Social effects of fractures of the neck of the femur

Mortality following hip fracture: Trends and geographical variations over the last SIXTY years

INTRODUCTION

The management of hip fractures has advanced on all aspects from prevention pre-operatively, specialised hip fracture units, early operative intervention and rehabilitation. This is in line with the appropriate recognition over the past years of an important presentation with significant mortality and socioeconomic consequences of ever increasing incidence in an aging population. It is therefore imperative to continue to gather data on the incidence and trends of hip fractures to guide future management planning of this important presentation.

METHODS

A review of all articles published on the outcome after hip fracture over a twenty year period (1999-2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 - 1998) and attempts to present trends and geographical variations over sixty years.

RESULTS

The mean age of patients sustaining hip fractures continues to be steadily increasing at approximately just over 1 year of age for every 5-year time period. The mean age of patients sustaining hip fractures increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from an overall mean of 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% (2010s). There is a decreasing trend in the proportion of intracapsular fractures from 54% (1970s) to 49% (2000s) and 48% (2010s).

CONCLUSION

Our study indicates that significant progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical urgency all playing a role in the improvements in mean age of hip fracture incidence and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally with results now being published from more widespread institutions indicating appropriate increased attention and commitment to an ever-increasing presentation.

Early Home Rehabilitation for the Patient with a Hip Fracture

This article is a report on the Peterborough hip fracture project, which is uniquely facilitated by the availability of the hospital at home service. It discusses the results of the first 44 months of the project and describes the role of the occupational therapist in this team approach to the management of the elderly patient with a broken hip.

Activities of Daily Living after Hip Fracture: Pre- and Post Discharge

Sixty-one individuals hospitalized for hip fractures received activities of daily living (ADL) assessments during the 3 days prior to discharge. Information was also collected regarding anticipated role loss, depression, mental status, health status, and social support. Independence in ADL at home was measured 3 weeks following discharge by telephone interviews. The concordance between predischarge and post discharge ADL scores was low but statistically significant (Kw = .223; p < .05). Approximately 50.8% of the subjects demonstrated greater dependence post discharge. More dependent ADL performance at home was not related to role loss, depression, mental status, health status, or social support. Predischarge ADL assessments are often taken into consideration when formulating discharge plans. However, these evaluations do not always accurately predict post discharge ADL independence. It is recommended, therefore, that community follow-up be carried out with patients who have fractured hips.

Determinants of rehabilitation following fracture of the hip in elderly patients

The objective of the study was to explore the relationships between rehabilitation outcomes in elderly patients admitted to a rehabilitation hospital following a surgically treated hip fracture and independent variables. Prefracture function, and independent patients' variables and particulars regarding the fracture were recorded. Functional and mental status as well as motivation and co-operativeness were assessed on admission to rehabilitation, during rehabilitation and six months after discharge. Data were transferred to structured questionnaires for analysis.

A total of 112 patients with a mean age of 74.8 years, made up of 75% females and 25% males, were admitted consecutively for rehabilitation after a surgically treated hip fracture sustained in a fall, during a two-year period (1989-91). Of these, 11 patients (9.8 per cent) died during rehabilitation; 86% of the 101 survivors returned to their prefracture residence, but 25% of survivors had not attained their prefracture functional status by discharge. Motivation, co-operativeness and unimpaired mental function on admission to rehabilitation were found to be the most important determinants of satisfactory outcomes.

It was concluded that attention should be paid to the elderly person who has sustained the fracture and not only to the fracture itself. Motivation and co- operativeness should be constantly monitored during the rehabilitation process.

Utility of diagnostic ultrasound in evaluating fracture healing

With increase in population, modes of transportation and a fast pace of life, an individual's chances of accident and thereby chances of getting fractured have increased significantly. Fracture has thus become a significant factor contributing to morbidity and mortality. To resume a normal life, after one suffers from a fracture is also an ordeal. The transition appears smooth if the fracture healing goes on in a smooth manner as is expected through its routine stages of reactive phase, reparative phase and remodeling phase. But if in this chain something goes wrong or some factors are not optimum upto the mark, then the process becomes unsuccessful and the repair is either partial or directionless. It is therefore very vital to confirm whether or not the callus which bridges the fractured fragments is healthy or not. Here in lies the role of imaging as it can show the status of callus without disturbing it. What complicates the picture is that a callus might not be well demonstratable unless it mineralizes or calcifies. An imaging modality like ultrasound therefore stands out as it can show the state of callus in its different stages. This article aims at demonstrating how ultrasound- a non invasive diagnostic imaging modality can give precise information about the progress of fracture healing and thereby aid in management of fractures, so that an individual can return back to normal productive lifestyle. This preliminary study highlights the spectrum of fracture healing as seen on ultrasound.

