|Year : 2023 | Volume
| Issue : 1 | Page : 101-105
A study of morbidity and mortality of surgically managed hip fractures in elderly patients in the 1st Year
TS Channappa, Manju Jayaram, HB Shivakumar, CL Karan
Department of Orthopaedics, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Submission||29-Aug-2022|
|Date of Decision||10-Sep-2022|
|Date of Acceptance||21-Oct-2022|
|Date of Web Publication||27-Dec-2022|
C L Karan
Department of Orthopaedics, Kempegowda Institute of Medical Sciences, Bengaluru - 560 004, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Fractures of hip are one of the most common injuries sustained by the elderly. They occur predominantly in patients aged over 60 years. For many, this fracture is often a terminal event resulting in death due to comorbidities and cardiac, pulmonary, or renal complications. The incidence of morbidity and mortality after hip fractures was evaluated in this study. Methodology: We included 102 patients who were divided into two groups; 54 patients with fracture neck treated by hemiarthroplasty as arthroplasty group, and 48 with intertrochanteric fracture treated by internal fixation with proximal femoral nail or with dynamic hip screw as internal fixation (IF) group were followed up for 1 year. The preexisting medical comorbidities, intraoperative findings, and postoperative complications were documented. The final functional results were evaluated using Merle d'Aubigne score at the end of 1 year. Results: This is a descriptive cohort study from the local population. The mean age was 74.5 years. We noted a total mortality of 17.6%. Diabetes mellitus and anemia were the most common comorbidities. Binary logistic regression analysis was performed to predict the survival status among the study patients. We found that male patients with anemia to be most associated with mortality. Excellent results were noted in 39% of cases of arthroplasty and 60% of cases of IF. Morbidity experienced was greater in extracapsular fracture type, who were less mobile during the postoperative period. Conclusion: Hip fractures are on a rising trend in the elderly population, especially in the Indian subcontinent. Mortality and morbidity in elderly patients in the 1st year are significant. Age and preexisting comorbidities contribute to morbidity. Morbidity leads to loss of independence and requirement of social support. The goal of treatment in fractures of the hip must be the restoration of the patient to their preinjury status at the earliest possible time.
Keywords: Comorbidities, hip fractures, Merle d'Aubigne score
|How to cite this article:|
Channappa T S, Jayaram M, Shivakumar H B, Karan C L. A study of morbidity and mortality of surgically managed hip fractures in elderly patients in the 1st Year. J Orthop Dis Traumatol 2023;6:101-5
|How to cite this URL:|
Channappa T S, Jayaram M, Shivakumar H B, Karan C L. A study of morbidity and mortality of surgically managed hip fractures in elderly patients in the 1st Year. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:101-5. Available from: https://jodt.org/text.asp?2023/6/1/101/365292
| Introduction|| |
Fractures of hip are one of the most common injuries sustained by the elderly, and are predominant in patients aged over 60 years. The perceptions among the general population demonstrated that they did not understand the implications of hospitalization and underestimated the mortality associated with these fractures. This fracture is associated with cardiac, pulmonary, or renal complications. They are often a terminal events resulting in death due to these complications combined with preexisting comorbidities.
The goal is to restore the patient to their preinjury status at the earliest. In recent times, the emphasis is on the surgical management to decrease the duration of hospitalization and reduce complications associated with prolonged recumbency. This increases patient comfort and facilitates nursing care in these patients. In a meta-analysis comparing conservative management with operative treatment for extracapsular adult hip fractures, they found operative management to result in fracture healing with a shorter hospital stay and good functional outcome.
In a randomized study, comparing 297 patients with displaced intracapsular fractures treated by reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty showed similar mortality rates among the treatment groups. However, the fixation group had the worst hip-rating-questionnaire at 12 months, and the total hip replacement group had a superior functional outcome than the other two. They concluded that fixation is associated with poorer outcomes and higher costs, suggesting that it is not as cost effective compared to bipolar hemiarthroplasty or total hip replacement. In developed countries, the inclination is toward the total hip replacement for all fractures of the hip. However, this procedure is costly and is out of the reach of many patients in our country. The surgical management aimed at reducing morbidity is evolving. Preexisting comorbidities contribute to the morbidity and mortality associated after sustaining these fractures. Morbidity leads to loss of independence and financial burden to the patient. The aim of this study was to evaluate the incidence of morbidity and mortality associated with hip fractures in the 1st year of surgical management and to determine the predictors of morbidity and mortality.
| Methodology|| |
This is a descriptive cohort study conducted at a tertiary care hospital conducted between October 2019 and January 2022. All the cases were from the local population.
