[Surgical treatment variation of displaced femoral neck fractures in certified centers for geriatric trauma DGU® and arthroplasty centers in Germany].

Abstract

Background: There is an almost unique certification structure in Germany in which clinics can be certified either as trauma center DGU® (TraumaZentrum DGU®), geriatric trauma center DGU® (AltrsTraumaZentrum DGU®) or arthroplasty center (endoCert), among others. Geriatric patients with displaced femoral neck fractures represent a highly relevant entity. The structural and process quality are validated within the framework of certification as both an AltersTraumaZentrum DGU® (ATZ) and arthroplasty center (EPZ), which represents a methodologically challenging approach to the analysis of treatment reality.

Objective: Is there a treatment variation between certified geriatric trauma centers (ATZ) and dual certified geriatric and arthroplasty centers (ATZ+EPZ) with respect to joint-preserving or joint replacement surgical procedures for geriatric displaced femoral neck fractures and short-term complications?

Material and methods: Data from the Registry for Geriatric Trauma of the German Trauma Society (ATR-DGU) from 46 clinics with ATZ and 52 clinics with ATZ + EPZ were analyzed. The follow-up period included both the in-hospital stay and a 120-day follow-up interval. The primary outcome was mortality, secondary endpoints included mobility, reoperations and health status. Univariate and multivariate analyses were performed to calculate odds ratios (OR) after adjustment for age, gender, ASA score and concomitant injuries.

Results: The median age of the collective (n = 7389) was 84 years, 29.6% and 29.8% respectively were male, the median time until surgery was 20.9 h (ATZ) vs. 20.5 h (ATZ + EPZ) and the median length of stay was 15.1 days for both types of center. The number of joint-preserving interventions was significantly increased in ATZ compared to clinics with dual certification (ATZ: 8.6% vs. ATZ + EPZ: 2.6%; OR = 3.63). The reoperation rate was comparable in the primary stay (3.7% vs. 3.9%) but was significantly increased over the 120-day course in clinics with dual certification (4.1% vs. 6.0%; p = 0.022). Revisions due to periprosthetic fractures occurred more frequently in ATZ without EPZ (8.2% vs. 3.5%). The multivariate analysis showed an increased mortality in the acute phase (OR 1.26; 1.02-1.56; p = 0.031), an increased rate of reoperations in the 120-day course (OR 1.45; 1.06-2.02; p = 0.024) and inpatient readmissions (OR 1.42, 1.02-2.00; p = 0.043) for centers with dual certification.

Conclusion: In Germany an institutional treatment variation for geriatric displaced femoral neck fractures exists. In certified geriatric trauma centers without certified arthroplasty center there is a significantly increased rate of joint-preserving treatment with differences in terms of morbidity and mortality in the acute phase.