Journal of Orthopaedic Diseases and Traumatology

: 2023  |  Volume : 6  |  Issue : 1  |  Page : 32--40

Influence of risk factors for hip injuries and effect of co-morbidities on postoperative complications and outcome after hip fracture surgery in the elderly

Khazi Syed Asif Hussain, Aluka Sundeep Kund Reddy, Mayani Raju, Chandrashekhar Patnala 
 Department of Orthopedics, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Correspondence Address:
Aluka Sundeep Kund Reddy
Department of Orthopedics, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, Telangana


Background: Older adults who sustain hip fractures usually have multiple comorbidities that may impact their treatment and outcome. This study aims to analyze the risk factors that contribute to falls in elders and analyze the effect of comorbidities on the outcome and the treatment decision-making in elderly patients with hip fractures. Materials and Methods: This cohort study was conducted on patients with hip fractures. We prospectively analyzed 140 cases of geriatric hip fractures who had undergone surgery. The Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) of each geriatric hip fracture patient were calculated based on data retrieved from the medical records. Clinical assessment was assessed using a modified Harris hip score during each visit. Results: The mean age of patients was 72.21 ± 12.2 years. The mean CCI was 1.02 ± 0.3, and ASA was 2.0 ± 0.53, and both were significantly associated with time-to-surgery (P < 0.001) and surgical treatment (P < 0.001). The length of hospital stay, duration of postoperative intensive care, and hospital expenses were associated with both CCI (P = 0.037) and ASA (P = 0.002). Greater the CCI and ASA, more chances of developing postoperative complications (χ2 = 15.724, P = 0.001). Delirium is the most common postoperative complication 15.7%, and pulmonary infection 11.4% is the most lethal complication. Conclusions: Patients with high CCI, ASA grading, and revision surgery are at high risk of developing postoperative complications, morbidity, and mortality. With efficient medical co-management of these patients, orthogeriatric care offers the best chance for a successful outcome.

How to cite this article:
Asif Hussain KS, Kund Reddy AS, Raju M, Patnala C. Influence of risk factors for hip injuries and effect of co-morbidities on postoperative complications and outcome after hip fracture surgery in the elderly.J Orthop Dis Traumatol 2023;6:32-40

How to cite this URL:
Asif Hussain KS, Kund Reddy AS, Raju M, Patnala C. Influence of risk factors for hip injuries and effect of co-morbidities on postoperative complications and outcome after hip fracture surgery in the elderly. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Mar 30 ];6:32-40
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Full Text


The term hip fracture includes both femoral neck fractures and inter-trochanteric fractures and is one of the significant causes of hospitalization, leading to loss of independence, morbidity, and mortality in elders. Incidence of hip fractures is drastically increasing worldwide, varies from country to country, and depends upon the age, sex, underlying risk factors, and comorbidities.

The incidence of hip fractures increases with age; most of the subjects are over the age of 65 years and experience an injury at the hip mostly after a fall and most commonly in women when compared to men.[1] This increase is considerably greater among women after menopause and among men after the age of 70 years, and the risk is further high in both sexes with underlying comorbidities such as hypertension, diabetes mellitus, and several systemic diseases such as hypo and hyperthyroidism, dementia, chronic obstructive pulmonary diseases, chronic kidney diseases, cardiovascular diseases, and neurological problems such as parkinsonism, vertigo, stroke, and epilepsy.[2],[3] Numerous factors may also predict the risk of hip fractures, including age, gender, ethnicity, hip axis length, bone mass, nutrition, height, and weight, prior history of hip fracture, chronic use of certain medications (antipsychotic drugs, antihypertensive medications, corticosteroids, antidepressants, and anticonvulsants), chronic smoking and alcohol consumption, place of residence, lack of caregiver, institutionalization, prolonged immobilization, decreased bone mineral density (BMD), arthritic of the knee, reduced level of activity, and visual impairment.

