Predictors of 5 year survival following hip fracture
Introduction
Hip fracture is a major cause of morbidity and mortality amongst the elderly2, [4], 5, 10, 12, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28 and the rising annual incidence of hip fracture15, 21, 23 has made it the most common cause for admission following trauma.12 Despite use of preventative measures, the ever expanding number of elderly citizens suggests admission rates will increase in future years.13, 15, 21, 23
Many studies demonstrate increased mortality following hip fracture, both during admission and following discharge.2, [4], 5, 6, 7, 10, 11, 12, 13, 15, 16, 18, 19, 20, 22, 24, 25, 26, 27, 28 Although mortality rates are greatest within the first month2, 10, 19, 21, 22 some studies show a persistence of excess mortality for five years and beyond.5, 6, 24, 26 One study demonstrates a significant excess mortality lasting for many years in patients of all ages and gender, and for at least 5–6 years for women below the age of 75 years.6
Predictions regarding survival and functional outcome following hip fracture can be correlated to pre-fracture determinants.2, 7, 15, 16, 19, 20, 21, 22, 23 Chronological age, male sex, reduced mobility, residence, cognitive impairment and baseline co-morbidities have all been shown to be positively associated with increased risk of mortality, institutionalisation and poor physical outcome during the first year following fracture.1, 2, 7, 9, 13, 15, 16, 22, 25, 30 The affects of these variables on mortality rates over a longer period of time have been researched in less detail. If patients who have a high chance of long-term survival can be identified on admission with a hip fracture then surgical management could be altered to procedures more appropriate to their pre-fracture health and function, and a better long-term outcome may be achieved.[4], 23 Long-term survivors may also have the greatest cumulative risk of further fragility fracture and could, potentially, be a group that requires special measures in the investigation and treatment of osteoporosis.
Further research is required into the surgical methods used to manage hip fractures. Of particular interest is the management of displaced sub-capital fractures which are often treated with a replacement arthroplasty.3 Prospective randomised studies are required to provide level II and level I evidence regarding the optimal prosthesis. Design of these studies will require a sample size analysis that includes an estimate of loss to follow-up due to death. Thus, a method to estimate 5-year survival in hip fracture patients would be helpful in the design of such studies.
The aim of the present study was to assess the 5-year mortality associated with a hip fracture in a geriatric population, and to evaluate the influence of age, cognitive state, mobility and residential status on long term survival after hip fracture.
Section snippets
Methods
A prospective audit of all patients with hip fracture admitted to a university hospital was undertaken. Data for all hip fracture admissions between the years of 1999 and 2003 were analysed. Every patient admitted in this period had a detailed admission questionnaire completed including, patient demographics, circumstances of injury, medical history, residence and pre-fracture mobility.
All data is collected by independent audit personnel using a detailed proforma. Integration with the database
Results
During the 4 year period, 1999–2003, 2912 people were admitted with a fractured neck of femur.
Of the patients admitted, 2640 fitted the inclusion criteria to be entered into the study. A total of 272 patients were excluded from the audit; 87 sustained pathological fractures and 9 sustained bilateral fractures. There were 176 patients with missing AMT Scores. Data for mortality were collected for 100% of the 2640 patients.
Excess mortality for the first year was 43.1% (850 patients). Overall
Discussion
There have been many studies documenting increased mortality following hip fracture.2, [4], 5, 6, 7, 10, 11, 12, 15, 16, 18, 19, 20, 22, 24, 25, 26, 27, 28 Few, however, have highlighted patients with a greater chance of survival over a longer period of time. This prospective audit has identified such patients.
Of the four variables found to be important in predicting 5-year mortality after hip fracture, age and cognitive state were shown to have the greatest relative risk of mortality. This
Conflicts of interest statement
None declared.
Acknowledgments
This project audits current clinical practice and, as such, does not require ethical approval in the UK. The project was funded internally by its University Hospitals NHS Trust. The authors wish to acknowledge the Orthopaedic Trauma Consultants of its University Hospitals and the audit and research team.
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