Scoring systems to evaluate elderly patients with hip fractures

PURPOSE

To report about different scales and scoring systems used to evaluate elderly patient with hip fracture during the acute post-fracture phase and during post-operative rehabilitation.

METHODS AND RESULTS

Report of the different scales from a literature review.

CONCLUSIONS

Standard validated scales are one of the tools to perform such an evaluation process as objectively as possible and to evaluate surgical, medical and rehabilitative management in these elderly patients. These scales are only a complementary tool, and they cannot replace physical examination. However, these validated tools are probably more accurate than just clinical impression. The appropriate combination of clinical experience and these scales may well contribute to a better care of elderly patients with hip fractures.

Mortality following hip fracture: trends and geographical variations over the last 40 years

Hip fractures are an ever increasing cause of morbidity and mortality. Treatment of this condition requires an all-encompassing approach from prevention to post-operative care. It is important in such a situation to gather data on the incidence and trends of hip fractures to aid in the future treatment planning of this important condition. A review of all articles published on the outcome after hip fracture over a four decade period (1959-1998) was undertaken to determine any changes that had occurred in the demographics of patients and mortality over this time period. The mean age of patients sustaining hip fractures was found to be steadily increasing over the study period at a rate of 1 year of age for every 5-year time period. The mean age in the 1960s was 73 years to a mean of 79 years in the 1990s. No notable differences were seen in the proportion of male patients over the years but a definite downward trend was noticed with regard to intracapsular fractures. The mortality at 6 and 12 months after injury remained essentially unchanged over the four decades reviewed. Mortality after a hip fracture remains significant, being 11-23% at 6 months and 22-29% at 1 year from injury. Geographical variations exist in the mortality after hip fracture. More detailed international comparisons are required to determine if these differences in outcome are accounted for by the variations in the demographics of patients or due to diversities in treatment methods.

Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men

OBJECTIVE

To determine gender-specific differences in prefracture status and postoperative outcome in elderly hip fracture patients who were ambulatory, community-dwelling, and cognitively intact prior to fracture.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Urban orthopedic referral hospital.

PATIENTS

A total of 983 consecutive patients (206 males and 777 females) who sustained a nonpathologic hip fracture were followed for a minimum of 12 months.

INTERVENTION

Operative treatment of a proximal femur fracture.

MAIN OUTCOME MEASUREMENTS

Postoperative medical complications, place of discharge, 1-year mortality, and postoperative recovery of ambulation, basic activities of daily living, and instrumental activities of daily living.

RESULTS

Men were more likely to be married or living with someone else, and they were more dependent in instrumental activities of daily living than women prior to hip fracture. Furthermore, men were sicker as evidenced by a higher American Society of Anesthesiologists rating of preoperative risk. Postoperatively, men were more likely to sustain a medical complication and had a higher mortality at 1 year compared to women. There were no statistically significant gender differences in patient age, fracture type, prefracture level of help, ambulation, or dependence in basic activities of daily living, place of discharge, and postoperative recovery of ambulation as well as basic and instrumental activities of daily living.

CONCLUSIONS

Male gender was a risk factor for sustaining a postoperative complication as well as a higher mortality at 1 year post hip fracture.

Predictors of functional recovery for hip fractured elders during 12 months following hospital discharge: a prospective study on a Taiwanese sample

To examine the longitudinal changes in overall and individual physical activities of daily living (PADLs) and instrumental activities of daily living (IADLs), at 1, 3, 6, and 12 months after hospital discharge in elderly subjects, 110 hip fractured elders (mean+/-SD age, 79.4+/-7.5; 60.9% females) were enrolled in a prospective study. At 12 months following hospital discharge, 56.1% subjects had recovered their overall PADLs, 37.9% had recovered their overall IADLs, and 74.2% could walk independently or with the aide of a cane. When analyzed by generalized estimating equations (GEE), for individual PADL, bathing and climbing stairs had consistently improved at every time point throughout the 1-year follow-up period, while transferring, toileting, and walking ability only improved significantly in the first 3 months after discharge. For individual IADL, the proportion of recovery for mobility appeared to increase significantly during the first 6 months post-discharge, and the remaining IADLs appeared to be stable. These results indicated that the recovery rate is varied for performance of different activities according to the complexity and the involvement of the lower extremities. We also found that less concomitant diseases, and a shorter hospital stay could predict a better recovery trend of overall and of most individual PADLs. These findings may be applicable to other countries with Chinese populations, and could provide a reference for health care providers to develop specific interventions for Chinese hip fractured elders.