These fractures have several complications. Some of these are medical, and others are related to the surgical treatment itself.[4],[5] Medical complications include – cognitive and neurological alterations, cardiopulmonary affections, venous thromboembolism, gastrointestinal tract (GIT) bleeding, urinary tract complications, perioperative anemia, and electrolytes imbalance are common medical complications related to preexisting medical illness and hospitality.[6],[7] postsurgical complications are fracture specific – avascular necrosis and nonunion are common complications related to disturbed biology in patients with intracapsular fracture. In extracapsular fractures, by contrast, the problem is mechanical and relates to load-bearing; hence, fixation failure is a notable complication. In addition to these, some factors determine the postsurgical outcome, including surgical, anesthetist skill and time laps between fracture to surgery, duration of the hospital stay, good peri- and post-operative management of premorbid conditions and postoperative complications, respectively, prevention of deep vein thrombosis (DVT) and pulmonary embolism.[8]

Hence, careful preoperative assessment of risk status, the American Society of Anesthesiologists (ASA) grade and predicted postprocedure functional outcome, which affects both treatment and prognosis, are of fundamental importance when approaching the hip fracture patients.[9] This study aims to (i) analyze and investigate the risk factors for hip fractures in geriatrics, (ii) establish the relationship between comorbid conditions and outcomes following hip fracture surgery, and (iii) analyze the influence of comorbidities to determine the risk stratification in terms of outcome (postoperative complications, get back to preinjury status, morbidity and mortality) among patient of hip fracture aged ≥60 years.

 Materials and Methods

This cohort study was conducted at Nizam's Institute of Medical Sciences, Hyderabad, between 2018 and 2019 over 140 hip fracture cases satisfying the proposed inclusion criteria. Hip fracture above 60 years, hip fracture of nonpathological origin, with no prior history of cognitive and functional disability, and who have a proper clinical and surgical indication, independent of surgical type and approach, were included in this study. Ethical committee approval was obtained for the study.

Inclusion criteria

Patients with age ≥60 years with diagnosed hip fractureAbility to do activities of daily living independently before hip fracture (preinjury functional status) and who is willing for surgery.

Exclusion criteria

Patients with age <60 yearsConservatively managed hip fracturePatients who are medically unfit for surgeryPatient with any other associated fracturePeriprosthetic hip fracturesPathological hip fracturesSimultaneously bilateral hip fractures.

Study design

The study is a prospective, observational cohort study. Data include demographics, type of fracture, preoperative comorbidities, operative treatment, and postoperative complications. Data will be identified from history, medication, and previous medical records. Anesthetists presurgical fitness and refer the unfit cases to the concerned department for treatment recommendation and surgical fitness.

Sample size

As per formula N = 4PQ/d2, where P = prevalence from previous studies, Q = 100 − P, and d = allowable error (2.5%–10%), ~140 patients were analyzed as per the study design. There were no dropouts in our study.

Assessment of comorbidities

The Charlson Comorbidity Index (CCI) was used to predict the outcome in relation to patient comorbidity. The CCI incorporates the number of preexisting comorbid conditions and their severity. It represents the sum of the weighted index for different subsets of conditions: one point was awarded for myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease (except hemiplegia), dementia, chronic pulmonary disease, connective tissue disorders, ulcer disease, mild liver disease, and diabetes without complications. Two points were awarded for diabetes with end-organ damage, hemiplegia, moderate or severe renal disease, or any malignancy, including leukemia, lymphoma, diabetes with chronic complications, and solid tumors (nonmetastatic). Three points were awarded for moderate or severe liver disease, while six points were awarded for acquired immune deficiency syndrome and metastatic solid tumors. Higher scores correspond to an increased risk of mortality. The total score was calculated for each patient; based on the total score, the study population was classified into four ordinal categories: 0, 1–2, 3–4, ≥5 points. In addition, age-adjusted CCI was also calculated, wherein one point was awarded for each decade of life after the age of 50 years. Hypertension and osteoporosis, which are not included in the CCI, were also included in the analysis.

The Charlson comorbidity index scoring

ASA grading

Functional outcome

Assessed by Harris hip score (HHS) taking different variables into consideration such as pain, functional status (limp, support, distance walked, stairs, shoes and socks, sitting, and public transport use.



Excellent result is between 91 and 100, Good result – (81–90), Fair – (71–80), and Poor – (<70).

