Key findings:

Key findings from the study on elderly patients undergoing surgical intervention for fracture neck of femur include: a peri-operative mortality rate of 5.95%, with all deceased patients being females. The study highlights the importance of considering peri and post-operative mortality in the management of hip fractures among the elderly in the Indian Subcontinent.

What is known and what is new?

The known aspect in this abstract is the increasing incidence of hip fractures among the elderly population worldwide, leading to disability and mortality. The new contribution is the specific evaluation of peri-operative mortality rates and associated factors in elderly patients undergoing surgical intervention for fracture neck of femur in the Indian Subcontinent, emphasizing the need for targeted policies to address this growing public health concern.

What is the implication, and what should change now?

The implication of this study on peri-operative mortality after surgical intervention for fracture neck of femur in elderly patients underscores the need for enhanced injury management policies focusing on reducing mortality rates in this vulnerable population. Changes needed include implementing strategies to improve peri-operative care, address gender disparities in outcomes, and enhance post-operative support to reduce mortality risks associated with hip fractures.

Hip fracture is a major public health problem that has a significant financial impact on patients and health care systems [1,2]. The incidence of hip fracture varies by age and sex; it is more common in older people. Hip fracture in elderly osteoporotic patients most often results from low-energy trauma such as falling down. [3-5].

Since fracture neck of femur prevalence increases exponentially with age, as population age and longevity increase worldwide, these injuries are likely to occur at accelerated rates. This is important because among those who sustain fracture neck of femur and survive, an increasing number continue to experience various degrees of subsequent disability including a high risk for falls and further injury likewise. Hip fractures remain a persistent cause of excessive morbidity, reduced life quality and premature mortality among elderly [6].

The incidence of hip fractures is increasing and the annual number worldwide is estimated to rise from 1.7 million in 1990 to 6.3 million by the year 2050 [7]. This will be a major challenge to the health care system and society. Most hip fractures are related to osteoporosis [8]. The accumulated risk for hip fracture is 20% for an 80-year-old woman and almost 50% for a 90-year-old woman [9]. 

In elderly fractures the neck of the femur are frequent and typically result from mild to moderate trauma in osteoporotic bones while in young adults these fractures are generally due to high energy trauma, such as road accidents. This is mainly because elderly people are unable to dissipate energy as compared to the young person and diminished ambulatory speed. Their protective responses are also diminished because of slow reaction time, weakness, disorientation and the side effects of medication [10].

Hip fractures in elderly patients are serious injuries that can lead to immobility and permanent dependence, negatively impacting patients’ quality of life and resulting in a financial burden for health systems and societies [11]. Hip fractures can also lead to death. Mortality rates among the elderly following hip fractures range from 14% to 36% within 1 year of the injury. During the first three months after hip fracture, elderly patients have a 5- to 8-fold increased risk of dying. The increased mortality risk persists up to ten years. Because of a predicted increase in life expectancy in western countries over the next decades, hip fractures and their consequences will have an even larger impact on health systems and societies in the future [12].

Fractures of the femoral neck are a devastating injury that extends far beyond the musculoskeletal trauma, with significant long-term consequences for the quality of life of both patients and careers. The fractures are common in the elderly. Patient care is complex, requiring multidisciplinary teams and integrated care pathways. Patients above the age of 90 represent a challenging subgroup as they have a number of concurrent medical co-morbidities, and are susceptible to postoperative complications and poorer outcomes [13].

Fracture neck of femur pose a number of management dilemmas depending on the age, sex, nutritional status, co-morbidities, status of the bones and type of fractures. Advanced age and associated co-morbidities are two decisive factors of mortality secondary to fracture neck of femur.

Poor nutritional status is known to be both a common causative factor of fracture neck of femur and predictor of excess mortality following surgical intervention. Many methods including anthropometry, the mini nutritional assessment, nutrition-related blood parameters and dietary analysis are used for nutritional status assessment in clinics. Serum albumin and total lymphocyte count are two of the most important blood parameters for nutritional status and have been recognized as prognostic factors of fracture neck femur.

Hip fractures in the elderly lead to functional decline and a diminished quality of life. Furthermore, these fractures are associated with an in-hospital mortality rate of 7-14%, reaching 14-36% within 1 year of surgery. Hip fractures are also complicated by a 0-49% need for revision surgery, which is influenced heavily by fracture characteristics and surgical interventions [14].