Participants and randomization
A total of 102 patients with a hip fracture meeting the inclusion criteria were included in the study. The patients were evaluated preoperatively and followed up postoperatively for 1 year. The patients were enquired and evaluated clinically and by laboratory investigations for associated comorbidities. The data were recorded in a case recording proforma. The data were transferred onto a master chart which was subjected to statistical analysis. The Institutional Ethical Committee approval was obtained before commencement of the study.
The patients were divided based on fracture pattern into arthroplasty group with fracture neck of the femur and intertrochanteric femur fracture patients were grouped as internal fixation (IF) group. The patients in arthroplasty group were managed by hemireplacement arthroplasty and IF group by dynamic hip screw or proximal femoral nail. The patients were started on physiotherapy exercises, and all necessary steps were taken to start mobilization with a walker support as early as possible. During discharge, the patients were given necessary advice for rehabilitation and medical advice. The patients were advised regular follow-up and evaluated for pain, walking aids, and mobility based on the Merle d'Aubigne hip score.
Inclusion and exclusion criteria
Patients who are more than 60 years of age, both males and females, who sustained a hip fractures which include neck of femur fracture and intertrochanteric fracture of femur were included. The patient who sustained a pathological fracture or had a previous hip fracture which has been treated and periprosthetic fractures were excluded from the study.
Patients were followed up for 1 year. With each follow-up, the patients were categorized as survivors and nonsurvivors, and the survivors were evaluated for pain, deformity, and mobility based on the Merle d'Aubigne hip score. The descriptive analysis includes the expression of all explanatory and outcome parameters in terms of frequency and proportions. Chi-square test and binary logistic regression were performed. P < 0.05.
| Results|| |
In our study, 102 cases were included. The mean age was 74.5 years. Females were the majority with 63 cases compared to 39 males. The cases were divided into two groups; the arthroplasty group with 54 cases and IF group with 48 cases. The overall time gap to surgery from the date of admission was on average 3.8 days.
Most of the patients in our study had more than one medical problem. The most common medical problem was diabetes mellitus in 50% of the patients and iron deficiency anemia in 35.2% of the total patients, as summarized in [Table 1].
|Table 1: Association between comorbidity in the two groups using Chi-square test|
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Binary logistic regression analysis was performed to predict the survival status among the study patients. We found that male patients with anemia to be most associated to mortality, as shown in [Table 2].
|Table 2: Binary logistic regression analysis to predict the survival status among the study patients|
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Mortality was related to age and preexisting comorbidities. The total mortality noted in this study was 17.6%. Mortality was higher in IF group, with 20.8%, compared to arthroplasty group, with 14.8% of cases. The risk of mortality was high when anemia was a comorbid condition, as summarized in [Table 3] and compared in [Graph 1].
|Table 3: Association between comorbidity and the survival status of patients using Chi-square test|
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Three patients were confined to bed post-operatively and developed pressure sores…. as summarized in [Table 4]. One of the patients of arthroplasty group had dislocation of prosthesis postoperatively, and a second surgery was performed to reduce the dislocation; the patient tolerated the surgery well and was mobilized. In our study, one of the patients of IF group had a history of fall and presented with a mechanical failure. The patient underwent a revision surgery, but did not survive at the end of 1 month.
Mobility and walking aids
Patients treated with IF tolerated weight-bearing mobilization better, as summarized in [Table 5]. Patients treated with arthroplasty were found to have a lesser dependence on walking aids at the end of 1 year. Three patients treated by IF continued to walk with a walker at the end of 1 year.
|Table 5: Comparison of patients' ability to walk with walking aids according to Merle d'Aubigne hip score using Chi-square test|
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The residual pain was tolerable in both the groups, as summarized in [Table 6]. In our study, 54% of patients experienced no pain. Patients with hemireplacement arthroplasty without cement complained of more pain at the end of 1 year. Pain was also assessed using the visual analog scale. The IF group had a higher mean visual analog scale (VAS) score compared to arthroplasty at the time of injury. However, at the end of 12 months, patients in the arthroplasty group had a higher mean VAS score of 1.28 compared to 0.55 in IF group.
|Table 6: Comparison of pain according to Merle d'Aubigne hip score using Chi-square test|
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Final functional results (Merle d'Aubigne hip score)
The final functional results at the end of 1 year were calculated using the Merle d'Aubigne hip rating scale in the surviving patients. Excellent results were noted in 37% of patients of arthroplasty and 63% of patients in IF as represented in [Table 7].