Re-evaluation of two simple prognostic scores of outcome after proximal femoral fractures

The Belfast and Newcastle simple prognostic scores of outcome after treatment of proximal femoral fractures were recorded shortly after admission on 250 patients. All patients were then followed until discharge, with 87 of those who were the more physically and socially dependent before admission being transferred after surgery for rehabilitation in a geriatric unit. The hospital mortality rate, a hospital stay of over 6 weeks and two measures of rehabilitation outcome, i.e. a delay of over 3 weeks after the operation in regaining independent mobility and any functional decline on discharge compared with the preadmission situation, were recorded for each patient. The prediction of a higher hospital mortality rate and a delay in reaching independent mobility in more dependent patients with both scores reached statistical significance. Longer hospital stays in the more dependent patients did not occur in a situation where care facilities for dependent patients were readily available. The scores, in particular the Belfast score, can be used to compare the casemix of patients with proximal femoral fractures within and between units over time and can predict mortality and delay in achieving independent mobility. They may be helpful in the early selection of patients for transfer to a geriatric unit or orthogeriatric unit for rehabilitation.

Use of standardised assessment scales in elderly hip fracture patients

Standardised scales recommended by a joint working party from the Royal College of Physicians (RCP) and The British Geriatrics Society (BGS) in 1992 for the assessment of elderly hospitalised patients were employed in an elderly hip fracture population to investigate their feasibility and usefulness in this group. Patients were assessed at the time of their fracture and one, six and 12 months later. An informant was invited to provide information on behalf of patients (39%) who were classified as having significant memory and cognitive impairment (Abbreviated Mental Test score < 7) or if they had some other communication difficulty. Patients and informants found the format and content of the scales acceptable as well as the administration time of around one hour. Difficulties with the depression (Geriatric Depression Scale) and quality of life (Philadelphia Geriatric Center Morale Scale) scales were due to some patients' digressions, and the fact that little change was noted in the scores over the one-year period of follow-up questions their sensitivity. In the cohort of survivors 31% were classified as being depressed at baseline (score > 5) and this rose to 36% at one year. Ten per cent of the surviving patients were classed as dependent by the Barthel Index at the time of their fracture (score < 12) and this increased to 24% at one year. Despite exhibiting a ceiling effect, this scale was the most responsive of the scales at all time points. The social checklist highlighted important aspects for the management of hip fracture patients.

Intracapsular fractures of the femoral neck. Results of cannulated screw fixation

The results of stabilization of an intracapsular fracture of the femoral neck with cannulated screws placed in parallel in 141 patients between 1980 and 1985 were reviewed retrospectively. Fifty patients (35 per cent) had a non-displaced fracture (Garden Stage I or II) and ninety-one (65 per cent) had a displaced fracture (Garden Stage III or IV). The median age of the patients was sixty-eight years (range, twenty-four to ninety-five years). The mean duration of follow-up was eight years. No patient died or had a wound infection during the stay in the hospital. Twenty-nine patients, who had a median age of seventy-five years (range, fifty-six to ninety-five years), died within sixty months after treatment; eleven of them (median age, seventy-five years [range, sixty-five to eighty-six years]) died within the first twelve months. There was a loss of position or a non-union of the fracture in five patients (4 per cent) and healing of the fracture in 136 patients (96 per cent). Thirteen patients (11 +/- 3 per cent) had histological or roentgenographic evidence of osteonecrosis within twenty-four months after treatment. Ten of these patients had had a displaced fracture. Osteonecrosis developed in thirteen additional patients during the remaining period of follow-up. Eight of these patients had had a displaced fracture. The prevalence of osteonecrosis at the time of the most recent follow-up (mean duration, eight years) was 22 +/- 4 per cent. Osteonecrosis developed in eight of the forty-one patients who had had a Garden Stage-II fracture, in six of the thirty patients who had had a Garden Stage-III fracture, and in twelve of the forty patients who had had a Garden Stage-IV fracture. The fifty-five surviving patients in whom the fracture healed without complications were found to be functioning well more than sixty months after the fracture.