Factors that influence prognosis of elderly patients after hip fracture are age, gender, co-morbidities, anticoagulation therapy, and general physical health status at the time of injury. Furthermore, timing of surgery is thought to play an important role regarding survival. Although international clinical practice guidelines recommend surgical treatment of acute hip fracture within 24 to 48 hours after admission, these recommendations are still discussed controversially. Some researchers argue that early surgery can lead to an increased risk of peri-operative complications, including pneumonia, deep venous thrombosis, bleeding, pulmonary embolism, urinary tract infections and decubital ulcerations because clinicians do not have enough time to optimize patients’ medical conditions preoperatively [15]. 

Thus, the present study was carried out to determine the Incidence and co-relates of mortality among elderly patients after surgical intervention for fracture neck of femur presenting to the department of Orthopedics at Dr. R. P. G. M. C., Tanda.

The present study, an open cohort, prospective study, was conducted in patients with fractures of the neck of femur (age 60 years and above) presenting to the Department of Orthopaedics, Dr. R. P. G. M. C., Kangra at Tanda and undergoing surgical intervention.

All cases presenting to the department and fulfilling the criteria were studied for a period of one year starting from the date of start of the study. In the first six months all patients fulfilling the inclusion criteria were recruited and followed up for the next six months. The last patient was recruited 6 months from the day of start of study.

The study was initiated following approval from the Institutional Ethics Committee. The patients were given the right to abstain from participation in the study or to withdraw at any time of the study without reprisal.

❖           Inclusion Criteria:

⮚           Patients of age ≥60 yrs with fracture neck of femur undergoing surgical intervention.

⮚           Those giving consent for inclusion in the study.

❖           Exclusion Criteria:

⮚           Concomitant trauma involving other systems

⮚           Associated fracture of the pelvis

⮚           Bilateral hip fracture

⮚           Pathological fracture

⮚           Who do not give consent

❖           Evaluation and Classification:

For classification of co-morbidities in the study population, the American Society of Anaesthesiologist (ASA) score was used. For assessment of general conditions on the day of admission, TCCS was used. It is important in demonstrating the general condition of the patient on the day of admission after sustaining a hip fracture. Using the CCI, three scores were calculated—the Total Charlson Co-morbidity Score (TCCS) is the sum of all co- morbidities combined with the score derived from the patient’s age; the Highest Charlson Co-morbidity Score (HCCS) is the highest single co-morbidity score of a patient; and the Charlson Co-morbidity Score (CCS) is the sum of all co-morbidity scores without consideration of age. All these scores were used to analyze and correlate with different mortality rates. 

Nottingham Hip Fracture Score (NFHS) was used to predict 30-days mortality after hip fracture surgery. Bone Mineral Density was evaluated using Singh's Index. The Singh index is commonly used to assess osteoporosis and is based on the radiological appearance of the trabecular bone structure of the proximal femur on a plain antero-posterior radiograph.

❖           Study Procedure:

After a detailed history, patients were clinically evaluated at the time of admission and details on socio-demographic data of the patients such as age, sex, socio- economic status were recorded according to the Udai Pareek or Kuppuswamy scale for patients from rural or urban areas respectively.

All data regarding pre-existing co-morbidities, type of fracture, degree of osteoporosis and type of surgical procedure, hospital stay and perioperative mortality and condition of patient at the time of admission and discharge were collected using the following indices.

After surgery, patients were discharged on the fourth day if the clinical conditions permitted. The telephone number of the investigator was written on the discharge card. The patients were followed up in Orthopedics OPD on the 15th postoperative day for sutures removal and further on 3rd month and 6th month postoperative day for assessment of outcome using defined indices as annexure number 4, 5, 6, 7 and 8.

The patient or their attendant were also contacted on phone by the investigator regarding the welfare of the patient every 15th day.

At the time of discharge the attendant was requested to inform the well- being of the patient to the investigator on the telephone mentioned on discharge card.

All patients reported as dead during the period of study were evaluated using the verbal autopsy performance. The queries enquired by the investigator investigated the attributable factors for mortality such as death, major cardiac or pulmonary complications, deep vein thrombosis, urinary tract complications, blood loss, surgical wound complications etc.

❖           Statistical Analysis:

The data were presented as frequency, percentages or mean±SD whereas applicable. Student t-test was used to compare continuous variables between 2 groups. Chi-square test was used to compare categorical variables. P value <0.05 was considered significant. Statistical analysis was performed using Epi Info version 3.4.3.

