Replacement of the femoral head due to fracture of the hip: prognostic factors for the duration of hospitalisation, institutionalisation and mortality

OBJECTIVE: To identify preoperative factors affecting length of hospital stay, residential status and mortality after replacement of the femoral head for a hip fracture. DESIGN: Prospective. METHOD: Of the 146 consecutive patients who had hemiarthroplasty for a displaced femoral neck fracture in the period 1996-1998, data were recorded on age, sex, the residential situation, ambulation, ADL dependency, the presence of dementia and the classification according to the American Society of Anesthesiologists (ASA). The operations were carried out in the IJsselland Hospital, Capelle aan den IJssel, the Netherlands. The study was terminated in October 2001. With the aid of uni- and multivariate analysis, the relationship was determined between the pre-operative factors and the length of hospital stay, need for institutional care, and mortality within 3 years after the operation. RESULTS: The study population consisted of 146 patients: 33 men and 113 women with an average age of 82 years (range: 60-98). The length of hospital stay averaged 21 days (range: 2-98). Independent pre-operative predictors for a longer period of hospitalisation were ADL dependency (OR: 1.3; 95% CI: 1.1-15.2), residence at home (0.7; 0.6-0.8), and poor ambulation (1.1; 1.0-1.3). The predictors for permanent institutionalisation were: prior stay in an institution (4-7; 1.1-19.5) and the presence of dementia (3.9; 1.0-1.5). Compared to the general Dutch population of the same age and sex, there was a significant excess mortality during the 3 years after the operation and especially during the first 12 months. Unfavourable prognostic factors for mortality within 3 years after the operation were: poor ambulation before the fracture (3.1; 1.8-5.3), an ASA classification of 3 or 4 (2.0; 1.2-3.1) and an age over 80 years (2.0; 1.2-3.3). CONCLUSION: The risk factors for a longer stay in hospital, placement in an institution or decreased survival in patients who underwent hemiarthroplasty as part of the treatment of a hip fracture can already be identified at the time of admission. The patients with these risk factors should be given special attention during the period of hospitalisation and after-care.     

Secular increase in the incidence of hip fractures in Belgium between 1984 and 1996: need for a concerted public health strategy.

OBJECTIVE: To determine the incidence of hip fractures (at the proximal end of the femur) in Belgium from 1984 to 1996. METHODS: Use was made of information from the national database on hospital bills, which fully covers the annual hospital stays in the whole of the country. FINDINGS: The mean annual incidence of hip fractures increased from 107.8 to 140.5 per 100,000 inhabitants between 1984 and 1996. The incidence of fractures of the femoral shaft (diaphysis), taken as a control, remained stable. The female to male ratio of these hip fractures was 2.3:1. Although the incidence by age group was identical for males and females, the fractures occurred approximately seven years earlier in women than in men. The demographic changes observed in Belgium during this period accounted for only 10% of the observed increase in the number of hip fractures. CONCLUSION: If no comprehensive preventive policy is set up promptly, there will be a sevenfold increase in the incidence of hip fractures between now and the year 2050 in Belgium.     

Incidence of hip fractures, United States, 1970-83

Hip fractures are a major cause of morbidity and mortality in the United States. Twenty to 40% of persons who fracture their hips die within 6 months of the injury, and many survivors need long-term care. To assess the public health impact of hip fractures in the United States, we analyzed sample-based data from the National Hospital Discharge Survey, National Center for Health Statistics, for the United States for the period 1970-83. For these years, an estimated annual average of 197,000 persons 45 years of age or older was hospitalized for hip fractures. The age-, race-, and sex-adjusted hospitalization rates for hip fractures rose from 28.9 per 10,000 persons in 1970 to 30.9 per 10,000 in 1983 (P less than .01). Hospitalization rates rose exponentially by successive 10-year age groups, with persons 85 years of age or older having the highest rate (251.4 per 10,000). For each age group, women had hospitalization rates twice those of men, and whites had hospitalization rates twice those of other races. Never-married and divorced persons had higher hospitalization rates than currently married persons. The percentage of mortality before discharge from hospital fell from 11% in 1970 to 6% in 1983, with most of the decrease occurring among persons 75 years of age or older. The age-adjusted mean length of hospital stay declined 24%, from 23.9 days in 1970 to 18.2 days in 1983.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reduce the mortality due to femur fractures via an integrated approach to the comorbidity