Factors affecting the outcome after proximal femoral fractures

One hundred and forty-two consecutive patients with proximal femoral fractures were audited prospectively over a 1-year period. Mobility, age and sex were recorded along with timing of surgery, complications, 'will to live', length of admission, mortality, mobility and housing requirements on discharge. Operative procedures were performed mostly by intermediate surgical staff, on night-time emergency lists shared with other specialties. Patients were treated on a ward with nursing staff levels less than the minimum recommended by professional bodies. Mean hospital stay was 31 days. In-patient mortality was 37 per cent in males and 5 per cent in females. It was possible to predict protracted hospital stay in 84 per cent, mortality in 84 per cent, mobility on discharge in 92 per cent and need for rehousing in 83 per cent of patients. Of the 10 principal variables that affected outcome, four could be influenced by hospital practice. These variables were associated with 1284 hospital bed days, which constituted 30 per cent of total bed occupancy. Fifty-five per cent of these were associated with non-medical delay to surgery, 25 per cent with wound infection or re-operation and 20 per cent with broken pressure areas. There would appear to be the potential to improve outcome in proximal femoral fractures by stabilizing fractures within 24 h, adopting measures additional to antibiotic prophylaxis to reduce infection and ensuring that patients do not develop pressure sores.

The mortality and social prognosis of hip fractures. A prospective multifactorial study

A prospective 5-year study was carried out of 143 patients with trochanteric fractures treated by Ender nailing. A detailed proforma was used for multifactorial analysis in order to identify the prognostic indicators of social function and quality of life of the patients. Their mean age was 81 years and the female: male ratio 7:1. The mortality rate 6 months after injury was 23%, and at the end of 5 years 45.5%. The patients surviving the first 6 months had the same life expectancy as the general population. Dementia, associated disease, medical complications, total dependency and age were the most significant predictors of mortality. These factors, with pressure sores and poor rehabilitation, were also significant in determining the prognosis of social function. Deterioration of health status was seen in 36% during the first 6 months after injury and 40% showed deterioration of their social condition within this period. Later, most survivors recovered and were restored to their previous state. Postoperative geriatric care is essential to achieve this aim.

Mortality and morbidity after hip fractures

OBJECTIVE

To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular).

DESIGN

Consecutive prospective study with 12 month follow ups.

SETTING

Two British trauma receiving centres.

PATIENTS

1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients.

RESULTS

Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury.

CONCLUSIONS

The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.

Historical assessment of risk factors in screening for osteopenia in a normal Caucasian population

BACKGROUND

Bone mineral density (BMD) can predict fracture, however, the common use of historical risk factors to predict low BMD is unproven.

AIMS

To identify significant historical risk factors for osteopenia. To establish predicting equations for BMD and test their ability to identify those who should be referred for BMD scanning.

METHODS

Three hundred and twenty female and 131 male volunteers underwent questionnaire assessment of risk factors and BMD by dual photon absorptiometer at hip and spine. Significant risk factors (P < 0.05) were used to construct a linear regression model to predict BMD. This was cross validated on a second sample of 107 females and 131 males selected from the electoral roll analysing the ability to detect those subjects with BMD in the lower third of the age matched normal range.

RESULTS

In women lower BMD at the spine was associated with increased age, decreased weight, smoking, and delayed menarche. Lower femoral BMD was associated with increased age, decreased weight, family history, inactivity, and smoking. In men lower BMD at the lumbar spine was associated with lower weight, and inactivity. Lower BMD at the femur was associated with increased age, decreased weight, family history, and low calcium intake. When cross validated on the second sample, the models produced sensitivity of 86-89% and sensitivity of 25-46%. Referring those with these risk factors could save 10-23% on scanning. Measuring BMD at the site in question remains the only accurate way of assessing an individual's risk of osteopenia.

Factors related to older women's recovery from hip fractures: physical ability, locus of control, and social support

Our purpose in conducting this study was to identify the nature of care provided by the informal support network available to older women with hip fractures and to examine the relationships among prior functional ability, locus of control, and reliance on social supports in predicting recovery from hip fractures. One hundred one women who had recently sustained a hip fracture participated in a structured interview process. Overall, the women received more frequent help from their spouse, children, and friends at the time of the interview than during the month before their hip fractures. Women who had higher activities of daily living capabilities prior to the fracture, had a greater internal orientation, and used fewer formal services reported higher levels of current physical functioning.

