The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

Abstract

Objective The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time. Methods This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5–89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results. Results The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05). Conclusions This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Anteromedial Cortical Support in Reduction of Trochanteric Hip Fractures

“…Meanwhile, the BRQC uses a general description, which does not differentiate between the conditions of poor alignment only in anteroposterior views, poor alignment in only lateral views, and poor alignment in both anteroposterior and lateral views, as these conditions are all grouped under the term "poor alignment." 22,29,59 Moreover, in the displacement description, the CRQC adopts expressions such as "1 or 0.5 cortical thickness." This not only provides practical means for surgeons to conduct evaluation visually, eliminating the need for measurement tools, but also underscores the buttress function of the anteromedial cortex in maintaining stability 22,59,60 .…”

“…22,29,59 Moreover, in the displacement description, the CRQC adopts expressions such as "1 or 0.5 cortical thickness." This not only provides practical means for surgeons to conduct evaluation visually, eliminating the need for measurement tools, but also underscores the buttress function of the anteromedial cortex in maintaining stability 22,59,60 . In contrast, the BRQC uses a 4-mm benchmark to describe displacement, requiring the use of measuring instruments for accurate appraisal and not engaging the surgeon's attention toward the anteromedial cortex 55 .…”

“…On the lateral view, the CRQC designates a good displacement as smooth anterior cortical contact. The displacement requirement (0.5 cortical thickness) in the CRQC is more stringent than the 4 mm defined by the BRQC, which further prevents negative ACS from being categorized as good 22,59 .…”

Reduction quality in lateral view of X-ray and hypoalbuminemia are associated with postoperative mortality in elderly pertrochanteric fracture patients

“…Some previous studies have indicated the correlation between fracture reduction quality and the postoperative survival of elderly patients with pertrochanteric fractures. He et al ( 28 ) found that compared with patients with an excellent reduction, those with an acceptable reduction had a 1.1-fold increase in mortality at the 1-year follow-up, whereas those with a poor reduction had a 13.8-fold increase in mortality. A study including 329 patients revealed that there appeared to be a correlation between fracture reduction and postoperative survival of geriatric hip fracture patients at 1 year ( 20 ).…”

Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks

“…However, based on the definition of anteromedial cortical support (buttress) in the most cited article, 2 the reduction illustrated in Figure 7B should be classified as negative medial cortical support (NMCS), which is inadequate. Here is the definition 2-4 of NMCS: the medial cortex of the femoral head–neck fragment (M-HN) is lateral to the medial cortex of the femoral shaft (M-FS), regardless of the displacement. We took the liberty to mark Figure 7B with red lines to highlight the NMCS (Figure L1). Even if there was a little contact between M-HN and M-FS, the cortical support is very likely to displace after secondary interfragmentary movement (Figure 7D).…”