Preliminary studies show that there is an annual increase in the number of operations for femur fractures in The Netherlands and that this increase can be ascribed totally to the increasing age of the population, even though the risk of falling has not increased. Although the hospital mortality in this category of patients has decreased, mainly as the result of a shortened hospital stay, the long-term mortality does not seem to have decreased in comparison to earlier analyses. The conclusion could well be that we in The Netherlands must be able, in the future, to reduce the long-term mortality by means of a better integrated approach to care, as has already been described in other studies.     

Trends in hospital admissions for fractures of the hip and femur in England, 1989-1990 to 1997-1998

BACKGROUND: Fractures of the hip are a major public health issue. Suggestions of a recent stabilization of age-specific admission rates would have implications for health service planning, thus we investigated this using hospital data. METHOD: Hospital episode statistics for England, 1989-1990 to 1997-1998, were examined for admissions and deaths for fractures of the hip and femur in NHS hospitals in patients aged 45 years and over. RESULTS: Age-standardized admission rates increased by 32 per cent between 1989-1990 and 1997-1998 in men, and by 30 per cent in women. The increase in admission rates was almost entirely confined to the period 1989-1990 to 1991-1992, with very little change after this. The proportion of admissions ending in death during the study period decreased in both men (-35 per cent) and women (-40 per cent) but this change was largely confined to the early years of the study. The number of admissions from hip and femoral fractures in people aged 65 years and over is projected to increase from about 57,300 in 1997-1998 to 69,500 by 2021-2022. CONCLUSIONS: Age-specific rates of admission appear to be stabilizing, which is in contrast to previous trends. The lack of any decrease in hospital admission and mortality rates over the last 5 years is of concern. The management of osteoporosis-induced fractures in hospitals, the prevention and treatment of osteoporosis in primary care and the prevention of falls should be seen as priorities for the NHS to help reduce the burden of disease from osteoporosis in the elderly.     

Time trends in incidence rates of first hip fracture in the Uppsala Health Care Region, Sweden, 1965-1983

Time trends from 1965 through 1983 for age-specific and age-standardized rates of first hospital admission for a proximal femur fracture were studied in the Uppsala Health Care Region, Sweden, using a centralized register for inpatient care. During the 19-year study period, 29,277 hospital admissions for a first hip fracture were recorded in this population of about 1.5 million persons. The total number of first hip fracture admissions per year increased for both sexes. Age-standardized admission rates for both cervical and trochanteric fractures increased in men (average change per year of 1.8% and 2.6%, respectively) in contrast to the decreased admission rate for cervical fractures (-1.6% per year) and a stable rate for trochanteric fractures (0.4% per year) in women. The cumulative rate of cervical or trochanteric fracture at ages 30-79 years increased 46% in men (from 42/1,000 population in 1965 to 61.5/1,000 population in 1983) in contrast to a 24% decrease in women (from 134/1,000 population in 1965 to 101.5/1,000 population in 1983). The female:male ratio of age-standardized incidence rates decreased for both types of fracture during the study period. This finding of stable or decreasing rates of hip fracture in women contrasts with the findings of most previous studies.     

Hip fracture in Hong Kong over the last decade--a comparison with the UK.