Length of hospital stay and outcome after femoral neck fracture: a prospective study comparing the performance of two hospitals

Length of hospital stay and outcome after femoral neck fracture were compared in a prospective study between two adjacent hospitals. In matched populations, mean length of stay was 30.8 days at Hospital X and 15.7 days at Hospital Y. Need for rehousing, age over 80 years and new nursing home placement prolonged length of stay at Hospital X, but not at Hospital Y. Hospital X had an orthopaedic rehabilitation ward and returned 88 per cent of patients to their own home, placing 9 per cent admitted from home in nursing homes. Hospital Y returned 76 per cent of patients to their own home and 19 per cent to nursing homes. The rapid discharge policy of Hospital Y saved significant resources within the acute hospital at the expense of returning significantly fewer patients to their own homes.

Continuous geriatric care in orthopedic wards: a valuable alternative to orthogeriatric units

The aim of this study was to assess whether assigning a geriatrician to provide daily medical care to geriatric patients in the orthopedic ward can improve the prognosis and reduce the length of stay. Time series analysis was performed in two parts: 1) prospective analysis of two years' workload, and 2) retrospective analysis of data collected over the 4 years prior to the intervention. Intervention and control populations were pooled, and the effects of geriatric care and patient-related factors on outcome measures were assessed by logistic regression analysis. All subjects were patients aged > or = 70 years who attended the orthopedic ward in a university hospital in years 1989-90 (studied group: 287 cases) and in years 1985-88 (control group: 474 cases). In the study period, mortality was 8.4% compared to 18% in 1985-86 (p < 0.0006) and 14% in 1987-88 (p < 0.01). The operation rate in the study period was 89.9% vs 83.8% in 1985-86 (p < 0.02) and 81.8% in 1987-88 (p < 0.005). Length of stay was 26.2 +/- 14.4 days vs 32.9 +/- 30.9 days in 1985-86 (p < 0.05) and 26.9 +/- 16.5 days in 1987-88 (NS). Length of stay was more strikingly shortened in the subset of patients with femoral fracture undergoing surgical management (28.5 +/- 12.7 vs 37.6 +/- 32.6 days in 1985-86, p < 0.003, and 30.8 +/- 15 days in 1987-88, p < 0.02). Given the positive relationship between geriatric care and operation rate (o.r. = 1.5, CI = 1.1-1.9), the protective effect of surgical treatment on mortality (o.r. = 0.6, CI = 0.4-0.8) to some extent may mask the collinear effect of geriatric care. We conclude that assigning a geriatrician to assist with the medical care of elderly orthopedic patients in orthopedic wards is associated with increased operation rate, decreased mortality and shortened length of stay.

The role of social supports in older women's recovery from hip fractures

Interviews were conducted with 101 women, ranging in age from 65 to 94, to determine the types of assistance that family members, friends, and formal services provide older women recovering from hip fractures, and the influence of social support variables on their recovery. More women were receiving help from members of their informal network in such areas as meal preparation, shopping, and running errands. More women were also using physical therapy and housekeeping services as a result of their fractures. The strongest predictors of recovery were the women's physical abilities prior to their fracture and the progression they had made at the time of the first interview. Results suggest that social support variables may have a more indirect than direct association with older women's recovery from hip fractures.

A study of the influence of technical adequacy on the clinical result of Moore hemiarthroplasty

The Moore and Thompson hemiarthroplasties are still commonly used for the displaced subcapital fracture in the elderly. The cemented Thompson has been claimed to be superior to the uncemented Moore prosthesis. However, the use of cement is associated with greater risks and the uncemented Moore appears to give good results in approximately two-thirds of patients. The technical adequacy of uncemented hemiarthroplasty has rarely been considered in assessing the outcome. This study indicates that, on the basis of four radiological criteria, incorrect insertion of the prosthesis leads to a high chance of a poor clinical result at 6 months. Good results are more likely when the postoperative radiograph shows the prosthesis to have been inserted accurately. This is possible in most cases, except where the femur is grossly osteoporotic with a wide intramedullary canal. Uncemented hemiarthroplasty can produce satisfactory results but, like uncemented total joint replacement, is a more demanding procedure.

