Fragility Hip Fracture: Predictive factors for mobility, institutionalization and survival

Markus Hongisto

Research output: Book/ReportDoctoral thesisCollection of Articles

Abstract

The purpose of this dissertation was to enhance older hip fracture patients’ treatment by evaluating present treatment protocols according to scientific evidence and determining factors associated with need for assisted living arrangements, impaired mobility and poorer survival. First, a register-based study containing 49,514 patients aged 50 or more who had been operated on for femoral neck fracture in Finland during the period 1998–2011 was analysed to ascertain the surgical interventions applied. The study identified an increasing use of uncemented hemiarthroplasty (HA) from 2005 through 2011, which contradicts current scientific evidence. Further, increasing numbers of hip fracture patients had been treated by total hip arthroplasty (THA), while the use of internal fixation had become less common.

The material for the clinical studies was obtained from a prospectively collected dataset of consecutive hip fracture patients aged 65 years and over admitted to and operated on at Seinäjoki Central Hospital. Only the first hip fracture of each patient was included in the database. The telephone interviews at one, four and 12 months included eliciting information from the person contacted (patient or proxy). A comprehensive geriatric assessment was conducted 4–6 months after hip fracture.

In the second study we evaluated two common activities of daily living and cognitive screening instruments applied at the 4 to 6-month clinical control as prognostic indicators for institutionalization within one year after hip fracture and assessed the change in living arrangements during the first year after hip fracture. Institutionalized living arrangements at the time of injury were noted in 12.5% of the study population and the incidence of high-energy hip fracture was 6.1%. During one-year follow- up, a 22.7% mortality rate was observed. A total of 581 patients were analysed and optimal cut-off values for the Instrumental Activities of Daily Living (IADL) and Mini Mental State Examination (MMSE) were determined to predict the increased risk of institutionalization one year after hip fracture. A receiver operating characteristics (ROC) analysis revealed excellent discrimination for both variables. For IADL and MMSE, the respective optimal thresholds predicting institutionalization were 5 (sensitivity 100%, specificity 38%) and 20 (sensitivity 83.5%, specificity 65%). Further, the change in residential location during between four and 12 months after hip fracture occurred in 11.3% of hip fracture patients.

Posterolateral and lateral approach are commonly used in HA depending on the surgeon’s preference. Differences in living arrangements, use of mobility aids, pain and mortality were examined in the third study, which indicated that a posterolateral approach predisposed to hip dislocation and a lateral approach led to increased use of mobility aids at one year after HA. There was no difference between groups in mobility level, pain in the operated hip and living arrangements one year postoperatively.

Older hip fracture patients sustaining osteoporotic hip fracture are at increased risk of death several years afterwards. The mortality rate is the highest during the first months after the injury. The effect of time to surgery on survival has been investigated comprehensively in observational trials using a threshold of 24–72 hours for surgical timing. Only limited evidence is available on whether rapid surgery within 12 h of admission confers a survival benefit. In the fourth study, rapid surgery on hip fracture patients who have at least one severe disease (ASA ≥3, American Society of Anesthesiologists) was associated with lower short-term (30-day) and long-term (365- day) mortality. Patient-related factors affected long-term survival more.

In conclusion, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland between 2005 and 2011, which contradicted scientific evidence. After 4 to 6 months from hospital discharge, IADL and MMSE may represent valuable clinical tests to screen the need for institutionalized living arrangements at 1 year after hip fracture. Hemiarthroplasty procedure using the lateral approach will increase the need for ambulatory aids at one year after hip fracture compared to the posterior approach at one year, whereas the posterior approach increases the risk of hip dislocation. Otherwise no differences between the two approaches were observed in regard with the one-year outcomes. Finally, delay in hip fracture surgery for more than 12 hours after admission may represent significant factor associated with impaired 30-day survival among patients with severe systemic disease (ASA ≥3).
Original languageEnglish
Place of PublicationTampere
PublisherTampere University
ISBN (Electronic)978-952-03-1656-3
ISBN (Print)978-952-03-1655-6
Publication statusPublished - 2020
Publication typeG5 Doctoral dissertation (article)

Publication series

NameTampere University Dissertations - Tampereen yliopiston väitöskirjat
Volume293
ISSN (Print)2489-9860
ISSN (Electronic)2490-0028

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