| BackgroundCurrently,the elderly trauma patient health care,especially the treatment for those patients combined with serious disorders of frail nonagenarian,brain insufficiency or chronic renal failure,has become a common medical problem in China.Such patients,because of serious combined-chronic disease,organ function decreased,activity of dairy living function declined,were tend to fall and hip fracture under low-energy trauma.In most of those patients,such a hip fracture with serious complication occurred were easy to cause the death in follow-up.World-widely,the surgical treatment was the major selection for hip fracture patients,however,the senile patients with serious chronic disorders and poor surgical tolerance,to a certain extent,were in risk of mortality and morbidity during and after surgery.Actually,how to evaluate the preoperative surgical risk and manage the perioperative period,after that,to let the elderly hip fracture safely through the whole perioperative period,and obtaining excellent prognosis,was still a great challenge for each of surgeons in orthopedic surgery.In present,there is no appropriate and standardizing trauma scoring system for the domestic senile orthopedics trauma patients in China.In 2008,Aimin Wang and his colleagues has created a surgical scoring system,named Daping orthopedics operative risk scoring system for senile patients(DORSSSP),this scoring got good clinical effect in the early stage.However,during the development of medical science and surgical technical enhanced,DORSSSP lost its accuracy in mortality and morbidity rate prediction gradually,the predicted scores were always higher than the observed values in morbidity and mortality.In short,it is imperative to create and develop a more suitable assessment scoring system for the orthopedics elderly patient operative risks.Purpose1.To summary the damage control orthopedics surgery theory treatment experiences on hip fractures patients suffering the frail nonagenarian patients or chronic renal failure patients or stroke sequelae patients.To investigate the importance of damage control surgery in orthopedic surgery and the necessity of surgical risk assessment in hip fracture treatment,and verify the accuracy of DORSSSP scoring system in clinic practice.2.To clarify the surgical risk elements in elderly patients still need the surgical procedures in orthopedic surgery,and by adopting reference to DORSSSP scoring system,and achieve the DORSSSP scoring system improvement and the related software invention.Method1.A retrospective analysis from December 1999 to January 2016 in our hospital,110 cases of nonagenarians underwent hip fracture,32 cases of renal failure underwent hip fractures,and 47 cases of stroke sequelae patients underwent hip fracture,were respectively selected and analyzed.During the step-by-step surgical risk assessment,all of those patients in those three groups were estimated and performed by using the following scoring systems,which included the American society of anesthesiologists(ASA)classification,Physiological and Operative Severity Scoring for the en Umeration of Mortality and Morbidity(POSSUM),Portsmouth-Physiological and operative severity scoring for the enumeration of Mortality and Morbidity(P-POSSUM),and the Daping orthopedics operative risk scoring system for Senile Patient(DORSSSP).The surgical risk between patients who suitable for operation and patients who cannot tolerate surgical treatment were compared in each assessment period of whole perioperative phases.To summarize treatment experience,the surgical procedure selection,the surgical timing,and the anesthesia choosing were analyzed carefully in all those three group cases.By comparing these patient outcomes,the bleeding volume,hospital stay,mortality and morbidity 30 days after surgical treatment were collected and analyzed separately.All those factors were useful to verify the effectiveness of damage control surgery in patient conditions of prognosis2.To summarize the general data of 1507 surgical treatment patients older than 60 years who were admitted from 2005 to 2013.We collected and screened the outcomes risk factors of patient separately.And then identified the precise risk factors of the elderly orthopedics surgery procedures by Logistic regression analysis.During the statistics analysis of various risk factors and anew got weight assignment,the novel scoring system–DORSSSP3.0 scoring system was created and designed which refer to the original DORSSSP and Modified DORSSSP.From the year of 2013 to 2015,we retrospectively selected and enrolled 574 cases of hip fracture patients with surgical treatment to test the DORSSSP3.0 scoring system.To compare DORSSSP3.0 scoring system with DORSSSP,M-DORSSSP,POSSUM,and P-POSSUM scoring,the mortality and morbidity rate were compared and explained.To further our study,the DORSSSP3.0 software designed and created to expand the clinical usage of the scoring system.Results1.Frail nonagenarian patients underwent hip fracture treatment1.1 Preoperative risk assessmentThe step-by-step