Statistical analysis

Continuous variables are expressed as mean ± standard deviation and compared using Student's t-test. Categorical variables are expressed as percentages and compared using the Chi-squared test. The CCI and other comorbidities were used as independent variables. Binary logistic regression models were used to examine the relationship of CCI with complications, surgical choice, time-to-surgery, transfusion, anticoagulation, analgesia, and complications after hip fractures. Linear regression analysis examined the relationship between the length of hospital stay and hospital expenses with CCI, age-adjusted CCI, osteoporosis, and hypertension. The results are presented as crude and adjusted regression coefficients and 95% confidence intervals, standardized coefficients, and P values. All statistical tests of significance were two-tailed, and P < 0.05 was considered statistically significant.


A total of 140 patients with hip fractures were included in the study. Of these, 92 (65.8%) were female, and 48 (34.2%) were male, with a male-to-female ratio of 1:1.9. The maximum number of the cases was in the age group of 60–70 years, with the mean age of patients being 72.21 ± 12.2 years.

Patients with femoral neck fractures accounted for 35%, whereas inter-trochanteric fractures are 65%, and right-sided (57.5%) injuries are more common than left (43.5%) side. Domestic fall (90%) is the most frequent mode of injury, and the majority of injuries occurred in the early morning hours (65.8%) while going to the washroom and carrying out their routine activities. The maximum number of hip fracture cases was reported in the lower middle and upper middle class as per Kuppuswamy Socioeconomic Scale. The average time lapse between injury to presentation is 24–48 h, and presentation to surgery is 48–72 h (χ2 = 18.250; P = 0.001). The delayed presentation was observed in femoral neck fracture with a maximum delay of 8 months.

Most of the patients had a CCI in the range of 0–2 points. Female patients exhibited a tendency for higher CCI than male patients (P = 0.057). The age-adjusted CCI for male patients was significantly higher than that for female patients (P = 0.017). The mean age-adjusted CCI of patients with intertrochanteric fracture was significantly higher than that of patients with femoral neck fracture (P = 0.010).

The prevalence of comorbidities and complications in our study population is presented in [Table 1]. Most of the patients scored one point for chronic diseases; there was a high proportion of patients who had uncomplicated diabetes and myocardial infraction with status postpercutaneous transluminal angioplasty.{Table 1}

The prevalence of hypertension was 74.2%, and most of them sustained an injury during early morning hours while carrying out their activities, particularly those on diuretics. The prevalence of osteoporosis was 84.2%, and most of them were under Singh's index Grade 3 (40%). Delirium is the most common postoperative complication 15.7%, and pulmonary infection 11.4% is the most lethal complication among all, and it is more in patients in Groups 3 and 4 as per CCI [Table 2].{Table 2}

Among surgical complications, wound infection and periprosthetic fractures are reported complications in hemiarthroplasty and screw back out or cut through and peri-implant fractures in dynamic hip screw (DHS) and proximal femoral nail (PFN) groups. Length of hospital stay, duration of postoperative intensive care, and hospital expenses showed a significant association in ASA Grading 3 onward and patients of CCI 3 and 4 Groups (χ2 = 15.724, P = 0.001) [Table 3].{Table 3}

Functional outcome

Functional outcomes were assessed using the HHS.

In hemiarthroplasty among 60 cases, 32 (53.33%) patients had excellent outcomes, 22 (36.66%) had good, 2 (3.33%) were fair, and 2 (3.33%) had a fair outcome. Not applicable to 2 patients due to death.

In DHS, among 50 cases, 6 (12%) patients had excellent outcomes, 22 (44%) had a good outcome, 2 (4%) had fair, and 2 (4%) had a poor outcome. Score not applicable to 9 members due to death.

In PFN, among 30 cases, 10 (33.3%) had excellent outcomes, 12 (40%) had a good outcome, 2 (6.6%) had fair, and 4 (13.3%) had a poor outcome. Not applicable to one patient due to death.

Functional outcomes according to CCI are reported in [Table 4]. We noticed that 30 (62.5%) and 14 (29.1%) cases had excellent outcomes with CCI Grades 1 and 2, respectively, and 4 patients (8.33%) had excellent outcomes even with 3 and 4.{Table 4}

The mean functional outcome (HHS) for 48 patients being excellent is 93.2, 56 patients having good mean HHS of 86.4, 6 patients have fair mean HHS of 76, and 8 patients have poor mean HHS of 61.