A total of 84 patients with fracture neck of femur were included in the study over a period of one year. 

Table 1: Socio-demographic characteristics of enrolled patients

Out of total, 47.6% (n=40/84) patents had fracture of left femur while 52.4 % (n=44/84) had fracture of right femur. (Table 1)

Bone density measurement by Singh’s index showed that 4/84 patients were in grade 1 and grade 2 each. Majority of the patients (32.1%; 27/84) were in grade 4 while 22.6% (19/84) patients were in grade 6. There were 12/84 (14.3%) patients in grade 3 and 18/84 (21.4%) in grade 5. (Table 2)

Table 2: Bone Density Measurement (Singh’s Index)

The most common surgery done was bipolar hemiarthroplasty which was done in 53 (63.1%) patients. Total hip replacement was done in 29 (34.5%) patients while CRIF with DHS and PTCS was done in 1 patient each. (Table 3)

Table 3: Type of surgery done

Table 4 summarizes that after 15 days post-surgery, there were 3 (3.6%) patients with infected wounds and 3 months later 1 (1.2%) out of those 3 patient had infection.

Table 4: Wound status after day 15 and 3^rd month

Mortality:

Table 5 summarizes the mortality of the patients after 9^th month and 12^th month. In our study, 1 (1.2%) patient died after the 9th month of surgery. Overall mortality during 1 year was 7.14%.

Table 5: Distribution of patients on basis of survival

There were 14 patients with diabetes and out of them 2 were not taking medication regularly. There were 11 patients of both hypertension and diabetes and all were taking their medication regularly. (Table 6)

Table 6: Diabetes and hypertension in enrolled patients

Other Co-morbidities:

There were 9 (10.7%) patients who were suffering from coronary artery disease followed by 6 (7.1%) patients with thyroid anomaly. 2 (2.4%) patients were having TB and bed sores each and 1 (1.2%) had asthma. (Table 7)

Table 7: Other co-morbidities in enrolled patients

Fracture neck of femur in elderly patients is serious injury that can lead to immobility and permanent dependence, negatively impacting patients’ quality of life and resulting in a financial burden for health systems and societies. It can also lead to death.

Mortality rates among the elderly following hip fractures ranges between 14% to 36% within 1 year of the injury. During the first three months after hip fracture, elderly patients have a 5- to 8-fold increased risk of dying. The increased mortality risk persists up to ten years. Because of a predicted increase in life expectancy in western countries over the next decades, hip fractures and their consequences will have an even larger impact on health systems and societies in the future.

Peri-operative mortality in our study was 5.95%. In a cohort study by Ramanathan TS [16] from August 2001 to May 2003, they reported mortality of 10.2% in one year. The increased mortality in their study can be due to the time period of their study which was 17 years back and in present study there are better equipment and medications which decrease the associated factors leading to mortality. Study by Shin HJ et al., [17] in 2013-2015 reported one year mortality of 15.1% in femoral neck fractures which is again higher than that observed by us which can be due to the reason that they enrolled patients of age more than 64 years. Another study by Higashikawa T [18] in 2016-2017 reported one year mortality of 11.6% in patients of age more than 65 years. A meta-analysis reported that the absolute risk of dying within 12 months was 21% in patients who had surgery after 48 hours and 17% in patients who had surgery within 48 hours resulting in a 20% smaller long-term mortality risk in patients operated on within 48 hours.[19]

Foss and Kehlet studied 300 hip fracture patients. They reported that Thirty-day mortality was 13.3% (40 patients) and the total peri-operative mortality was 15.6% (47 patients). Low postoperative mortality rates in our study could be associated with selective patient intake, exclusion of patients with pathological fractures, exclusion of patients sustaining fracture while in hospital, exclusion of patients receiving conservative fracture treatment, and finally insufficient follow-up especially after early discharge or transfer to secondary rehabilitation units. [20]

Studies reported that an overall mortality rate of 20% to 30% is reported in the majority of the literature in patients that suffer a femoral neck fracture [21, 22].

One present study reported a mean survival of 29 months and of the 19% of patients in this study who were deceased on follow-up, there was no difference by gender. Diamond et al., reported that men of advanced age who presented with a femoral neck fracture had a greater rate of mortality than women. Of note, the results of the present study were that 10% of study patients lived less than 2 months after hip fracture and 32% lived less than one year [23].