surgical risk assessment,ranging from one to three times,was performed in all patients.In this cases study,the first surgical risk assessment was performed in 110 patients,27 patients can be operated directly.The second surgical risk assessment was performed with the rest of 83 patients,54 patients can selected the surgical treatment.Twenty-nine patients underwent the third surgical risk assessment,22 patients were finished surgical treatment.The rest of 7 patients after damage control surgery guided recuperate,because of the physical conditions remaining serious deteriorated and the surgical risk unable to abate,were given the conservative treatment without surgery.The risk assessment criterion for patients to treat with surgery were included: the expected DORSSSP surgery mortality rate less than 20%,POSSUM expected morbidity and complication rate less than 80%,P-POSSUM mortality rate less than15%.After the pre-operative risk assessment and step-by-step conditioning procedures,patients who cannot surgery and continuing recuperate,had significantly higher risk assessment values than the patients suitable with surgery(p < 0.05).The group of 110 patients,103 patients(93.64%)underwent surgery,and the remaining 7 patients(6.36%)treated conservatively.In this study,totally 103 patients finished the surgical treatment,which is included 67 cases finished surgery within 48 to 72 hours,and 36 cases finished surgery between 4 to 10 days.1.2 The surgical patients in generalWith the 103 study cases underwent surgical treatment,preoperative preparation time was 3.95 ± 2.18 d,operation time was 108.16 ± 30.98 min,bleeding volume was 272.86 ± 188.9 ml,the total length of stay was 15.49 ± 7.51 d,ICU length of stay was 2.81 ± 2.06 days.The selection of surgical procedures was mainly hemiarthroplasty,and the anesthesia method choose was nerve block anesthesia dominated.According to the patient’s vital physical signs,timely adjustment of surgical and anesthesia,and ultimately to identify the successful completion of surgery.1.3 Comparison of morbidity and mortalityAfter 30 days’ fellow up,a total of 46 cases(44.67%)were reported with complications occurred,29 patients(28.16%)were reported with two more morbidity occurred.Preoperative evaluation and estimation of complications compared to the situation,the actual rate of morbidity of the surgical patients were significantly lower than the predicted value in DORSSSP and POSSUM scoring system with statistically significant(p < 0.01,respectively).Two patients died during hospitalization(1.94%).After 30 days’ follow up,10 patients died totally(9.71%).The actual mortality rate in both groups was significantly lower than the P-POSSUM and the DORSSSP preoperative risk assessment(p < 0.01 respectively).2.Chronic renal failure with hip fracture treatment2.1 Preoperative risk assessmentThe surgical risk assessment as the former section method used.In this cases study,the first surgical risk assessment was performed in 32 patients,9 patients can be operated directly.The second surgical risk assessment was performed with the rest of 24patients(71.87%),17 patients can selected the surgical treatment.Seven patients underwent the third surgical risk assessment,3 patients were finished surgical treatment.The rest of 4 patients after damage control surgery guided recuperate,because of the physical conditions remaining serious deteriorated and the surgical risk unable to abate,were given the conservative treatment without surgery.The surgical risk assessment criterion for patients to treat with surgery were included: the expected DORSSSP surgery mortality rate less than 20%,POSSUM expected complication rate less than 80%,P-POSSUM mortality rate less than 15%.After the pre-operative risk assessment and step-by-step conditioning procedures,patients who cannot surgery and continuing recuperate,had significantly higher risk assessment values than the patients suitable with surgery(p < 0.05).The group of 32 patients,28 patients underwent surgery,and the remaining 4 patients treated conservatively without surgery.In this study,28 patients finished the surgical treatment,which is included 8 cases finished surgery within 48 to 72 hours,and 10 cases finished surgery between 4 to 10 days.2.2 The surgical patients in generalWith the 28 study cases underwent surgical treatment,preoperative preparation time was 4.79 ± 2.86 d,operation time was 117.46 ± 21.89 min,bleeding volume was 317.48±170.46 ml,the total length of stay was 21.54±8.95 d,ICU length of stay was 3.64±1.69 d.The selection of surgical procedures was mainly hemiarthroplasty,and the anesthesia method choose was nerve block anesthesia dominated.According to the patient’s vital physical signs,timely adjustment of surgical and anesthesia,and ultimately to identify the successful completion of surgery.2.3 Comparison of morbidity and mortalityAfter 30 days’ fellow-up,a total of 13 cases(46.43%)were reported with complications occurred,9patients(32.14%)were reported with two or more complications occurred.Preoperative evaluation and estimation