In this study, 75% were complication-free among the excellent and 71.42% good outcome group, whereas 75% developed ≥3 complications in the fair and poor outcome group (χ2 = 51.491 P = 0.001). Greater the CCI and ASA grading, the chances of developing postoperative complications were more (χ2 = 15.724, P = 0.001).

The reported death rate in this study was 22 (15.7%), out of which 20 (90.9%) developed more than 3 complications in the postoperative period, and 17 (77.27%) of them had CCI Grades 3 and 4, and ASA 4 onward (χ2 = 15.724; P = 0.001) and remaining cases are because of inadequate preoperative optimization. A higher chance of death rate was reported among revision surgeries 8 (66.6%) out of 12 revision cases (χ2 = 9.000, P = 0.002).


In the present study, 76.9% of geriatric patients with hip fractures were not operated on during the first 48 h. This is likely attributable to the time required to assess and stabilize comorbid diseases. The weight of comorbidities in elderly patients with hip fracture (as assessed by CCI) was associated with time-to-surgery in excess of 48 h, which implies that an increase in the CCI increased the risk of delayed surgery. However, it showed no significant association with time-to-surgery in excess of 48 h after adjusting for age. In addition, the weight of comorbidities in elderly patients with hip fracture (as assessed by age-adjusted CCI) was associated with the unavailable operation, increased transfusion, increased hospital stays, and hospital expenses.

The maximum number of the cases was in the age group of 60–70 years, with a mean age of 72.1 years. There is a female preponderance (male: female ratio 1:1.9) in our patients due to postmenopausal osteoporosis and a higher frequency of falling while engaging in household activities and longevity of life. Domestic fall is the most frequent mode of injury in both females and males, but road traffic accidents are quite common in males compared to females as they engage in more outdoor activities such as agriculture and driving motor vehicles. The delayed presentation was common in the upper lower class and poor population due to a lack of caregivers, financial issues, and superstition.

In the present study, hip fractures showed diurnal variation and were most common during the early morning hours, and this may be correlated with the fact that older people do most of their routine activities in the early morning hours. In this study, most of the patients had either hypertension or diabetes and with increased frequency of urination, either because of diabetes

or due to diuretics medication for hypertension management and also because of electrolyte imbalance contributing to the event of fall in early morning hours in this population. The second peak was during evening hours. This may be because of impaired vision.

In the present study, most of the fractures occurred in the lower middle and upper middle groups compared to the upper class according to Kuppuswamy Socioeconomic Scale. This is attributed to a lack of dependents and caregivers; they have to do their homework by themselves. Most of the patients are self-dependent without a caregiver. This could be one of the reasons for the fall.

In the present study, mean time to hospital presentation was 8.94 days with a minimum delay of 6 h to a maximum delay of 4 months. Delay in the presentation was quite common in the Intracapsular group compared to the inter-trochanteric group because of less pain and impact on mobilization. The delayed presentation also was because of a lack of caregivers, ignorance, and the superstition among rural people that they will be cured by native treatment. The average time delay for hospital presentation and diagnosis of hip fracture is 9.6 days in the study conducted by Sangbong et al.[10]

The mean time for surgery in the present study is 4.39 days, with a minimum period of 3 days to a maximum of 9 days. Time-lapse between presentation to surgery is individualized based on general condition and number of comorbidities and drug therapy. In the present study, the reason for the delay in surgery was because of variable perioperative blood sugars among the diabetics and hypertensives, uncontrolled blood pressures, further evaluation, and preoperative optimization of patients with other systemic illnesses. There was a delay in surgery because of certain drug therapy like antiplatelet medication, where we had to wait for surgery. In this study, 12.8% of patients were on dual antiplatelet medication either for treatment purposes or for prevention of impending stroke or myocardial ischemia. In such cases, we waited up to 5 days until platelet count returned to the desired level (>1 lakh), and in a few cases, a platelets aggregometry test was done for whom platelet count was not in the optimal range (<1 lakh). The mean time for surgery is 3 days in the study done by Vidán et al.[11] Delay in surgery >48 h was associated with more postoperative complications in a study by Smeets et al., but like we said time to surgery needs to be individualized.[12]

In the present study, 102 out of 140 patients were hypertensive, and among 102, 52 cases were using diuretics in combination with other antihypertensives for hypertension management with a history of falling in the early morning hours of the day. This is due to the increased frequency of urination and electrolyte imbalance in them. People with diabetes with uncontrolled blood sugars also have an increased frequency of urination and falling in the washroom. In some cases, those on longstanding insulin and oral hypoglycemic agents lead to osteoporosis and are vulnerable to falls. Among the patients with central nervous system disturbance who are on anticonvulsants for epilepsy and benzodiazepines and antidepressants probably contribute to the fall event because of side effects such as confusion, dizziness, and drowsiness. In our present study, patients on polypharmacy therapy are at risk of injury because of their side effects.

