98–1.03) |
< 0,001 |
1.04 (1.03–1.05) |
< 0.001 |
1.02 (1.01–1.03) |
< 0.001 |
1.005 (0.89–1.01) |
< 0.04 |
|
|
Men |
0.61 (0.47–0.89) |
|
0.67 (0.49–0.92) |
< 0.012 |
0.62 (0.44–0.88) |
< 0.05 |
0.64 (0.46–0.92) |
< 0.007 |
|
|
Value of ISS b |
1.54 (1.44–1.64) |
< 0.001 |
1.47 (1.38–1.56) |
< 0.001 |
1.37 (1.33–1.46) |
< 0.001 |
1.51 (1.41–1.61) |
< 0.001 |
|
|
All complications |
1.04 (1.03–1.05) |
< 0.001 |
2.30 (1.9–2.7) |
< 0.025 |
1.67 (1.44–1.8) |
< 0.029 |
2.81 (1.18–6.66) |
< 0.019 |
|
|
Infectious complications |
|||||||||
|
Pyoinflammatory (wound infection) b |
|
2.67 (2.34–2.8) |
< 0.025 |
|
3.55 (3.20–3.90) |
< 0.001 |
|||
|
Periprosthetic infection b |
|
2.07 (1.74–2.20) |
< 0.025 |
|
3.49 (3.13–3.84) |
< 0.001 |
|||
|
Urinary tract infection b |
|
1.43 (1.13–1.65) |
< 0.025 |
|
3.28 (3.00–3.56) |
< 0.001 |
|||
|
Pneumonia b |
|
1.27 (1.04–1.53) |
< 0.025 |
|
3.13 (2.79–3.46) |
< 0.001 |
|||
|
Non-infectious complications |
|||||||||
|
Metal construct instability b |
|
1.87 (1.64–1.96) |
< 0.025 |
|
3.63 (3.33–3.93) |
< 0.001 |
|||
|
Femoral artery thrombosis b |
|
|
|
3.34 (3.12–3.56) |
< 0.001 |
||||
|
Thrombophlebitis and thrombosis in lower extremity veins b |
|
|
|
3.22 (2.89–3.56) |
< 0.02 |
||||
|
Thromboembolism b |
|
|
|
2.78 (2.38–3.18) |
< 0.02 |
||||
|
Infarction b |
|
|
|
2.20 (1.46–2.94) |
0.4 |
||||
|
Cerebral perfusion disorders b |
|
|
|
1.93 (1.67–2.2) |
0.2 |
||||
|
Sciatic nerve neuritis b |
|
|
|
1.61 (1.36–1.86) |
0.2 |
||||
|
Renal insufficiency b |
|
|
|
1.38 (1.28–1.48) |
0.08 |
||||
|
Contact dermatitis b |
|
|
|
1.07 (1.03–1.11) |
0.2 |
||||
Note: a – odds ratio for annual increase; b – odds ratio for the moment of increase; * – p < 0.05.
As
compared to the young patients, the older patients demonstrated the higher
duration of hospital stay (24 % vs. 13 %, p < 0.001) and 2.4-fold increase
in the risk of complications (p < 0.001) such as wound infection,
periprosthetic infection, urinary tract infection, pneumonia, instability of
metal constructs, femoral artery thrombosis, deep venous thrombosis in the
lower extremities, progression of neurological manifestations, renal
insufficiency (the table 3).
The
following values were used for creation of the multiple logistic model (Fig.
1): age, gender, ISS, preselected categories of comorbidity (0, 1-2, 3+). Each
age increase by 5 years was accompanied by the average increasing risk of
complications by 10 % (95 % CI, 8.7-10.5 %). The assessment of the comorbidity
categories showed that 56 % the patients had the preexisting risks of
concurrent pathology with three or more diseases (3+) (95 % CI, 36-78 %). 29 %
of the patients received the comorbidity categories 1-2 (95 % CI, 15-47 %) as
compared to the patients without concurrent diseases (0 – a comorbidity
category).