BACKGROUND: Hip fracture is a major public health problem in Asia and the UK. The objectives of this study were to describe the trends of hip fracture in Hong Kong over the last decade, and to compare the incidence in Hong Kong with that from the Wessex Health Region of the UK in 1995. METHODS: The number of hip fractures was calculated using hospital discharge records for all public hospitals in Hong Kong in 1991 and 1995. Age-specific incidence rates were then calculated using the mid-year census population for the two years. These rates were presented with previously reported age-specific rates for Hong Kong in 1966 and 1985. These age-specific rates for Hong Kong in 1995 were compared with rates for the Wessex Health Region of the UK. The total number of hip fracture expected in 2010 was calculated by applying the age-specific rates of 1995 to the projected population for 2010. RESULTS: In 1995, a total of 1138 men and 2782 women in Hong Kong fractured their hip. The age-specific rates had remained static from 1985 to 1995, after substantial rise from 1966 to 1985. In 1995, the rates of hip fracture rates were 11/1000 in women and 5/1000 in men who were 70 years and older. These rates were almost identical to those observed in the Wessex Health Region of the UK. CONCLUSION: The age-specific incidence rates of hip fracture had not risen in Hong Kong in the last decade. The incidence of hip fracture in Hong Kong was similar to that in the UK in 1995. The total number of patients with hip fracture in Hong Kong will increase substantially in the future, as a result of the ageing of the population.     

Characteristics of hospital admissions in the Unified National Health System for osteoporotic hip fracture in elderly people in Brazil, 2006-2008

Osteoporosis is a multifactorial syndrome of the skeletal system, and hip fracture is the most serious consequence for the elderly, due to the high mortality and cost. This article describes osteoporotic hip fractures in Brazilian elderly in 2006-2008. Secondary data were obtained from the Authorization Forms for Hospital Admissions (AIH) and allowed the creation of indicators for hip fracture in elders. The proportion of elderly patients hospitalized for hip fractures in the Unified National Health System was 1%. The percentages of hospital admissions and deaths were higher in females, and increased with age. Hip fractures accounted for approximately 2% of health care expenditures for persons 60 years or older. Length of hospital stay ranged from one to seven days, 50.1% occurred in charity hospitals, and 42.7% occurred outside the county of residence. The findings emphasize the need for greater attention to osteoporosis and show the relevance of costs in hospital admissions for elderly with osteoporotic hip fractures. Understanding such hospitalizations can contribute to the formulation of health policies to address this issue.     

Mortality from violent causes among the elderly population in Finland in 1951-1979

The changes in violence-related mortality rates among the population aged 65 years or older in Finland from 1951-1979 were studied with the help of the official mortality statistics. Factors underlying these changes were also examined. The most distinctive findings were, first, the increase in accident-related mortality rates of both males and females in the 1950s and, second, the sharp decrease of those rates with respect to women from 1960-1975 compared to the decrease for males during that same period. The changes in mortality for males were mainly due to changes in frequency of motor-vehicle fatalities, whereas the changes for females were mainly due to changes in mortality caused by accidental falls and limb fractures. Improvements in classification methods resulting in the decrease of unspecified causes of death were apparently the main cause of the recorded increase in violent mortality in the early 1950s. The incidence of traffic accidents has decreased in the latter half of the 1970s. Thus, the minor decrease in motor-vehicle accident mortality for men most evidently was due to a decreased incidence. The incidence of hip and limb fractures in women increased. Thus, it was not a lowered incidence but instead a decreased case-fatality rate which caused the decreased mortality in females. Early mobilization after hip operations and decreased dependence level among the elderly apparently resulted in the decreased fatality rates.     

