Abstract
Background
Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries.
Methods
A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS.
Results
Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789).
Conclusion
This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.
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Introduction
Femoral fractures are recognized as a serious, debilitating problem worldwide, especially concerning the geriatric population. As this issue continues to rise, with an annual estimate of 1.6 million patients with a hip fracture hospitalized [1], the number of hip fracture surgeries simultaneously expands alongside their associated complications, like postoperative pneumonia. It has been estimated that the total annual incidence of geriatric hip fractures in the Middle East in general is between 60 and 150 per 100,000 [2,3,4,5]. There is a scarcity of research examining the incidence and complications of hip fractures among the Jordanian population. According to recent research in Jordan, it was estimated that the annual incidence of hip fracture patients above the age of 55 in 2021 was approximately 96 cases per 100,000 individuals [6].
Factors such as advanced age, anemia, diabetes, prior stroke, the number of comorbidities, an American society of anesthesiologists (ASA) score ≥ III, general anesthesia, and delay in surgery were positively correlated to acquiring pneumonia after surgery [7, 8]. On the other hand, many elements, regardless of pneumonia, were found to affect the length-of-stay (LOS) following a hip fracture surgery. These included advanced age, higher ASA physical status scores, comorbid burden, with the addition of female gender, severe obesity with a body mass index (BMI) exceeding 40, the use of a cemented implant in the total hip replacement, previous hip fractures, acute renal failure, diabetes, cerebrovascular disease, smokers, and others [9,10,11]. Others were linked with death after these surgeries. For instance, longer LOS, age over 80, poor mobility prior to the surgery, inability to return to baseline mobility, the presence of 3 or more comorbidities, an ASA over III or IV, chest infection, and heart failure [10, 12, 13]. In the management of hip fractures, particularly among elderly patients, postoperative complications significantly influence outcomes and mortality rates [14,45]. This further confirms our findings of increased POP and LOS in patients with cardiovascular diseases on univariate analysis. Preoperative cardiac evaluation guidelines set out by the American College of Cardiology/American Heart Association (ACC/AHA) categorize any orthopedic procedure, including femoral fracture repair, as “intermediate risk.” [46]. Specifically, heart failure has been previously found to increase LOS following hip fracture surgeries, which goes hand in hand with our findings [47].
A Danish study in 2019 confirmed our findings regarding postoperative pneumonia. It suggested that a delay of 12 h was associated with an increased risk of pneumonia in patients with no comorbidities, a delay of 24 h was associated with an increased risk of pneumonia in patients with a medium level of comorbidity, and a delay of 48 h was associated with an increased risk of reoperation due to infection in patients with a high level of comorbidity. In conclusion, a delay in surgery was associated with an increased risk of hospital-treated pneumonia and reoperations due to infection within 30 days of surgery [48]. Many articles have confirmed that a delay in surgery over 48 h is concurrent with worsening outcomes, hence increased LOS, reasoning that a delay in the performance of surgery is linked to major medical complications, minor medical complications, and pressure sores [49, 50]. Furthermore, prior research involving polytrauma patients has demonstrated that early stabilization of femur fractures is linked to a reduced risk of acute respiratory distress syndrome and mortality [51]. Interestingly, a retrospective review conducted in 2018 revealed that increasing time to surgery was associated with longer postoperative lengths of stay but not with adverse outcomes of surgery [52].
The retrospective study investigating the impact of pneumonia on the length of hospital stay and mortality in elderly femoral fracture patients exhibits several notable strengths. The study addressed a clinically significant issue by investigating the impact of pneumonia, specifically in femoral fracture patients. In addition, understanding the interplay between these two conditions can inform healthcare strategies and improve patient care. Furthermore, a larger sample increases the likelihood of detecting true associations, strengthens the study’s external validity, and utilizes multivariate analysis controlled for potential confounding variables. However, certain limitations warrant consideration. The study’s retrospective design is inherently limited by its reliance on existing medical records, which may lack some critical information. Moreover, conducting the study at a single healthcare center may limit the generalizability of the findings. Also, failure to account for nosocomial cases could underestimate the true impact of hospital-acquired infections on the studied outcomes. Future studies could benefit from incorporating ASA grades and utilizing the CURB-65 scoring system, which could potentially enrich the analysis and provide deeper insights into the prognostic factors influencing postoperative outcomes.
Conclusion
In light of our findings, this study underscores the significant impact of postoperative pneumonia on the outcomes of patients undergoing femur fracture surgery. With a notable incidence of 10.8%, postoperative pneumonia was associated with older age, prolonged hospital stay, and intensive care unit (ICU) admissions, though it did not significantly affect mortality rates. In addition, prolonged hospital stay was associated with surgery not being performed within 48 h of admission, lower hemoglobin levels upon admission, and ICU admission. For clinicians, our study emphasizes the importance of early identification and management of risk factors for postoperative pneumonia. Implementing targeted interventions, such as preoperative optimization, timely surgical intervention, and enhanced postoperative care protocols, could mitigate the risk of develo** pneumonia, improve overall outcomes, and lower the incidence of postoperative pneumonia in patients with femur fractures.
Data availability
The datasets generated and/or analysed during the current study are not publicly available due to the sake of patient privacy but are available from the corresponding author on reasonable request.
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Conceptualization, MH and BH; methodology, TA and AMA; validation, MH, BIH and HAR; formal analysis, MAA and JA; investigation, JA, HAR, ME , AMA, and TA; resources, JA and MAA; data curation, JA, AMA, ME, TA, HAR, and MAA; writing—original draft preparation, MAA, and JA, HAR, ME , AMA, and TA; writing—review and editing, MAA, MH, BH, JA, HAR, ME , AMA, TA, and MAA; visualization, MAA and JA; supervision, MH, BH and MAA; project administration, MH. All authors made substantial contributions to conception and design and have read and agreed to the published version of the manuscript. All authors read and approved the final manuscript.
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The study was conducted according to the guidelines of the Declaration of Helsinki and approved by Institutional Review Board of the University of Jordan (approval number 101202315854; 2/3/2023). Informed written consent was obtained from the patients.
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Hamdan, M., Haddad, B.I., Almohtasib, J. et al. Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis. BMC Musculoskelet Disord 25, 413 (2024). https://doi.org/10.1186/s12891-024-07529-4
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DOI: https://doi.org/10.1186/s12891-024-07529-4