Simply osteoporosis--or multifactorial genesis for the increasing incidence of fall injuries in the elderly? The need for a scientific approach to reducing injuries

Both the high and rising incidence of injuries in old age and a situation where accidents are looked upon as "super-human" events, impossible to prevent, call for a scientific approach to the problem. Another strong reason for stressing the scientific approach is the complex aetiological origin of injuries in the elderly. Individual factors as well as factors overrepresented in the injured population must find a developed model as site for their importance compared to agent factors and environmental factors. If not, there will be an everlasting contradiction between the discussion on monofactorial "causes" of injuries like osteoporosis, lacking physical exercise, environmental risks, etc. Still another reason is that the present serious situation with an increasing incidence of injuries in the elderly call for urgent preventive programmes as well as development of operation methods, rehabilitation methods and environmental changes. Unfortunately, in spite of the importance and magnitude of the number of injuries as a public health problem, relative little scientific attention has been given to the area of injury control. In the paper it is concluded that there is a need for model development. These models should combine an epidemiological approach with a behavioural scientific method as well as a system-oriented model. Such models are available in occupational injury prevention and should as well be tested in prevention of injuries in the elderly.

Bone mineral density and fracture in postmenopausal women

This retrospective study examined bone mineral density (BMD) for discrimination of female patients with fractures. Bone densitometry was done in 146 patients over the age of 50 years at radius, lumbar spine, and proximal femur sites using single and dual photon absorptiometry. The patients were divided into three groups: (A) no osteoporotic fractures (n = 92); (B) mild spine fractures with greater than 15% compression (n = 38); and (C) hip fractures (n = 16). Groups B and C did not differ significantly from each other in BMD, but these groups differed significantly from group A for spine and femur BMD. No significant differences between groups were found for the radius. Receiver operating characteristic (ROC) analysis showed that the BMD of the proximal femur had the highest diagnostic sensitivity for both spine and femur fractures; the radius had the lowest overall sensitivity, and the spine was intermediate.

Survival experience of aged hip fracture patients

Hip fracture has long been considered a major threat to survival in aged populations. This report describes the survival experience of 814 aged, community dwelling hip fracture patients treated in seven Baltimore hospitals between 1984 and 1986: 4.3 per cent died during hospitalization; 8.2, 12.6, and 17.4 per cent died within three, six, and 12 months after fracture, respectively. The mortality rate for the entire population approaches expected mortality approximately six months post-fracture, but varies by age and sex. The most important factors predicting mortality are presence of serious concomitant illness and marked delirium (in the absence of dementia) at the time of hospital admission. The authors suggest that medical factors that may contribute to patient disorientation be investigated and treated, when possible, in an effort to improve the survival status of hip fracture patients.

Total hip replacement in patients aged 80 years and older

Total hip replacement was performed in 27 patients aged 80 years and older. In the early postoperative period, medical complications occurred in 13 patients and arthroplasty-related complications in 5 patients. At the time of the follow-up, after an average of 31 months, there was one case of acetabular cup loosening, which was revised. Twenty of 22 patients were free from pain at rest, and the social function of the patients had remained almost unchanged.

Hip fractures--patient background

A consecutive series of 282 patients with hip fractures, with a mean age of 76 years, was studied. Two-thirds of the patients (182) lived in their own homes, half of them alone and one-third of the 182 requiring regular help. Widows were more common in the age group 75-84 years and widowers and single men in the age group 65-74 years. Thirty % of the patients used walking aids and had previously sustained fractures of the osteoporotic type. One-fourth of the patients were confused on arrival at hospital. Laboratory tests differed little from values in the normal population. Chest X-ray was of value and cardiac decompensation was diagnosed in a small group. Time aspects of the hip fracture accident are discussed. No increase in incidence in the age group over 70 years was found during the period 1971-1981.

The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial

OBJECTIVE

To compare postoperative collaborative care between orthopaedic surgeons and physicians in geriatric medicine with routine orthopaedic care in elderly women with proximal femoral fracture.

DESIGN

Exclusion of patients dying before fit enough to enter trial, those with pathological fractures, those likely to be discharged within seven days of entering the trial, and those remaining unfit for transfer to a peripheral hospital. Remainder allocated to two groups: treatment group and control group.

SETTING

District hospital acute admission ward and rehabilitation ward.

PATIENTS

144 sequentially admitted elderly women with proximal fracture of the femur; 36 excluded on above criteria and remainder entered into trial.

INTERVENTION

Both treatment and control groups (n = 54 in each) received physiotherapy and other services. The treatment group also received thrice weekly supervision by a geriatrician.

END POINTS

Physical independence, residence after discharge, and length of hospital stay.