The
men had the higher probability of complications (increase by 18 %, 95 % CI,
14-22 %) as compared to the women (p < 0.001). The most positive and
significant relationship was found between the age and comorbidity (OR, 1,005,
p < 0.04 per year for patients with three and more concurrent diseases),
because the relationship between the age and comorbidity was left in the final
model (Fig. 1).
The area under the curve, which
describes the corresponding model, was 74 % (Fig. 1). Therefore, it is possible
to use the presented model for estimating the risk of complications in patients
with injuries to the proximal femoral bone in clinical practice.
Discussion
The
older patients with the proximal femoral bone injuries showed more complicated
and often unfavorable clinical course as compared to the young patients during
the postsurgical period. Moreover, the registered infections (wound infection,
periprosthetic and urinary tract infection, pneumonia) were associated with at
least double risk of development of infectious complications in the older
patients as compared to the young ones. Some non-infectious causes were also
associated with the increasing risk of severe postsurgical course in the older
patients, including instability of metal constructs, femoral artery thrombosis,
thrombophlebitis, thrombosis in veins of the lower extremities,
thromboembolism, infarction, cerebral perfusion disorder, sciatic nerve
neuritis, renal insufficiency (the table 3).
In
our study 14 % of the patients with the proximal femoral bone injuries
experienced at least one complication during admission. As compared to younger
patients, the older patients demonstrated 34 % risk of development of
complications. These findings comply with the previous studies of the risk
factors of mortality after traumatic injuries [3]. As result, early diagnostics
and timely preventive measures are the main priorities in the treatment of
older patients with the proximal femoral bone injuries.
In
our study we used the estimation of comorbidity on the basis of three
categories of the general amount of preexisting diseases. A close relationship
was found between the age and the complications in the patients with 3 and more
diseases (3+), which existed before an injury (the table 3). It corresponds to
the previous observations that showed the increasing risk of mortality in
trauma patients at the age > 45 [16]. Comorbidity can be a partial
explanation of increasing risk of mortality [17].
The
use of the primary information (acquired at the moment of admission, i.e. age,
gender, chronic diseases) allowed developing the nomogram (Fig.1) for
stratification of risk of complications in patients with the proximal femoral
bone injuries. Such approach to estimating the clinical risk is supported by
the modern guidance for treating trauma in older patients [7, 8].
The
modern practical guidance does not recommend the use of the injury severity
values for the treatment of individual patients, because these values are
unknown up to the moment of discharge. However since the injury severity is a
main predictive factor of complications and mortality in older patients, then
the use of ISS was the necessary part of the design of our clinical study and
was considered in compliance with the injury severity criteria – injuries of
middle severity (ISS ≥ 15). The older patients had the lower value of ISS than
the young ones, although this difference was not statistically significant.
Probably, the cause of these differences can be the fact that the older
patients are admitted with higher probability than younger patients, but with
the same values of ISS. Other potential explanation is difference in the injury
mechanism between two groups. Injuries after fallings from low height were the
most common in the older patients.
For risk stratification it is
necessary to conduct additional studies of the estimation methods, which can
identify the injury mechanism and the injury severity degree at the early stage
of inhospital treatment.
CONCLUSION
The
conducted study has shown that the high risk of postsurgical complications has
a close relationship between the age increase and the comorbidity index.
The
perspective estimation of the functional status with consideration of
preexisting concurrent diseases is a necessary screening measure for prediction
of hospital complications in older patients. Finally, the complications, which
were identified in the older patients with the proximal femoral bone injuries,
should be interpreted as the complications with probable high risk of their
development, but not as the complications causing such injuries.
The
developed simple nomogram for clinical estimation of the risk of complications
at the background of concurrent diseases in patients with the proximal femoral
bone injuries can be used in combination with screening of the previous
functional and physiological parameters for identification of older patients
with maximal risk of complicated clinical course in the postsurgical period
(Fig.1).
The perspective use of the offered
nomogram requires the realization of future population-based studies that will
confirm the possibility of its use and to define more efficient clinical
approaches in the treatment of older patients with injuries and multiple
chronic diseases.
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