Elsevier

Injury

Volume 42, Issue 11, November 2011, Pages 1253-1256
Injury

Predictors of 5 year survival following hip fracture

https://doi.org/10.1016/j.injury.2010.12.008Get rights and content

Abstract

Background

This study aims to assess the mortality associated with hip fracture at 5 years in a geriatric population, and evaluate the influence of age, cognitive state, mobility and residential status on long term survival after hip fracture.

Methods

A prospective audit was carried out of all patients with a hip fracture admitted to a university hospital over a 4 year period. Data from 2640 patients were analysed and multivariate analysis used to indicate the important variables predicting mortality. Patients fulfilling the criteria of age < 80 years, Abbreviated Mental Test Score (AMT)  7/10, independently mobile and admitted from own home were put into group A (low risk group). Patients not meeting the criteria were placed into group B (high risk group).

Results

2640 patients fitted the inclusion criteria, 482 in group A and 2158 in group B. 850 patients (43.1%) died in their first year following hip fracture. 302 patients (63%) of group A were still alive at 5 years in comparison with only 367 (17%) of group B. Overall, 669 (25%) patients survived for 5 years. Increased survival was shown for the following variables: age < 80 years RR 5.27 (p < 0.01), AMT  7/10 RR 6.03 (p < 0.01), independent mobility RR 2.63 (p < 0.01) and admitted from own home RR 4.52 (p < 0.01).

Conclusions

These findings will allow for early recognition of those patients with an increased chance of long-term survival following hip fracture. Such patients may be suitable for surgical treatment, such as total hip replacement, which has a good long-term outcome.

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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