Relationship between preoperative immuno-inflammatory indicators and impaired consolidation of femoral fractures in elderly and senile patients

Background. Impaired consolidation of femoral fractures in elderly patients is a clinically significant problem determined not only by mechanical but also by biological factors. Understanding of the role of preoperative immuno-inflammatory and osteometabolic markers in shaping the union outcome remains insufficient. The purpose was to assess the relationship between preoperative post-traumatic indicators of systemic inflammation, cytokine regulation, and bone remodeling with subsequent impaired consolidation of femoral fractures in elderly and senile patients. Materials and methods. A single-center retrospective ­cohort study included 43 patients operated on for femoral fractures (2020–2022). Each patient was assigned one mutually exclusive category based on clinical and radiological assessment at 6–12 months or at the time of revision surgery: physiological consolidation (n = 15), delayed consolidation (n = 17), nonunion (n = 11). The primary laboratory indicator was the RANKL/OPG (receptor activator of nuclear factor-kappa B ligand/osteo-protegerin) ratio. Additionally, the neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-), IL-10, transforming growth factor (TGF-), RANKL and OPG were studied. Welch’s analysis of variance, the Fisher-Freeman-Halton exact test, and the Benjamini-Hochberg and Holm corrections were applied. Results. As the outcome worsened, the NLR (2.2 ± 0.7 3.5 ± 1.1 5.1 ± 1.8), IL-6 (7.8 ± 2.6 15.4 ± 5.1 26.7 ± 8.9 pg/mL), TNF- (9.6 ± 3.4 17.8 ± 5.7 29.3 ± 9.1 pg/mL) and the RANKL/OPG ratio (0.29 ± 0.08 0.66 ± 0.19 1.49 ± 0.44; p < 0.001 for all) increased consistently. IL-10 and TGF- levels ­decreased. When delayed consolidation and nonunion were combined, the RANKL/OPG ratio was higher by 0.70 units (95% confidence interval 0.49–0.90; Hedges’ g = 1.63), IL-6 by 12.04 pg/mL, and TNF- by 12.72 pg/mL. All additional laboratory differences, except for monocyte levels, remained significant after correction for multiple comparisons. Conclusions. Impaired consolidation of femoral fractures in elderly patients was associated with a preoperative pro-inflammatory and resorptive profile. The largest and most consistent differences were found for RANKL/OPG, IL-6 and TNF-. The findings reflect unadjusted clinical associations and require confirmation in a prospective study on an independent sample.

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