MEASUREMENTS AND MAIN RESULTS

At discharge significantly more patients in treatment group were independent in terms of activities of daily living than controls (41 v 25) and their median stay was 24 days (range 8-197) compared with 41 (9-365) (95% confidence intervals for difference 2 to 25). Significantly fewer treatment patients were discharged to institutional care (10% v 32%; 95% confidence interval for difference 6% to 37%) and more to their own homes (63% v 38%; 95% confidence interval for difference 6% to 44%). These beneficial effects were consistent across a range of ages and mental state.

CONCLUSIONS

Both hospital and patient benefited when postoperative rehabilitation was provided in a setting specialising in such care for elderly patients with trauma.

Differences in the incidence of hip fracture. Comparison of an urban and a rural population in southern Sweden

The incidence of hip fracture from 1981 to 1984 inclusive in the urban population of the city of Malmö was compared with three rural municipalities around the city of Ystad in southern Sweden. A higher incidence of hip fracture was found in the urban population, especially among women. Patients with a hip fracture in Malmö had a lower mean age. Women in Malmö lived more often alone or in institutions.

Differences in outcome between black and white elderly hip fracture patients

Because blacks make up a small proportion of the hip fracture population, little is known about how blacks' experience following hip fracture compares to that of whites. This study, a retrospective review of the medical records of 119 community residing subjects, 60 years of age and older, 37% of whom were black, admitted with a diagnosis of hip fracture to a large urban teaching hospital, investigated differences between black and white patients in factors associated with outcome following hip fracture and outcomes at time of hospital discharge. Blacks were significantly more likely than whites to exhibit a high total number of diagnoses, urinary incontinence following surgery, low admission hemoglobins and mental impairment. Blacks experienced significantly longer hospitalizations than whites, were significantly more likely to be nonambulatory at discharge and showed different patterns of discharge destination. Multiple regression and logistic regression indicated that the greater amount of illness of blacks is a consistent significant predictor of these differences in outcomes, but that race, delays to surgery and non-surgical treatment also make independent significant contributions. These findings indicate the importance of planning for the in-hospital care of black hip fracture patients, and the examination of the financial consequences of DRG's for hospitals serving black or poor populations.

Are geriatric units needed for elderly patients with hip fractures?

To assess the need for a multidisciplinary geriatric unit in the treatment of elderly patients with hip fractures, we reviewed the charts of all patients aged 60 years or older who were treated for hip fractures in five hospitals in Hamilton, Ont., between August 1982 and September 1983. We hypothesized that discharge to a different location from that before admission would indicate reduced functional status and classified the reasons for a change in residence as poor patient motivation, need for rehabilitation, compromised ambulation, postoperative complications and inevitable deterioration. We believed that geriatric care would be most beneficial to those in the first three groups. Of the 327 patients with hip fractures 40 (12%) died before discharge. Of the 287 surviving patients 149 (52%) had been discharged by 4 weeks, and only 29 (10%) remained in hospital by 12 weeks. Of the 287, 44 (15%) were discharged to a different location from that before admission: in 75% the cause appeared to be inevitable deterioration (57%) or postoperative complications (18%). The remaining 25% needed rehabilitation and were all sent to appropriate facilities. None of the patients with ambulation problems or poor motivation required an increased level of care. We could not show a need for geriatric care in our population; possible explanations are discussed.

Assessment of depression and cognitive impairment after hip fracture

Fifty patients, over 60 years of age, were evaluated for mental status change at the time of hip fracture. Specifically, demographic and historical data were gathered and patients were given an assessment battery to evaluate depression and cognitive impairment during hospitalization for femoral fracture. Prevalence of depression was 28%, and cognitive impairment was present in 40% of the patients evaluated. Pre-fracture activities of daily living were estimated. These data provide the first systematically accumulated baseline data for patients in the immediate post-hip fracture period. Patients will be reassessed at three-month intervals to quantify mental status change and to evaluate its effects on morbidity, mortality, and rehabilitative success.

Function after lower limb amputation

Functional ability and social dependence were investigated by personal interview of 107 lower limb amputees surviving 1-5 years postoperatively. Among eight independent variables studied by multiple regression analysis, increased age was associated unfavorably with physical ability and social dependence. Independence from social provisions preoperatively showed favorable relationships with functional capacity and postoperative dependence. Above-knee or bilateral amputation and postoperative pain were associated with reduced functional ability, but not with social dependence. No significant association was found with cause of operation or sex of the amputees. The importance of proper prosthetic fitting and pain control is emphasized.

