influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life/Author’s reply, The
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© 2004 British Editorial Society of Bone and Joint Surgery
J Bone Joint Surg [Br] 2004;86-B: 1220-1.
We read with interest the article by Dorotka, Schoechtner and Buchinger’ in the November 2003 issue entitled ‘The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life: operation within six hours of the fracture versus later than six hours’.
We are concerned about the internal validity of this observational study. Due to lack of randomisation, known and unknown differences could not be balanced.
The study does not mention the outcome in different age groups. Younger patients with hip fractures are brought to hospital early when compared with elderly patients especially those who live alone. The two groups studied differed with respect to age and walking ability, with those operated on earlier being younger and presumably fitter. While this difference was not statistically significant, had a larger sample of patients been used it would have reached statistical significance and the conclusions of the paper would be different. Furthermore, the survival curve demonstrates a difference in mortality which becomes apparent one to two months after surgery. This was some time after the initial surgery, an indication that the differences in outcome were due to the general health of the patients, not the timing of surgery.
The study is certainly commendable in demonstrating that it is possible to operate on these patients shortly after the injury which suggests this may have a beneficial effect on outcome. Now, we must set about evaluating the effects of the timing of surgery in a more rigorous fashion.
Luton and Dunstable Hospital
M. J. PARKER
Peterborough District Hospital, Peterborough, UK.
1. Dorotka R, Schoechtner H, Buchinger W. The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life: operation within six hours of the fracture versus later than six hours. J Bone Joint Surg [Br] 2003:85-8:1107-13.
We appreciate the interest of Messrs Pervez and Parker in our study. We cannot confirm that younger patients with hip fractures are hrought to hospital earlier than elderly patients as there were four patients in each of our study groups who were less than 60 years of age, with the youngest patient being in the delayed group. The two groups differed minimally with respect to age (77.1 vs 79.3 years) and walking ability; however, the differences were not statistically significant. Physical health graded by the American Society of Anesthesiologists (ASA) was identical (3.2 vs 3.3) in both groups. We agree that a more rigorous method for evaluating the effects of the timing of surgery must be established. Further studies with a prospective and randomised design and a larger number of patients are required. However, the number of patients is a limiting factor. In order to achieve statistically significant differences with respect to age between our groups, a sample size of 468 in each group would be needed, and in order to calculate statistically significant differences with respect to the ASA grade 1570 subjects would be needed.
R. DOROTKA, MD
University of Vienna
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