A Clinical Study Of Damage Control For The Treatment Of Hip Fracture Patients With Chronic Organ Failure

Background:Hip fracture is still one of the most common diseases in the hospitalization of orthopedic patients.The occurring rate of hip fracture in elderly patients is increasing with their ages growing.Now our country has entered into the aging society.Some reports have said the occurring rate will grow at 30% speed every 10 years during 1980~2020.The number of the hip fractures will be four times than that this year.The large occurring rate of hip fractures brings a lot of economic and social burden on the countries around the world.According to the reports by UK,more than eighty-six thousand cases of hip fractures occur every year,which spends 1.7 billion pounds on the related medical services.Some reports predict that the related medical services on the hip fractures will cost about 60 billion dollars in China by 2020,and this number will become four times in the year of 2040.Hip fracture in elderly patients is called the last fracture in their life.Some reports have said that about 4% of hip fracture patients will be dead during hospitalization.One third of the patients will lose their lives in the following one year.In the remaining patients,only 30% of the patients can revive to the normal life state before the injury.As much as 20% of the patients will lose their independent living ability.The high mortality rate of hip fractures is a great challenge to every family and doctors.Hip fracture in elderly patients always accompanies with the chronic diseases like chronic heart failure,chronic respiratory failure and chronic liver failure,and the risk and treatment difficulty are both very high.Based on the hip fracture,the choice of operation opportunity,ways of operation and anesthesia and perioperative managements for failure organs are great challenges and difficulties which our doctors must confront.According to the statement above,we analyze the hip fracture patients with chronic heart failure,respiratory failure and liver failure in orthopedics department of Daping hospital,third military medical university.Then we conclude the characters of hip fractures during perioperative period.At the same time,we apply the damage control techniques on these patients.We propose the new concept---damage control of surgery.It defines that the patients who need operation is still on the emergency state,so their operation opportunities must be delayed.What's more,we take some safe measures during perioperative period.The basic solution including,1.Period before operation: assessment,adjustment,re-assessment,re-adjustment and definite treatment;2.Stage on surgery: choice of ways of surgery and anesthesia.3.Management after operation.The core process of damage control of surgery is the choice for the operation opportunities before surgery,that's to say,the process of assessment and adjustment.After the analysis to the technique applying on the hip fracture patients with chronic organ failure,we ensure that the technique is safe,and we have absorbed much experience from it.Objective:To sum up the treatment experience of damage control of surgery on the chronic heart failure,chronic liver failure and chronic respiratory failure.To sum up the safety and effect of DCS on these patients.Method:1 To collect the data of hip fracture patients with CHF,CLF,and CRF between January 2006 and January 2016.In the end,53 cases with CHF,15 cases with CLF,and 61 cases with CRF are enrolled.To analyze ASA scores,POSSUM scores,P-POSSUM scores,and DORSSSP scores in different periods,and then compare the surgery risks between direct patients with operation and indirect patients with operation.2 To record the ways of operation and anesthesia,duration of surgery,and recovery management after operation.To conclude the experience during perioperative period each group.3 To compare the difference of the mortality rate before and after surgery in the operation group.The we can analyze the treatment effect of DCS according to the data above.Result:1.Hip fracture patients with CHF1.1 Assessment before operationEach patient received one to three times of risk evaluation.The first risk evaluation enrolled 53 cases,19 of which could receive the surgery.The second risk evaluation enrolled 34 cases,20 of which could receive the surgery.The third risk evaluation enrolled 14 cases,10 of which could receive the surgery.The remaining 4 cases couldn't receive the operation.we conclude that: 1.Prediction of DORSSSP about mortality rate <20%;2.Prediction of POSSUM about syndrome occurring rate < 80%;3.Prediction of P-POSSUM about mortality rate <15%.The patient who was in the state above could receive the operation.The indicators in each stage of indirect operation patients are higher than those of direct patients.What's more,there are significant differences between them(p<0.05).1.2 DCS increases the successful rate of treatmentIn the initial risk assessment,18 cases of patients at low risk received surgeries directly,the remaining 35 patients who had high evaluation risk received the subsequent re-evaluation DCS.In the end,31 patients received surgical treatment.The treatment success rate of DCS was 88.57%.1.3 DCS decreases the complication rate and mortalityThe initial assessment of expected POSSUM complication rate of 49 cases before surgery was(79.00�11.22)%,P-POSSUM predicted mortality was(14.33�7.07)%.25 cases appeared postoperative complications,the actual complication rate for 51.02%,lower than the preoperative expected rate of complications(P < 0.05).2.Hip fractures patients with CLF2.1 Preoperative assessmentEach patient accepted risk assessments ranging from one to three times.The number of risk assessment for the first time was 15 cases,3 of them received the operation;12 people received the second risk assessment,and 6 of them received the surgery;6 people received the third risk assessment,and half of them received the surgery.The remaining 3 people received the conservative treatment.Anyone who met the following conditions can receive surgical treatment:(1)DORSSSP expected mortality rate is less than 20%;(2)POSSUM expected complication rate is less than 80%;(3)P-POSSUM expected mortality rate is less than 15%.Each evaluation stage in patients who need the regulation are significantly higher than that of surgery group(p < 0.05).2.2 DCS increases the success of treatment rateIn the initial risk assessment,3 cases of patients at low risk received surgery directly,the remaining 12 patients who had high evaluation risk received the subsequent DCS re-evaluation.In the end,9 patients received surgical treatment.The treatment success rate of DCS was 75%.2.3 DCS decreases the complication rate and mortalityThe initial assessment of expected POSSUM complication rate of 12 cases before surgery was(81.95�7.05)%,P-POSSUM predicted mortality was(15.82�5.32)%.7 cases appeared postoperative complications,the actual complication rate was 58.33%,lower than preoperative expected rate of complications(P < 0.05).2.4 Harris scoreIn the last follow-up,the Harris score of the patients was 83.2(68~93).The perfect patients were 5,the great patients were 6,the good patient was 1 and the poor patient was 1.The rate of perfect and great was 84.6%.3.Hip fracture with CRF3.1 preoperative risk assessmentEach patient preoperative risk assessment accepted one to three times of risk assessment.Risk assessment for the first time,61 people were enrolled,23 of which received the operation;The second risk assessment was 38 people,23 of which received the operation;Risk assessment for the third time was 15 people,11 of which received the operation.The remaining 4 received the conservative treatment.Anyone who met the following conditions could receive surgical treatment:(1)DORSSSP expected mortality rate is less than 20%;(2)POSSUM expected complication rate is less than 80%;(3)PPOSSUM expected mortality rate is less than 15%.The predictors of each evaluation stage in patients who need the regulation are significantly higher than those of surgery group(p < 0.05).3.2 DCS increases the success of treatment rateIn the initial risk assessment,23 cases of patients at low risk received surgery directly,the remaining 38 patients who had high evaluation risk received the subsequent DCS re-evaluation.In the end,34 patients received surgical treatment.The treatment success rate of DCS was 89.47%.3.3 DCS decreases the complication and mortality rateThe initial assessment of POSSUM expected complication rate of 12 cases before surgery was(81.95�7.05)%,P-POSSUM predicted mortality rate was(15.82�5.32)%.7 cases appeared postoperative complications,the actual complication rate was 58.33%,lower than the preoperative expected rate of complications(P < 0.05).Conclusion:Damage control of surgery in treating hip fracture with CHF,CLF and CRF is effective.It can effectively reduce the operation risk,the rate of complication and mortality.The establishment of the operation time should be closely combined with preoperative risk assessment.Assessment and treatment on the basic diseases are the core process of DCS.