Background 

Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion.

Questions/purposes 

(1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections?

Methods 

Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD_6-9], 10-19 [MELD_10-19], and 20-40 [MELD_20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test.

Results 

Patients in the MELD_20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD_6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD_20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD_6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD_20-40 group compared with the other two MELD classifications (13% for MELD_20-40 and 0% for both MELD_6-9 and MELD_10-19; p = 0.02).

Conclusion 

The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

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肝硬化患者的髋部骨折：肝功能恶化与死亡率增加相关

背景 

肝硬化与骨质疏松症、导致跌倒的不平衡以及随后的脆性骨折有关。了解不同严重程度的肝硬化患者髋部骨折时的预后将有助于医生确定这一复杂患者群体的治疗方案。

问题/目的 

(1)不同严重程度的肝硬化与髋部骨折患者的死亡率之间是否存在相关性？(2)不同严重程度的肝硬化与院内、术后30天和术后90天的症状性血栓栓塞和感染（包括伤口并发症、肺炎和尿路感染）并发症之间是否存在关联？

方法 

2015 年至 2019 年间，我们确定了 128 名肝硬化患者，他们在两个一级创伤中心之一接受髋部骨折治疗。年龄小于18岁、病历不完整、髋部骨折或假体周围骨折以外的骨折、非肝硬化性肝病、肝移植后状态以及肝细胞癌以外的转移性癌症的患者被排除在外。根据这些排除，77%（128 名患者中的 99 名）符合资格；1 年内失访率为 0%，2 年内失访率为 4%（99 人中的 4 人）。中位随访时间为 750 天（四分位数范围 232 至 1000）。根据终末期肝病模型 (MELD) 评分亚组对 94 名患者进行分层（MELD 评分为 6-9 [MELD _6-9 ]、10-19 [MELD _10-19 ] 和 20-40 [MELD] _20-40 ]）和99根据代偿或失代偿状态进行分层，这两种指标都是肝硬化严重程度的指标。MELD 评分结合了与肝病相关的实验室参数，用于根据代谢异常预测肝硬化相关死亡率。然而，失代偿是肝功能急性恶化的临床表现，其特征是腹水、肝性脑病和静脉曲张出血，与死亡率增加相关。MELD 分析由于实验室值缺失而排除了 5%（99 名患者中的 5 名）。髋部骨折时的中位年龄为 69 岁（IQR 62 至 78），55%（99 名患者中的 54 名）为女性。主要结局是在术后 90 天、1 年和 2 年确定死亡率。次要结局是有症状的血栓栓塞和感染，定义为任何有记录的手术伤口并发症、肺炎或需要治疗的尿路感染。这些是通过三个时间点的图表审查确定的：住院期间以及出院后 30 天内或 90 天内。主要结果是使用 MELD 评分和代偿或失代偿分类的 Cox 比例风险分析进行评估；使用Fisher精确检验分析次要结果。

结果 

MELD _20-40组患者的 90 天（风险比 3.95 [95% CI 1.39 至 12.46]；p = 0.01）和 1 年（HR 4.12 [95% CI 1.52 至 11.21]；p < 0.001）较高和 2 年死亡率（HR 3.65 [95% CI 1.68 至 7.93]；p < 0.001）死亡率高于 MELD _6-9组。失代偿患者的住院率较高（9% vs 0%；p = 0.04）、90 天（HR 3.35 [95% CI 1.10 至 10.25]；p = 0.03）、1 年（HR 4.39 [95% CI 2.02 至 9.54]；p < 0.001）和 2 年死亡率（HR 3.80 [95% CI 2.02 至 7.15]；p < 0.001）死亡率高于代偿性疾病患者。所有院内死亡均与肝功能衰竭有关，且均发生在手术后 30 天内。_{MELD 20-40}患者的 1 年死亡率为 55%，失代偿性疾病患者的 1 年死亡率为 53%，而 MELD _6-9患者的 1 年死亡率为 16% ，代偿性疾病患者的 1 年死亡率为 15%。在 MELD 和（去）代偿分析中，院内和出院后 30 天的症状性血栓栓塞和感染并发症在各组之间没有差异（均 p > 0.05）。与其他两种 MELD 分类相比， MELD _20-40组的 90 天症状性血栓栓塞率更高（MELD _20-40为 13% ，MELD _6-9和 MELD _10-19均为 0% ；p = 0.02）。

结论 

已有肝硬化的患者发生髋部骨折的死亡率很高，并且与肝硬化的程度和肝功能下降有关，特别是那些有失代偿迹象的患者，定义为腹水、肝性脑病和静脉曲张出血。轻中度肝硬化（MELD评分<20）和代偿性疾病患者可根据预后进行常规骨折治疗。重度（MELD评分> 20）或失代偿性肝硬化患者应接受多学科、个体化治疗，考虑到术后1年内死亡风险较高，应考虑姑息治疗和非手术治疗。

证据水平 

III级，治疗研究。