In our study, the mean body mass index (BMI) is 23.3, with a minimum of 14.7 to a maximum of 31.2. Most of the patients fell underweight and overweight in our study. Higher BMIs were prevalent among people with diabetes and hypothyroid patients. The prevalence of BMI in this study is 42.8% among overweight, 35.7% among underweight, and 21.4% among normal-weight people. The risk of falls is more prevalent among both underweight and overweight people.

In a study conducted by De Laet et al., they observed that low body weight had been recognized as a risk factor for fracture in the elderly.[13] The increased risk associated with low BMI may result from several factors, including low BMD, less soft tissue that may protect bone from impact forces, and increased fall risk resulting from muscle weakness. Other risk factors that may contribute to the event of the fall in this study are visual impairment, osteoporosis, lower limb arthritis, and alcohol addiction. In a study conducted by Shafiei et al. the age has been found the major risk factor for 1 year moprtality.[14]

In this study, 60 members were operated by hemiarthroplasty, 50 by DHS, and 30 by PFN. The operating time varied from procedure to procedure. The mean duration for hemiarthroplasty was 41.25 min; for DHS, it was 70 min, and for PFN, it was 58.6 min. In our study, the mortality at the end of 1 year was found less in patient treated with hemiarthroplasty as compared to DHS or PFN similar to the results found by Zandi et al. comparing mortality in hemiarthroplasty versus DHS.[15] CCI and ASA grading influence the duration of postoperative intensive care unit (ICU) stay. Greater the ASA and CCI grading more the chances of postoperative complications leading to prolonged intensive care support. In our study, the mean duration was 2.54 (±3.14) days, and the maximum number of cases was 80 (57.4%). In the study conducted by Eschbach et al. observed 336 (85%) of all patients in the ICU postoperatively for a mean of 2.5 (±3.7) days.[16] In Mousapour et al.'s study, patients with bipolar hemiarthroplasty for hip fractures were found to have lower morbidity and mortality compared to DHS fixation.[17] In a study by Saeb et al. Tranexamic acid's effectiveness in bleeding control during surgery has been found significant in contrast to our study where there is no significance of intraoperative bleeding.[18]

Postoperative systemic complications

Pulmonary complications

Lower respiratory tract infection (Pneumonia) and acute respiratory distress syndrome are lethal complications among patients with high ASA grading and CCI, especially male patients who are a smoker and alcoholics.

In our study, chest physiotherapy and advised spirometry for optimization of the pulmonary reserve, and patients were made to sit in fowler's position while feeding to prevent aspiration-related complications. To prevent volume overload and related complications in patients with renal compromise, strict monitoring of fluid input and output is done.

Cardiac complications

We monitored patients with serial electrocardiography (ECG), cardiac profile for the patients with significant ECG changes, and strict fluid management to prevent volume overload on the heart in patients with compromised cardiac function.

Central nervous system

Cognitive complications were reported in 21.42% of patients in which delirium is the most common among the cognitive complications.

In this study, most of our patients with delirium had electrolytes imbalance and a history of alcoholism, and we treated them with proper management of fluid and electrolytes and prompt initiation of certain drug therapy.

The study done by Smeets et al. reported underlying mechanisms responsible for developing cognitive complications; in this study, delirium was frequently reported cognitive complication.[19]

Urinary tract complications

Urinary retention (10%), urinary tract infections (5.7%), and acute kidney injuries (1.4%) were reported as postoperative urinary tract complications in this study.

We monitored renal function with strict input and output charting and corrected metabolic disturbances based on arterial blood gas avoided using nephrotoxic medications, epidural drugs, and opioids for postoperative pain management.

