Die Auswirkung von Immunsuppression auf den perioperativen Verlauf in der Versorgung von Patienten mit Frakturen des proximalen Femur

„The impact of immunosuppression on patient outcome during the early peri-operative period following proximale femural fractures“ The proximal femur fracture is a frequent reason for orthopedic surgery worldwide. Most of the patients with proximal femoral fractures are elderly and its incidence is expected to rise due to the increasing life expectancy. The proximal femoral fracture is related with a relevant rate of complications and mortality, thus resulting not only in a financial burden for health systems, but also in a turning point in each patient’s life. Furthermore, a relevant number of patients do not recover completely and fail to regain the pretraumatic life quality. The assessment of the individual risk for complications remains to be difficult. One of the risk factors for complications during the peri-operative period could be immunosuppression. This case control study tried to evaluate the impact of immunosuppression on the peri-operative period in patients with a proximal femural fracture who underwent surgery at the “Universitätsklinikum Gießen Marburg” during 01/2007-11/2012. Immunosuppressed patients were defined by receiving chemotherapy or radiotherapy during the last 6 months before surgery, at least one medication with an immunosuppressiv effect at the time of surgery or suffering from leukopenia. Using these criterias, 34 female and 19 male index patients were identified and matched with a control group. Matching criteria were sex, age, score in the Charlson Comorbidity Index and type of surgical procedure (prothesis vs. osteosynthesis). In each group, 26 patients received an osteosynthesis and 27 patients an endoprothesis. The following items were analyzed by comparative statistics: BMI, CCI, time from trauma until admission, length of the patients hosptial stay, length of inpatient treatment, postoperative complications using the Clavien Dindo classification, number of days at intensive care unit, operation procedure and number of medications. Comparing both groups, there were no significant difference in BMI, CCI, time from trauma until hospital admission, time of surgery or antibiotic prophylaxis. The index group was statistically younger and took significantly more medication. Six patients of the index group received local anesthesia, while all patients in the control group received general anasthaesia. There was no significant difference between both groups regarding the post-operative duration at the intensive care unit, even though the index group stayed significantly longer in the hospital overall. There were no significant differences in the perioperative complications between immunosuppressed and immune-competent patients as assessed by the Clavien-Dindo classification. To the best of our knowledge, this is the only study that has analysed the influence of immunosuppression on patients with proximal femoral fractures and the data provided by studies analyzing to the influence of immunosuppression on the peri- operative period after elective surgery is inconsistent. The main limitations of this case control study are the small number of cases of the the index group, the heterogenous reasons resulting in immunosuppression and its retrospective study design. While our results do support the current recommendations to not necessarily stop immunosuppression before a surgical intervention, prospective multicentric studies are needed to further clarify the role of immunosuppression in patients with proximal femoral fractures.