Université Paris Cité, équipe ECAMO, Centre of Research in Epidemiology and Statistics (CRESS), Inserm, UMR 1153, Paris, France; Service de chirurgie orthopédique et traumatologique, Beaujon/Bichat, université Paris Cité, AP-HP, Paris, France.
Université Paris Cité, équipe ECAMO, Centre of Research in Epidemiology and Statistics (CRESS), Inserm, UMR 1153, Paris, France; Service de chirurgie orthopédique et traumatologique, Cochin, université Paris Cité, AP-HP, Paris, France.
Orthop Traumatol Surg Res. 2024 May;110(3):103827. doi: 10.1016/j.otsr.2024.103827. Epub 2024 Jan 26.
Proximal Femur Fractures (PFFs) are a significant public health issue and occur in the context of global frailty and aging. Recent literature identifies new patient-related prognostic factors that focus on socioeconomic environment, patient well-being, or nutrition status. Specific scores have been developed, but in most cases, they fail to be in line with the comprehensive geriatric assessment, or do not assess the newly identified prognostic factors, contain multitude collinearities, or are too complex to be used in the daily practice. Hypothesis A comprehensive score with equal representation of the patient's dimensions does at least as good as the Charlson score (CCI), to predict complications and mortality.
To develop a new comprehensive prognostic score, predicting inpatient complications and mortality up to 5-year after PFF.
The patients treated surgically for PFF on a native hip, between 2005 and 2017 were selected from a French national database. The variables were the gender, age, the type of treatment (osteosynthesis or arthroplasty), and the CCI. The outcomes were the medical and surgical complications as inpatient and the mortality (up to 5-year). Variables were grouped into dimensions with similar clinical significance, using a Principal Component Analysis, for instance, bedsores and malnutrition. The dimensions were tested for 90-day mortality and complications, in regressions models. Two scores were derived from the coefficients: SCORE (strict ponderation), and SCORE (with loose ponderation: 1 point/risk factors, -1 point/protective factors). Calibration, discrimination (ROC curves with Area Under Curves AUC), and cross-validation were assessed for SCORE, SCORE, and CCI.
Analyses were performed on 7756 fractures. The factorial analysis identified seven dimensions: age; brain-related conditions (including dementia): 1738/7756; severe chronic conditions (for instance, organ failures) 914/7756; undernutrition: 764/7756; environment, including social issues or housing difficulties: 659/7756; associated trauma: 814/7756; and gender. The seven dimensions were selected for the prognostic score named AtoG (ABCDEFG, standing for Age, Brain, Comorbidities, unDernutrition, Environment, other Fractures, Gender). The median survival rate was 50.8 months 95% CI [49-53]. Anaemia and urologic complications were the most prevalent medical complications (1674/7756, 21%, and 1109/7756, 14.2%). A total of 149/7756 patients (1.9%) developed a mechanical inpatient complication (fractures or dislocations), with a slightly higher risk for arthroplasties. The AUCs were 0.69, 0.68, and 0.67 for AtoG, AtoG, and CCI, respectively, for 90-day mortality, and 0.64, 0.63, and 0.56 for complications. Compared to patients with AtoG=0, Hazard Ratios for 90-day mortality were 2.3 95% CI [1.7-2.9], 4.2 95% CI [3.1-5.4], 6 95% CI [4.5-8.1], 8.3 95% CI [6.5-12.9], and 13.7 95% CI [8-24], from AtoG=1 to AtoG≥5, respectively (p<10); the 90-day survival decreased by 5%/point, roughly. The sur-risk of mortality associated with AtoG was up to 5-year: HR=1.51 (95% CI [1.46-1.55], p<10). Compared to AtoG=0, from AtoG=1 to AtoG≥5, the pooled Odd Ratios were 1.14 95% CI [1.06-1.2], 1.53 95% CI [1.4-1.7], 2.17 95% CI [1.9-2.4], 2.9 95% CI [2.4-3.4], and 4.9 95% CI [3.3-7.4] for any complication (p<10).