Dynamic hip screw versus 3 parallel screws in the treatment of garden 1 + 2 and garden 3 + 4 cervical hip fractures

OBJECTIVE: The main objective of this study was to evaluate the failure rate following operations of undisplaced and displaced cervical hip fractures with a dynamic hip screw compared with 3 parallel screws. DESIGN: The study was retrospective. The minimum follow-up time was 1 year. The data tta collested between January 1990 and December 1993. SETTING: University Hospitals. PATIENTS: A total of 456 patients (352 women and 104 men) with cervical hip fractures were included. The mean age was 80 years (range 51-100 years). INTERVENTION: This was internal fixation of the fractured hip with a dynamic hip screw or 3 parallel screws. MAIN OUTCOME MEASURES: Failure was defined as nonunion, fixation failure or avascular necrosis and reoperation was found indicated. The 3 months mortality rate, the wound infection rate, the delay between admission and time of surgery and the blood transfusion requirement were also recorded. RESULTS: A total of 456 cervical hip fractures were operated with a dynamic hip screw or 3 parallel screws. The failure rate for fractures treated with a dynamic hip screw was 14/98 = 14% for Garden 1 + 2 fractures and 43/108 = 40% for Garden 3 + 4 fractures. The failure rate for fractures treated with 3 parallel screws was similar: 23/154 = 15% for Garden 1 + 2 fractures and 38/196 = 40% for Garden 3 + 4 fractures. The average follow-up time was 2.5 years. CONCLUSION: Operation of cervical hip fracture with a dynamic hip screw or 3 parallel screw seem to give similar results.     

Water fluoride concentration and fracture of the proximal femur.

STUDY OBJECTIVE--The aim of the study was to examine the relationship between water fluoride concentration and the incidence of hip fracture, since evidence on this is at present inconsistent. DESIGN--Numbers of hospital admissions for fractures of proximal femur were obtained from hospital activity analysis data for the years 1978-1982. The fracture rates were compared with water fluoride concentrations in 39 county districts of England and Wales (fluoride concentrations had been measured in these districts between 1969 and 1973 as part of the British Regional Heart Study). PATIENTS--During the study period, 4121 men and 16,272 women aged 45 years and over were discharged from hospital after hip fracture. RESULTS--Poor correlations were found between discharge rates and both total (r = 0.16, p = 0.34) and natural (r = 0.01, p = 0.95) water fluoride concentrations. CONCLUSIONS--Water fluoridation to levels of around 1 mg/litre is unlikely to reduce hip fracture incidence markedly in this country.     

Lung cancer in the Netherlands in the period 1989-1997: the epidemic is not over yet

OBJECTIVE: To describe and interpret changes in incidence, mortality and survival of lung cancer in the Netherlands in the period 1989-1997. DESIGN: Secondary data analysis. METHODS: Data on the incidence of lung cancer were collected from the Dutch Cancer Registration (1989-1997), on mortality from Statistics Netherlands (CBS; 1989-1994), on the incidence of lung cancer in other European countries from EUROCIM (1990-1994), on survival of Dutch lung cancer patients from the Comprehensive Cancer Centre Amsterdam (1988-1997) and the Comprehensive Cancer Centre South (1988-1992) and on survival of other European lung cancer patients from EUROCARE (1985-1989). Incidence rates were calculated per 100,000 person years and standardized by age according to the European population structure. Survival was calculated as the ratio of observed survival among the lung cancer patients and the expected survival of the general population. RESULTS: The incidence of lung cancer among men decreased from 109 to 93, whereas that among women increased from 18 to 23. The incidence of lung cancer among Dutch men was high in comparison to other European countries, whereas that among women was average. The trends in lung cancer incidence were probably related to the trends in past smoking behaviour. Mortality decreased among men from 106 to 91 and increased among women from 15 to 20. Survival was better for younger patients, a localised tumour, and better for squamous cell carcinoma or adenocarcinoma than for large-cell undifferentiated or small-cell carcinoma. The relative 5-year survival was 12%, the relative 1-year survival 39%; these were good in comparison with other European countries. CONCLUSION: The incidence and mortality of lung cancer among Dutch men decreased, but still in 1997 almost 20 men in the Netherlands died each day of lung cancer. Among women the end of the increase is not in sight and in 1997 over 5 women died each day of lung cancer.     