Fransen et al., reported that femoral neck fractures in men implied a greater risk of death or being institutionalized within 2 years after the fracture [24].

Our results also demonstrated that the risk of death increased by 4 times as age increased, with female preponderance with p value of 0.029. Butler et al., [25] in their review of the literature demonstrated that age, gender, cognitive impairment and functional capacity prior to injury were associated with mortality rate. This was affirmed by Erickson et al., [26] who found that 90% of the deaths in their population occurred in patients greater than 75 years of age.

In our study, age, sex, economic status, BMI and Singh’s index were comparable in the non-survivors and surviving patients. Bone mineral density was significantly associated with mortality with p value of <0.001. The bone mineral density (BMD) starts falling with increasing age especially in postmenopausal women due to loss of protective effect of estrogen on bone mineralization [27].

57.1% (n=486) of the patients were males while the remaining 42.9% (n=36) of the patients were females. The Udai Pareek scale showed 35.7% of these patients in class IV while 34.5% patients were in class III. Mean BMI of the patients was 22.33±1.95 Kg/m² with a range from 18.6 to 26 Kg/m². Bone density measurement by Singh’s index shows that the majority of the patients (32.1%; n=27) were in grade 4 while 22.6% (n=19) patients were in grade 6 and 21.4% (n=18) in grade 5. 52.4% (n=44) had fracture of right femur while remaining 47.6% (n=40) patients had fracture of left femur. 63.1% (n=53) of the patients underwent bipolar hemi-arthroplasty while 34.5% (n=29) underwent total hip replacement (THR). CRIF with DHS and PTCS was done in 1 patient each. Out of 84 patients, 1 patient died within 9 months of surgery and a total of 5 patients died in one year with a peri-operative mortality rate of 5.95%. Mean age of the patients who died, was comparable to the mean age of the patients who survived (76.2±10.28 vs. 71±7.0; P=0.08). All the patients who died were females.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of R. H. Reckongpeo.

1. Brauer, Carmen A., et al. "Incidence and Mortality of Hip Fractures in the United States." JAMA, vol. 302, no. 14, 2009, pp. 1573-1579. doi:10.1001/jama.2009.1462.

2. Jiang, Hong X., et al. "Development and Initial Validation of a Risk Score for Predicting In-Hospital and 1-Year Mortality in Patients with Hip Fractures." Journal of Bone and Mineral Research, vol. 20, no. 3, 2005, pp. 494-500. https://doi.org/10.1359/JBMR.041133.

3. Forsh, David A., and Tania A. Ferguson. "Contemporary Management of Femoral Neck Fractures: The Young and the Old." Current Reviews in Musculoskeletal Medicine, vol. 5, 2012, pp. 214-221. https://link.springer.com/article/10.1007/s12178-012-9127-x.

4. Verettas, D. A. J., et al. "Fractures of the Proximal Part of the Femur in Patients Under 50 Years of Age." Injury, vol. 33, no. 1, 2002, pp. 41-45. https://doi.org/10.1016/S0020-1383(01)00070-5.

5. Farooq, M. A., et al. "Intracapsular Fractures of the Femoral Neck in Younger Patients." Irish Journal of Medical Science, vol. 174, 2005, pp. 42-45. https://link.springer.com/article/10.1007/BF03168981.

6. Marks, Ray. "Physical Activity and Hip Fracture Disability: A Review." Journal of Aging Research, vol. 2011, 2011. https://www.hindawi.com/journals/jar/2011/741918/abs/.

7. Cooper, C., Campion, G., and Melton, L. J. 3rd. "Hip Fractures in the Elderly: A World-Wide Projection." Osteoporosis International, vol. 2, 1992, pp. 285-289. https://link.springer.com/article/10.1007/bf01623184.

8. Haentjens, Patrick, et al. "Meta-Analysis: Excess Mortality After Hip Fracture Among Older Women and Men." Annals of Internal Medicine, vol. 152, no. 6, 2010, pp. 380-390. https://doi.org/10.7326/0003-4819-152-6-201003160-00008.

9. Robustillo, V. S. A., Juchno, P., and Marcui, M. "Wronsk." Eurostat Demography Report-Short Analytical Web Note 3, 2015.

10. Xu, Jiaquan, et al. "Mortality in the United States, 2015. NCHS Data Brief, No. 267." National Center for Health Statistics, Hyattsville, MD, 2016.