of complications compared to the situation,the actual rate of morbidity between the two groups was significantly lower than the predicted value in DORSSSP and POSSUM scoring system with statistically significant(p<0.01,respectively).No case died during hospitalization.After 30 days fellow up,3 patients died(10.71%).And the mortality rate was no statistically significant difference(p > 0.05)between each groups.The actual mortality rate in both groups was significantly lower than the P-POSSUM and DORSSSP preoperative evaluation(p < 0.01,respectively).3.The stroke sequelae elderly patients underwent hip fracture treatment3.1 Preoperative risk assessmentThe surgical risk assessment as the former section method used.In this cases study,the first surgical risk assessment was performed in 47 patients,10 patients can treat with surgery directly.The second surgical risk assessment was performed with the rest of 37 patients(78.72%),21 patients(44.68%)can selected the surgical treatment.Seventeen patients underwent the third surgical risk assessment,12 patients were finished surgical treatment.The rest of 5 patients after damage control surgery guided recuperate,because of the physical conditions remaining serious deteriorated and the surgical risk unable to abate,were given the conservative treatment without surgery.In this study,totally42 patients underwent surgical treatment,23 patients underwent surgery within 48 to 72 hours,and 19 patients underwent surgical treatment in 4 to 11 days.3.2 The surgical patients in generalWith the 28 study cases underwent surgical treatment,preoperative preparation time was 4.26 ± 3.42 d,operation time was 102.42 ± 21.43 min,bleeding volume was 285.43±108.21 ml,the total length of stay was 24.94±15.34 d,ICU length of stay was 3.04±1.79 d.The selection of surgical procedures was mainly hemiarthroplasty,and the anesthesia method choose was nerve block anesthesia dominated.According to the patient’s vital physical signs,timely adjustment of surgical and anesthesia,and ultimately to identify the successful completion of surgery.3.2.2 Comparison of morbidity and mortalityAfter 30 days’ fellow-up,a total of 18 cases(42.86%)were reported with complications occurred,14patients(33.33%)were reported with two or more morbidity occurred.Preoperative evaluation and estimation of complications compared to the situation,the actual rate of morbidity of the surgical patients were significantly lower than the predicted value in DORSSSP and POSSUM scoring system with statistically significant(p<0.01,respectively).No cases died during hospitalization.After 30 days fellow up,7 patients died(14.89%).And the mortality rate was no statistically significant difference between patients underwent early surgical treatment and delayed surgical treatment.The actual mortality rate in both groups was significantly lower than the P-POSSUM and DORSSSP preoperative evaluation(p < 0.01,respectively).4.The DORSSSP scoring system improvement and the clinical assessmentIn this study,from 2005 to 2013,we retrospectively reviewed and analyzed 1507 cases of surgical treated hip fracture patient clinical data.With the mono-and multi-factor analysis of Logistic regression,the morbidity and mortality regression equation were calculated,and then,the updated Daping orthopedics operative risk assessment system for senile(DORSSSP3.0).was formed directly.In order to verify the validity and effectiveness of the DORSSSP3.0 scoring,a total of 754 patients underwent hip fracture surgery data analyzed.To compare with those four scoring system,these predicted mortality and morbidity rates of DORSSSP3.0 were more accuracy and reliable than another scoring system(p<0.05).To further applying the DORSSSP3.0 scoring,we designed and created the DORSSSP3.0 scoring software to help doctors to calculate and evaluate all the elderly patients.This software was simple and easy to get the predicted morbidity and mortality rate of each patients.Aimed to help doctors managed all patients perioperative and postoperative conveniently,this software was also have the function to record the follow-up information in a simple way.ConclusionIt is effective to apply damage control orthopedics surgery for treating hip fracture nonagenarian patients or renal failure patients or stroke sequel patients.It could effectively reduce the risk of surgery,the complications,as well as the mortality rate.The surgery timing should be based on the preoperative risk assessment,and the adverse event incidence would not increase due to the delay of surgery caused by adopting damage control surgery.By improving DORSSSP scoring system,we invented the DORSSSP3.0 scoring system,and the mortality and morbidity rate predicting by this system is closer to the actual observed value measured 30 days follow up after the surgery.By developing the scoring software,this scoring system would be adopted more widely in orthopedic surgery clinical issues and it has significant clinical value in a wide range of potential applications. |
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