AtoG is a multidimensional score in line with the concept of comprehensive geriatric assessment. It had good discrimination and performance in predicting 90-day mortality and complications. Performances were as good as CCI for 90-day mortality, and better than it for the complications.
IV; retrospective cohort study.
股骨近端骨折（PFF）是一个重大的公共卫生问题，发生在全球衰弱和老龄化的背景下。最近的文献确定了一些新的与患者相关的预后因素，这些因素集中在社会经济环境、患者福祉或营养状况上。已经开发出了特定的评分，但在大多数情况下，它们不符合综合老年评估的要求，或者不能评估新发现的预后因素，包含多种共线性，或者太复杂而无法在日常实践中使用。
一个全面的评分，具有患者各维度的同等代表性，至少与 Charlson 评分（CCI）一样，能够预测并发症和死亡率。
开发一种新的综合预后评分，预测 PFF 后 5 年内的住院并发症和死亡率。
从法国国家数据库中选择了 2005 年至 2017 年期间因股骨近端骨折接受手术治疗的患者。变量包括性别、年龄、治疗类型（骨合成或关节置换术）和 CCI。结局是住院期间的医疗和手术并发症以及死亡率（最长 5 年）。变量使用主成分分析（例如褥疮和营养不良）按照具有相似临床意义的维度进行分组。在回归模型中测试这些维度的 90 天死亡率和并发症。从系数中得出两个评分：SCORE（严格加权）和 SCORE（松散加权：1 分/危险因素，-1 分/保护因素）。评估了 SCORE、SCORE 和 CCI 的校准、区分度（ROC 曲线下面积 AUC）和交叉验证。
对 7756 例骨折进行了分析。因子分析确定了七个维度：年龄；与大脑相关的状况（包括痴呆症）：1738/7756；严重慢性疾病（例如器官衰竭）：914/7756；营养不良：764/7756；环境，包括社会问题或住房困难：659/7756；合并创伤：814/7756；性别。这七个维度被选为命名为 AtoG（ABCDEFG，代表年龄、大脑、合并症、营养不良、环境、其他骨折、性别）的预后评分。中位生存率为 50.8 个月（95%CI[49-53]）。贫血和泌尿科并发症是最常见的医疗并发症（1674/7756，21%和 1109/7756，14.2%）。共有 149/7756 名患者（1.9%）发生了机械性住院并发症（骨折或脱位），关节置换术的风险略高。AtoG、AtoG 和 CCI 的 90 天死亡率的 AUC 分别为 0.69、0.68 和 0.67，并发症的 AUC 分别为 0.64、0.63 和 0.56。与 AtoG=0 的患者相比，90 天死亡率的风险比为 2.3（95%CI[1.7-2.9]）、4.2（95%CI[3.1-5.4]）、6（95%CI[4.5-8.1]）、8.3（95%CI[6.5-12.9]）和 13.7（95%CI[8-24]），从 AtoG=1 到 AtoG≥5，风险比逐渐升高（p<10）。90 天死亡率的风险每增加 5%/点，大约降低 5%。与 AtoG=0 相比，AtoG=1 至 AtoG≥5 与 5 年内的死亡率相关（HR=1.51[95%CI[1.46-1.55]，p<10）。与 AtoG=0 相比，从 AtoG=1 到 AtoG≥5，任何并发症的汇总优势比分别为 1.14（95%CI[1.06-1.2]）、1.53（95%CI[1.4-1.7]）、2.17（95%CI[1.9-2.4]）、2.9（95%CI[2.4-3.4]）和 4.9（95%CI[3.3-7.4]）（p<10）。
AtoG 是一种多维评分，符合综合老年评估的概念。它在预测 90 天死亡率和并发症方面具有良好的区分度和性能。在预测 90 天死亡率方面，其性能与 CCI 相当，在预测并发症方面优于 CCI。
IV；回顾性队列研究。