11. OECD. Health at a Glance 2015: OECD Indicators. 2015, pp. 1-220.

12. Holt, G., et al. "Outcome After Surgery for the Treatment of Hip Fracture in the Extremely Elderly." Journal of Bone and Joint Surgery, vol. 90, no. 9, 2008, pp. 1899-1905. doi:10.2106/JBJS.G.00883.

13. Lu, Jun, et al. "Laboratory Nutritional Parameters Predict One-Year Mortality in Elderly Patients with Intertrochanteric Fracture." Asia Pacific Journal of Clinical Nutrition, vol. 25, no. 3, 2016, pp. 457-463. https://search.informit.org/doi/abs/10.3316/INFORMIT.208110100208433.

14. Mundi, Simran, et al. "Similar Mortality Rates in Hip Fracture Patients Over the Past 31 Years: A Systematic Review of RCTs." Acta Orthopaedica, vol. 85, no. 1, 2014, pp. 54-59. https://doi.org/10.3109/17453674.2013.878831.

15. Carpintero, Pedro, et al. "Complications of Hip Fractures: A Review." World Journal of Orthopedics, vol. 5, no. 4, 2014, pp. 402. https://doi.org/10.5312/wjo.v5.i4.402.

16. Roberts, Karl C., et al. "Management of Hip Fractures in the Elderly." JAAOS: Journal of the American Academy of Orthopaedic Surgeons, vol. 23, no. 2, 2015, pp. 131-137. doi:10.5435/JAAOS-D-14-00432.

17. National Guideline C. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Management of Hip Fractures in the Elderly. 2014.

18. NICE. Hip Fracture: Management, Clinical Guideline [CG124]. 2014.

19. Bhandari, Mohit, and Marc Swiontkowski. "Management of Acute Hip Fracture." New England Journal of Medicine, vol. 377, no. 21, 2017, pp. 2053-2062. doi:10.1056/NEJMcp1611090.

20. Orosz, Gretchen M., et al. "Association of Timing of Surgery for Hip Fracture and Patient Outcomes." JAMA, vol. 291, no. 14, 2004, pp. 1738-1743. doi:10.1001/jama.291.14.1738.

21. Parker, Martyn J., and Glyn A. Pryor. "The Timing of Surgery for Proximal Femoral Fractures." The Journal of Bone & Joint Surgery British Volume, vol. 74, no. 2, 1992, pp. 203-205. https://doi.org/10.1302/0301-620X.74B2.1544952.

22. Smektala, Rüdiger, et al. "The Effect of Time-to-Surgery on Outcome in Elderly Patients with Proximal Femoral Fractures." BMC Musculoskeletal Disorders, vol. 9, 2008, pp. 1-9. https://link.springer.com/article/10.1186/1471-2474-9-171.

23. Shin, Hyeon Ju, et al. "Allogeneic Red Blood Cell Transfusion Is an Independent Risk Factor for 1-Year Mortality in Elderly Patients Undergoing Femoral Neck Fracture Surgery: Retrospective Study." Medicine, vol. 99, no. 35, 2020, e21897. doi:10.1097/MD.0000000000021897.

24. Higashikawa, Toshihiro, et al. "Mortality and the Risk Factors in Elderly Female Patients with Femoral Neck and Trochanteric Fractures." Journal of Clinical Medicine Research, vol. 12, no. 10, 2020, pp. 668. https://doi.org/10.14740/jocmr4292.

25. Foss, N. B., and H. Kehlet. "Mortality Analysis in Hip Fracture Patients: Implications for Design of Future Outcome Trials." British Journal of Anaesthesia, vol. 94, no. 1, 2005, pp. 24-29. https://doi.org/10.1093/bja/aei010.

26. Klestil, Thomas, et al. "Impact of Timing of Surgery in Elderly Hip Fracture Patients: A Systematic Review and Meta-Analysis." Scientific Reports, vol. 8, no. 1, 2018, pp. 13933. https://www.nature.com/articles/s41598-018-32098-7.

27. Miller, Christopher P., Rafael A. Buerba, and Michael P. Leslie. "Preoperative Factors and Early Complications Associated with Hemiarthroplasty and Total Hip Arthroplasty for Displaced Femoral Neck Fractures." Geriatric Orthopaedic Surgery & Rehabilitation, vol. 5, no. 2, 2014, pp. 73-81. https://doi.org/10.1177/2151458514528951.