Determining factors for the mortality following hip fractures

In this study 518 patients with hip fractures were followed up prospectively for an average of 3 years (range 2.5-3.5 years). On admission to hospital the patients were allocated to one of 4 social function groups according to their dependence on the social welfare system. The life expectancy was analysed at follow-up and found to be determined primarily by the patient's social dependence prior to fracture, and secondarily by the age of the patient. Other generally accepted determining factors were not found to have any significant influence on the survival rates.

Long-term social prognosis after hip fractures

A long term follow-up study of 518 patients with hip fractures was undertaken 2.5 years after the operation. The total mortality was 35 per cent (180/518). The risk of social deterioration for patients admitted from home was 47 per cent (132/281). A statistical analysis showed this risk to be determined primarily by the age of the patient and secondarily by the placement of the patient on discharge from hospital. A thorough description of these factors is presented.

Costs of treatment of hip fractures. A calculation of the consumption of the resources of hospitals and rehabilitation institutions

A series of 518 patients with hip fractures and a median age of 78 years was followed for 6 months. On admission to hospital the patients were assessed and were found to be evenly distributed among four social function groups according to their level of dependence on the social welfare system. At the 6 months follow-up the mortality rate was about 16 per cent, leaving 437 patients for a reassessment of social function. The average hospitalization time was 23 days; thus 17 per cent of all orthopaedic hospital beds in the area were occupied by patients with hip fractures. Patients staying the longest time in hospital were those waiting for discharge to a nursing home. The average stay in rehabilitation institutions was 71 days. The total rehabilitation course was longest for the most dependent patients. The risk of death or deterioration of social function among patients admitted from home was 48 per cent. In the case of social deterioration or technical failure following the fracture treatment the total rehabilitation course was considerably prolonged. The resources required for the treatment of hip fractures in a suburban area of 500,000 inhabitants were calculated to the 32 hospital beds, 43 rehabilitation beds and at least 21 nursing home beds.

Differentiated care of hip fracture in the elderly. Mean hospital days and results of rehabilitation

Two series of elderly patients with hip fracture were compared with regard to hospitalization time and social situation after discharge from hospital. Our series included 131 patients from 1966 with late weight-bearing and 362 patients from 1972--1973, mobilized with early weight-bearing. Approximately two-thirds of the patients came from their own homes and one-third from institutions. The mean hospital stay for patients discharged to their own homes was 7 weeks in 1966 and 3--4 weeks in 1972--1973. This decrease in hospitalization time did not cause any increase in the proportion of patients discharged to institutions. Thus, among patients admitted from their own homes 48 per cent of the survivors returned directly home in 1966, and 62 per cent in 1972--1973. As compared to the prefracture mobility, postoperative mobility at 2 weeks proved to be a better indicator of the patient's chances of returing home. This may be a helpful guide when planning the aftercare of these patients.

Rehabilitation after hip fracture in the elderly

Sixty-eight patients with hip fracture, mean age 79 years, from the city of Lund, were studied with special reference to functional and social rehabilitation at follow-up 1 year later. As compared with patients coming from institutions for permanent care, patients coming from their own homes had a significantly better prognosis in terms of survival, mobility and ability to cope with activities of daily living (ADL). However, patients returning home needed increased domestic help. Patients living with someone returned home sooner than those living alone. Although many of the patients who returned home could walk without support or with a walking-stick, more than one half did not go out shopping. More active measures, e.g. early home visits by a rehabilitation team, might give the patients more self-confidence and independence. Immediate weight-bearing did not appear to impair healing of the hip fracture or increase the risk of necrosis of the femoral head.

Social rehabilitation following hip fractures

A prospective 6 months' study of 518 patients with hip fractures was undertaken. The patients were classified into four social function groups on admission to hospital and again at the follow-up, according to their dependence on home-help and other services of the social welfare system. This dependency increased with the age of the patients. Life tables for the case material showed that the mortality depended more on pre-fracture social function than on age. At the follow-up, the risk of death or increased social dependency among primarily independent patients was found to be 38 per cent compared with 48 per cent among slightly dependent patients and 62 per cent in moderately dependent patients. A total of 17 per cent of the surviving patients admitted from home became nursing home patients. The pre-fracture social assessment determined the end-result to a greater extent than the age at the time of fracture. About 75 per cent of the patients discharged to their homes maintained their social function compared with 68 per cent of the patients discharged to a convalescent home and 47 per cent of the patients discharged to rehabilitation clinics.