Chong et al. studied over medical problems in hip fracture patients; in their study, they reported that urinary retention and urinary tract infection are common postoperative urinary tract complications.[5]

Gastrointestinal tract complications

GIT complications are the most commonly reported complications within the first 3 days, and the underlying mechanism responsible for this is multifactorial, probably due to drug-induced or due to fluid and electrolyte disturbance. Constipation and dyspepsia are common reported postoperative gastrointestinal complications, and we treated them with laxatives. Paralytic ileus is the most attention-seeking GIT complication and is managed with correction of electrolyte imbalance and enteral feeding with Ryle's tube.

Chong et al. studied over medical problems in hip fracture patients; in this study, they observed constipation and dyspepsia, common gastrointestinal complication.[5]

Deep vein thrombosis

The incidence of DVT in our study is 2.8%. The underlying mechanism responsible for this is unclear-all of these are operated by osteosynthesis (DHS and PFN), which may be related to the length of immobilization. In addition to this, all of them had high ASA grading and CCI. We treated them with anticoagulation therapy and intermittent compression stockings.

Liu et al. analyzed 222 patients with geriatric hip fractures, and they observed incidence of DVT was 1.4% in their study.[20]

In a study by Kastanis et al. patients with a high ASA score require a multidisciplinary approach and a special assessment to decrease postoperative morbidity and mortality and offer optimal functionality.[9] With the presence of multiple preoperative comorbidities, high ASA grading, and revision surgery, patients are at high-risk development of postoperative complications, morbidity, and mortality [Table 5].{Table 5}

Postoperative surgical complications

The reported incidence of surgical site infection is 10%, and it is 7.2% among the hemiarthroplasty and 2.8% among DHS. No infection was reported in the PFN group. We managed with appropriate antibiotics and wound care.

Malunion (varus malunion) was the most commonly reported complication among DHS 22 (44%); the underlying reason for this is multifactorial-either insufficient reduction, presence of lateral wall comminution, screw back out, and presence of posteromedial comminution and osteoporosis and among PFN group varus malunion reported 6 (20%) cases. Out of this, 4 (13.33%) cases developed screw cut out, and 2 had varus mal reduction. Factors responsible for varus mal union in this study may be due to varus mal reduction leading to the placement of screws in a superior and posterior position in the head and neck, leading to varus collapse and early cut out of the screw and unstable fracture pattern and poor bone quality may also be determining factors. Considering four screw cut-outs in this study with resultant fixation failure, we believe it is a technical failure, fracture, and patient characteristics rather than implant failure. We reported one peri-implant fracture and one PFN case with a broken implant. By this time, the fracture had already united. Periprosthetic fractures were reported in 4 (6.66%) patients with hemiarthroplasty, 1 occurred intraoperatively during forceful implantation, and 1 occurred during the postoperative period. The reason for intraoperative periprosthetic fractures may be because of iatrogenic injury and also depends upon the preexisting bone quality.

Hrubina et al. studied 367 postoperative cases of DHS and analyzed the cut-out phenomenon (6), avascular necrosis of the femoral head (5), progression of coxarthrosis (4), screw breakage (2), femoral fracture under the plate (2). Screw backout was reported in 6 (20%) cases of DHS fixation, unstable fracture pattern, and the presence of osteoporotic bone are probable contributing factors.[21]

Siddiqui analyzed modes of failure of the PFN in 45 cases of unstable trochanteric fractures.[22] They observed varus malunion in four cases; two patients developed cut-out, and the rest went into successful varus malunion.

Our study analyzed risk factors and comorbidities in elderly patients and their influence on postoperative complications and outcomes after hip fracture surgery. These findings cannot be generalized to the entire population as sample size is less. Meta-analysis is required to explore the findings in the current study.


In view of the increasing life span, the incidence of geriatric hip fractures is on the rise. Early optimization, meticulous surgery, proper postoperative management, and early mobilization are the key factors for a successful outcome. Patients with high CCI, ASA grading, and revision surgery patients are at high risk of developing postoperative complications, morbidity, and mortality requiring special attention to appropriate management. With efficient medical co-management of these patients, orthogeriatric units offer the best chance for a successful outcome, reducing the length of stay, in-patient problems, and mortality, allowing the patient to recover to their preinjury ambulatory state.


We would like to express our special thanks to the staff of the orthopedic wards in NIMS Hospital, Hyderabad.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.


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