Fractured proximal end of the femur in the elderly--a medico-social study

Sliding hip screw fixation of trochanteric hip fractures: outcome of 1024 procedures

The results for a consecutive series of 1024 trochanteric hip fractures surgically treated by internal fixation with a sliding hip screw in a single centre are presented. The mean age of patients was 81.7 years and 78% were female. Seventy-five percent of fractures were classified as unstable. At 1 year from injury, 69% of patients were surviving. Of these, 95% had minimal or no pain, 85% had at least returned to their pre-fracture level of accommodation and 50% to their pre-fracture level of mobility. Complications related to surgical fixation were encountered in 3.6% of cases. Overall, 2.6% of patients required further surgery as a result of these. While significant mortality remains an issue, the overall fixation failure rate and re-operation rate for trochanteric fractures fixed with a sliding hip screw is low. The final outcome of surgery for the survivors is good, with most patients returning to their pre-fracture level of accommodation and mobility, with minimal pain 1-year post-fracture.

Clinical outcomes and treatment of hip fractures

The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. Undisplaced intracapsular fractures can be treated with bed rest and 6-8 weeks' delay of weight bearing in the "younger" elderly (< or = 70 years). The timing of surgery remains controversial, and evidence that a delay in operating leads to increased morbidity is inconclusive. In general, early surgery is indicated in premorbidly fit patients, whereas surgery should be delayed if correctable comorbidities are present. Methods of intracapsular fracture repair very geographically and according to surgeon preference. Prospective, randomized, case-controlled studies are needed to compare repair methods, including internal fixation versus hemiarthroplasty for intracapsular fractures and use of uncemented versus cemented hemiarthroplasty protheses. Extracapsular fractures are usually repaired using a dynamic hip screw or other variant of sliding nail fixation. The mortality rate after hip fracture appears to vary in association with poorly controlled systemic disease (particularly if multiple comorbidities are present); cognitive disorders; operative intervention before stabilization if > or = 3 comorbidities are present; and, in the absence of prophylaxis, deep vein thrombosis; the associations between mortality and male sex, advanced age, and anesthetic type are less clear. The factors associated with the recovery of walking ability include young age, male sex, absence of dementia, absence of postoperative confusional state, and use of a walking aid before the fracture. Many determinants of outcome are independent of the level of care given and are dependent on prefracture status. To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.

Drugs and femoral neck fracture: a case-control study

Two hundred consecutive patients with femoral neck fractures (FNF) and 200 controls matched by age, sex, nursing home residency and number of admissions within the last 2 years, were interviewed about recent drug use. The matching criteria were chosen to achieve case and control groups that were comparable with regard to overall physical disability. Thus a preliminary study had shown FNF to be strongly associated with nursing home residency and to be correlated with the number of recent hospital admissions. FNF was found to be negatively associated with use of coronary drugs (OR = 0.27; 95% CI = 0.11-0.70) and positively associated with drug use in general (OR = 2.00; 95% CI = 1.04-3.05). The OR for the various classes of psychotropic drugs was consistently greater than 1., although this was not statistically significant. An inherent problem in interpreting such findings is that underlying disease may predispose the subject to both FNF and drug use, thus creating a non-causal relationship.