|Table 7: Comparison of final functional results as per hip rating scale of Merle d'Aubigne using Chi-square test|
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| Discussion|| |
Hip fractures typically occur in elderly patients following low-energy falls from standing height. There is an increased risk of falling with age due to the rising prevalence of risk factors in older age groups. The elderly patients often have a deteriorating eyesight, abnormal gait or balance, neurologic disease, muscle weakness, and sedative or cardiovascular side effects of medication which increase the risk of falls. There is a rising trend of these fractures, especially in the Indian subcontinent. Factors such as poor nutrition, deficiency of Vitamin D, lack of awareness about nutrient supplementation, and hormone replacement therapy in postmenopausal women are specific to the Indian population for early-onset osteoporosis. These make them prone to fracture of the hip. There is a significant risk of mortality and morbidity postinjury.
In our study, mortality was found to be more with intertrochanteric fractures compared to fractures of the neck of the femur. Keene et al., in 1992, found that mortality was higher in extracapsular fractures than intracapsular fractures at 1 year. Mundi et al., in a review of RCTs, found that the mean 1-year mortality diminished from 24% in the 1980s to 23% in the 1990s and 21% after 1999. In intertrochanteric fractures, the mean mortality rates reduced from 34% before 2000 to 23% in studies done after 1999, whereas those of femoral neck fractures were found to be similar.
In our series, 14.8% of patients in IF group and 20.8% in arthroplasty group did not survive at the end of 12 months. Of the remaining patients, the final outcome was satisfactory as far as the hip rating system. The mortality rates described in various studies in patients of the arthroplasty group and IF group are comparable to our series, as shown in [Table 8].
|Table 8: The mortality rates described in various studies compared to our study|
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Mortality is found to be associated with the gender of the patients in various studies. In a population-based study in the United States by Brauer et al. documenting 786,717 hip fractures in people aged 65 years and older between 1986 and 2004, found mortality at the end of 1 year to be 21.9% in females and 32.5% in males in 2004. In our study, men had a higher risk of mortality compared to other studies. The reason is unclear, and this disparity could be due to comorbidities and the prevalence of smoking among men.
In a study done by Kopp et al. to determine the incidence of pressure ulcers after surgical treatment of proximal femoral fractures in the elderly and its impact on mortality, found that there is a high incidence of pressure ulcer (34.2%) in the postoperative period which significantly lowered survival. One of the patients in our study with uncontrolled diabetes was confined to bed. The patient developed pressure sores and died at the end of 2 months.
In a large cohort study quantifying the burden of disease due to hip fractures by Papadimitriou et al., used disability-adjusted life years (DALYs). They found an average loss of 2.7% of healthy life expectancy after hip fractures. Disability was found to predominate over mortality. Comorbidities such as diabetes, sedentary lifestyle, and smoking increased the burden in hip fractures. Morbidity leads to loss of independence and the requirement of social support. This leads to potential implications on society. The goal of treatment in fractures of the hip must be the restoration of the patient to their preinjury status at the earliest possible time.
Surgical management is more likely to result in fracture healing and early mobilization, which leads to a shorter hospital stay. Bulstrode reported that early fixation reduces mortality, morbidity, and length of hospital stay after the surgery. In a study conducted by Bredahl et al., concluded that survival at 1 year was higher for those patients operated on within 12 h. The presence of pneumonia, urinary infection, wound infection, and pressure sores can lead to a delay in surgery. In another study done on 850 patients, it was found that an early surgery in these patients leads to an improved ability to return to independent living, reduces the risk of pressure ulcers, and a short hospital stay.
| Conclusion|| |
Hip fractures are on a rising trend in the Indian subcontinent in the elderly population. Morbidity and mortality in elderly patients after fracture of the hip are significant in the 1st year. Morbidity leads to loss of independence and the requirement of social support. Male patients with anemia were found to be most associated with mortality. The total mortality noted in this study was 17.6%. Excellent results were noted in 40% of cases in our study. The goal of treatment in fractures of the hip must be the restoration of the patient to their preinjury status at the earliest possible time. The surgical management is evolving, but morbidity remains. The management strategy should consider the age and comorbidities. A treatment plan should be made according to the patient needs and fracture type, in a cost-effective way to reduce the morbidity and burden following these fractures in the elderly.
We acknowledge the patients who participated in this study for their consent for publication.
Dr. T S Channappa: Conceptualization, Methodology; Dr. Manju Jayaram: Data curation; Dr. H B Shivakumar: Supervision; Dr. Karan CL: Writing-Original draft preparation, Reviewing and Editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]