OBJECTIVES: To compare persons with and without hip fracture for subsequent mortality and change in disability and nursing home (NH) use.

DESIGN: Population-based historical cohort study.

SETTING: Olmsted County, Minnesota.

PARTICIPANTS: All residents who experienced a first hip fracture between January 1, 1989, and December 31, 1993, and, for each case, a resident of the same sex and similar age who had not experienced a hip fracture and was seen by a local care provider.

MEASUREMENTS: Data on disability (Rankin score), comorbidity (Charlson Index), and NH residency before baseline (fracture date for cases and registration date for controls) were obtained by review of complete community-based medical records. The records were then reviewed from baseline through December 31, 1994, for Rankin disability at 1 month and 1 year, all NH admissions and discharges, and date of death for those who died.

RESULTS: There were 312 cases and 312 controls (81% female, mean age ± standard deviation = 81 ± 12 years). Before baseline, cases had higher comorbidity (45% vs 30% had Charlson Index ≥ 1, P < .001) and disability (mean Rankin score = 2.5 ± 1.1 vs 2.2 ± 1.1, P < .001) and were more likely to be in a NH (28% vs 18%, P < .001) than controls. One year after baseline, estimated mortality was 20% (95% confidence interval (CI) = 16–24) for cases vs 11% (95% CI = 8–15) for controls, 51% of cases versus 16% of controls had a level of disability one or more units worse than before baseline (P < .001), and the cumulative incidence of first NH admission was 64% (95% CI = 58–71) for cases versus 7% (95% CI = 4–11) for controls. The risk of NH admission for cases relative to controls diminished over time, but remained elevated 5 years after the event (risk ratio = 20.0 at 3 months and 2.1 at 5 years), but, in persons admitted to a nursing home, cases were two times more likely than controls to be discharged alive within a year (P < .001).

CONCLUSIONS: Hip fracture is an important contributor to disability and NH use, but the potential savings from hip fracture prophylaxis may be overestimated by studies that fail to consider differential risk, mortality, and long-term follow-up.

Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study

Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and debridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Outcomes after Displaced Fractures of the Femoral Neck. A Meta-Analysis of One Hundred and Six Published Reports.

In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Kuntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head.

Intertrochanteric femoral fractures. Mechanical failure after internal fixation

The study goal was to use population-based data to model aspects of lifetime osteoporosis impact not previously studied, specifically: (1) to estimate person-years of fracturerelated functional impairment against the trajectory of functional status in the general population; (2) jointly to consider hip, vertebral, and Colles' fractures in estimating the percent of women who will ever fracture; and (3) to estimate the lifetime number of fractures expected in a cohort of 10 000 50-year-old white postmenopausal women. The model estimates that 54% of 50-year-old women will sustain osteoporosis-related fractures during their remaining lifetimes. Beyond the functional impairment expected in similarly aged, unfractured women, osteoporosis-related fractures are estimated to cause 6.7% of women to become dependent in basic activities of daily living; 7.8% are expected to require nursing home care for an average of 7.6 years. (Arch Intern Med. 1991;151:2026-2032)

A model of lifetime osteoporosis impact.

The socioeconomic burden of fractures: Today and in the 21st century

Eighty unstable trochanteric fractures were treated with the sliding screw-plate system. Early weight-hearing was encouraged and mobilization was obtained within the first week in 47 per cent of the cases (37/78). Technical complications were encountered in 5 per cent of the patients (4/76) but none required re-operation. Telescoping of the screw occurred in 49 per cent (37/76). Through this secondary fracture impaction a stable load transmission system was established. Fracture union in the postoperative position was obtained in 49 per cent of the patients (37/76) and non-union did not occur.

Unstable trochanteric fractures treated with the sliding screw-plate system. A biomechanical study of unstable trochanteric fractures. III.

Moore arthroplasty was performed for medial femoral neck fractures in 169 patients. The mortality rate was 21.3 per cent within 3 months. The general postoperative complication rate (39.6 per cent) was dominated by cardiopulmonary (17.2 per cent) and thromboembolic (16.0 per cent) events. Of local complications, wound infection was found in 4.7 per cent and osteitis in 3.0 per cent of cases. A total of 60 patients were followed up with a mean observation time of 4.9 years. Of these, 8.3 per cent sustained femoral fractures during this period. The results classified according to the criteria of the American Academy of Orthopedic Surgeons showed 52 per cent excellent or good, 43 per cent fair and 5 per cent poor results. The roentgenological finding of settling or osteolysis along the prosthesis was significantly correlated to reduced hip mobility. Ossification in the prosthetic fenestres gave significantly diminished settling, and was correlated to better hip mobility and less pain. In our opinion, Moore arthroplasty has proved to be an acceptable method for the treatment of femoral neck fractures in elderly patients, as 73 per cent had an acceptable range of motion, 40 per cent managed walking distances of more than 500 m and 70 per cent had minimal or no pain. Although 25 per cent became nursing home patients, this reduction of vitality could be related to the hip arthroplasty in only two cases.

https://www.tandfonline.com/doi/pdf/10.3109/17453677508989263

A long term follow-up of Moore arthroplasty in femoral neck 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, a...

Social rehabilitation following hip fractures

Out of a series of 207 consecutive fractures of the tibial shaft, 102 were treated conservatively, 64 fractures were treated by AO compression plate osteosynthesis and 41 by internal fixation using...

https://www.tandfonline.com/doi/pdf/10.3109/17453677708985136

Tibial shaft fractures. A comparison of conservative treatment and internal fixation with conventional plates or AO compression plates.

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 functionThe 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 patientsThe 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 reha

J. Steen Jensen

Papers

Unstable trochanteric fractures treated with the sliding screw-plate system. A biomechanical study of unstable trochanteric fractures. III.

A long term follow-up of Moore arthroplasty in femoral neck fractures.

Social rehabilitation following hip fractures

Tibial shaft fractures. A comparison of conservative treatment and internal fixation with conventional plates or AO compression plates.

Costs of Treatment of hip Fractures: A Calculation of the Consumption of the Resources of Hospitals and Rehabilitation Institutions