Università Cattolica del Sacro Cuore

Fondazione Policlinico «Universitario Agostino Gemelli»

Medicine and Surgery Degree Program

Department of Trauma and

Orthopedics Surgery
Head: Prof. Giulio Maccauro

Euthyroid sick syndrome in elderly patients

with proximal femur fracture: clinical outcomes
and pathophysiological implications
Supervisor: Co-Supervisor:
Prof. Carlo Perisano Prof. Giulio Maccauro
Candidate:
Giacomo Dughiero
4450250
1
 OVERVIEW

Proximal femur fracture

Euthyroid Sick Syndrome

(ESS)

Is the thyroid profile of elderly patients with hip fractures relevant?

2
 INTRODUCTION

PROXIMAL FEMUR FRACTURE

Epidemiology

• 1/100 in the over 65 population

• F:M = 3:1

• Cases per year are always increasing

3
 INTRODUCTION

～ 30% are PROXIMAL FEMUR FRACTURE

admitted to
long-term
Mortality and Morbidity ～ 30% die
within one
care in the year
first year

～ 40% are ～ 60% still

unable to walk require
unaided assistance a
year later

4
 INTRODUCTION

PROXIMAL FEMUR FRACTURE

Economic burden

• 50.000 $/patient in the US

• Yearly expense estimate is 6 billion $

(6.000.000.000) in the US

• 3.4 million hospital bed days in the US

5
 INTRODUCTION

PROXIMAL FEMUR FRACTURE

Classification

The most precise classification is the

AO/OTA foundation classification:
1. 31 A: Peritrochanteric fractures
2. 31 B: Neck fractures
3. 31 C: Head fractures

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 INTRODUCTION

EUTHYROID SICK SYNDROME

Euthyroid Sick Syndrome (ESS) is a
thyroid profile imbalance in the
absence of an underlying thyroid
pathology:
Early/Mild Severe
fT3
• fT3 < 2.3 pg/mL fT4 Normal
• fT4 within 0.34-2.20 mIU/L TSH Normal
• TSH within 8.5-16.5 pg/mL rT3

• rT3 > 250 pg/mL 7

 INTRODUCTION

EUTHYROID SICK SYNDROME

Adaptive or maladaptive?

It decreases
metabolism in a
condition of stress

It’s a predictor of poor

prognosis in severely ill
patients
8
 INTRODUCTION

EUTHYROID SICK SYNDROME

To treat or not to treat?

Scientific evidence only points

towards the administration of T3
in specific settings, as patients
under intensive care and
particular cases of heart failure.
How and when does ESS need
addressing in the context of
elderlies with hip fracture?

9
 INTRODUCTION

THYROID HORMONES
An overview

Thyroid hormones increase

metabolism, but they also have
specific actions depending on the
target organ/system.

They exert responses in various

immune cells and play an
important stimulatory role on
erythropoiesis.
1
0
 INTRODUCTION

PTH
Its role in calcium metabolism

PTH acts on calcium metabolism

at many different levels: bone,
kidney and intestine

11
 INTRODUCTION

VITAMIN D
An overview

• It increases calcium absorption

at the intestinal level
• It’s an immunomodulator
• It has a supportive role in
erythropoiesis

12
 STUDY

Study’s objectives

PTH Type of
fracture

Vitamin D Infections
Anemia 13
 STUDY

Study design

All patients over 65 arriving to our

ER with a proximal femur fracture
were recruited.

Upon arrival, routine hematological

investigations and thyroid profiling
were performed.
The same analyses were
performed on 1st and 3rd
postoperative days. 14

Study design
INCLUSION CRITERIA
• Age > 65
• Proximal femur fracture
• ER admission within 72 hours
from trauma
STUDY
EXCLUSION CRITERIA
• Pre-existing thyroid pathology
• Drugs interfering with thyroid
function
• Acute coronary syndrome
• Active pneumonia
• Ongoing neoplastic disease
• Refusal of surgical intervention
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 STUDY

Results
Variables ESS Non-ESS p-value
Population:
Gender 11 M - 38 F 9 M - 21 F
• 79 patients (20 M and 59 F)
Age 84,9 83,5 0,8
• 49 patients affected by ESS (62%)
BMI 23,5 24,5 0,02

Hb 11,9 12,4 0,2

BMI is lower in the syndromic group,
Na 138,7 139,1 0,6
with a statistically significant
K 4,3 4,3 0,8
difference.
Albumine 28,6 29,8 0,2

Creatinine 0,89 0,96 0,3

The two populations are otherwise
ALT 14,5 17 0,3
homogeneous.
CCI 0,7 1,1 0,2
16
 STUDY

Results
Calcium Metabolism
35 ESS Non-ESS
30

25

20

15 30.1

10
11.2 12.4
5 9.2 9.4 8.3 8.7

2 2.8
0
-4
-6.4
-5
-2.2

-10

17
 STUDY

Results
Type of fracture
40
35
30
25
Syndromic patients more
20
15 34 frequently suffer lateral fractures
10
5
15 12
18 of the hip (p < 0,01).
0
ESS Non-ESS

31 A 31 B

18
 STUDY

Results
Anemia
Transfusions
2
Variables ESS Non-ESS p-value 1.5
Transfusions 1,56 0,5 0,01 1
INR 1,07 1,23 0,34 0.5
NAO 0 0 1 0
ESS Non-ESS
TAO 0 2 1

ASA 16 13 0,72
After ruling out confounding factors, ESS
Duration of surgery (min) 67 86 0,1
proved to be a statistically significant
predictor of increase need for transfusions

19
 STUDY

Results
Infections

Syndromic patients have a higher

risk of postoperative infection,
40
35
but this relationship is not
30 statistically significant (p = 0,1).
25
20 38
15
26
Risk of infection with ESS: 24%
10
5 11

0
ESS
4
Non-ESS Risk of infection in controls: 11%
No infection Infection
20
 STUDY

Discussion
• Syndromic patients can’t
develop an appropriate PTH Does this influence long term
response to the fracture and functional recovery and
hypovitaminosis D, impairing implant fixation?
calcium metabolism

• Syndromic patients’ Are thyroid profiles of

abnormal PTH levels syndromic patients already
positively correlate with unbalanced before the
lateral fractures trauma?
21
 STUDY

Discussion

• Syndromic patients need, Should we implement more

on average, more preventive measures in
transfusions than controls syndromic patients in order to
reduce postoperative anemia?

• Infections are more Do syndromic patients

frequent in syndromic deserve particular
x attention in
patients infection prevention?

22
 CONCLUSIONS

A substantial subset of elderlies

with hip fracture develops ESS
as a consequence of trauma,
showing:
• Reduced ability to cope with
stress
• Higher infection incidence
• Greater need for transfusions
• Lower metabolism
Study’s limits:
• Modest sample size
• Lack of thyroid profile
before trauma
Future prospective:
• Focus on long term
functional recovery and
mortality
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Thanks for your attention!

«On a day when the wind is perfect, the

sails just need to open and the world is
full of beauty.
Today is such a day»
-Rumi
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