Introduction. The management of patients with an acute fracture of the femoral neck who suffered an acute myocardial infarction during the previous 3 months before surgery is still a challenge.
Objectives. By studying the relationship between preoperative cardiovascular evaluation and post-operative morbidity and mortality of these patients, the time to surgery may be shortened and we can guide the option of operative vs non-operative treatment by better decision making on when to operate and wheather to operate these patients.
Methods. The study included 28 patients with femoral neck fracture that underwent surgery between 2011-2016, with a documented acute myocardial infarction during the 3 months prior to surgery. The end-point of the follow-up was 60 day postoperatively. Main outcome measure was death after surgery, up to 60 days postoperatively. Preoperative evaluation included standard evaluation and cardiovascular evaluation – revised cardiac risk index evaluation, electrocardiogram,
echocardiography for left ventricular dysfunction, Duke Activity Status Index (DASI) questionnaire, troponin I, NT pro BNP and high sensitivity CRP values.
Results. Ten patients died at the 60 days follow-up (35.7%), five deaths being due to cardiovascular complications. One patient from the survivors had an acute myocardial re-infarction, 10 days after surgery,
and one patient has been hospitalized for acute onset of arrhythmia. All twelve patients had troponin I levels greater than 0.10 μg/L, a NT-proBNP level greater than 800 pg/mL and high sensitivity CRP greater than 1.57 mg/L, showing an increased preoperative risk of cardiovascular events. The Duke activity index for the ten patients was higher than 4 but less than 6 METS.
Conclusions. The femoral neck fracture in a patient with recent myocardial infarction involves a difficult decision and a multidisciplinary collaboration. Although rare, this combined pathology is difficult to manage and still has no consensus on when to wait, how long to wait until surgery and whether to operate or to treat functionally these particular patients. Our conclusion is that we have to make a fast preoperative evaluation of these patients and decide for each patient individually, balancing the risks of non-operative treatment and operative treatment.
Key words: femoral neck fracture, myocardial infarction, preoperative evaluation.
Dr. Dan Anghelescu
Trauma and Orthopaedic Surgery Department, University Emergency Hospital