Fractures of the hip

This contribution assesses the incidence, aetiology, classifications, diagnosis, intracapsular and extracapsular fractures, postoperative management and prognosis associated with fractures of the hip. A hip fracture or proximal femoral fracture refers to any fracture of the proximal femur down to a level of about five centimetres below the lower border of the lesser trochanter. Fractures of the femoral head involving the articular surface are, strictly speaking, included in this definition. A hip fracture is the most common reason for an elderly person to be admitted to an acute orthopaedic ward. There has been a continued increase in hip fractures in the last 50 years.     

All-terrain vehicle-related hospitalizations in the United States, 2000-2004

OBJECTIVES: To estimate the incidence of all-terrain vehicle (ATV)-related injury hospitalizations in the United States from 2000 through 2004, and to describe the types of injuries and associated hospital costs for the entire population. METHODS: Data for 2000 through 2004 were obtained from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample--a stratified probability sample of 1004 community hospitals from 37 states. ATV injuries were defined by ICD-9-CM external cause of injury codes within E821. Variables included age, gender, primary diagnoses, patient disposition, primary payer, and hospital charges. Data were analyzed in 2007. RESULTS: There were an estimated 58,254 ATV-related hospitalizations, increasing 90% over the 5-year period. Eighty percent were men. Thirty percent of the cases involved youth under age 18, and 8% were over age 60. Passengers accounted for 9% of the hospitalizations. Eighty-five percent were routinely discharged to home while 13% required long-term rehabilitation or home health care. Payers included private insurance (62%), Medicaid/Medicare (19%), and self-pay (12%). Rural hospitals treated 23% of the cases and urban teaching hospitals 47%. Estimated total hospital charges were about $1.1 billion (20% paid from public funds) with an average charge per patient of $19,671. Leading injuries included fractures of lower limbs (22%; mean hospital charges of $19,626), other fractures (15%; $18,873), and intracranial injuries (14%; $26,906). The overall hospital admission rate was 4.4 per 100,000 population with variation by year, gender, and age. CONCLUSIONS: Voluntary industry and government safety efforts have had little impact on the increasing incidence and cost of ATV injuries. Renewed prevention efforts to making ATV riding safer are warranted.     

Fractures as predictors of excess mortality in the aged—A population-based study with a 12-year follow-up

INTRODUCTION AND OBJECTIVE: The association between fractures and excess mortality in old age is ambiguous. The objective of this study was to analyze the long-term gender-specific association between fractures and mortality among older persons by controlling several survival related confounders. METHODS: A population-based prospective cohort study in the municipality of Lieto, south-western Finland. Data on health, health behaviour, fractures, and mortality in 482 men and 695 women aged 65 or older was collected from 1991 until 2002. The Cox Proportional Hazards regression model with fractures as time-dependent variables was used in the analyses. RESULTS: During the 12-year follow-up, 295 (25%) persons sustained at least one fracture. Sustaining any kind of fracture was related to excess mortality both in men (age-adjusted Hazards Ratio, HR 2.2, 95% confidence intervals, CI 1.6-3.1) and in women (HR 1.6, 95% CI 1.3-2.1). In the multivariate analyses, hip fractures in men (HR 8.1, 95% CI 4.4-14.9) and in women (HR 3.0, 95% CI 1.9-4.9), and proximal humerus fractures in men (HR 5.4, 95% CI 1.6-17.7) were related to increased mortality. CONCLUSION: A hip fracture was a powerful independent predictor of long-term excess mortality in both genders but the risk in men was more than 2-fold compared to women. Proximal humerus fractures were associated with increased mortality in men. Actions to improve prevention, acute care and rehabilitation of fractures are needed in order to reduce excess mortality in older people.     

Hip fracture incidence in an urban area in Northeast Brazil

Hip fractures involve high morbidity and mortality and extensive treatment costs and are thus considered an important public health issue. Hip fracture incidence varies greatly between countries and even between cities in the same region. This study aimed to determine hip fracture incidence in Fortaleza, Ceará State, Brazil. Hip fracture cases were identified prospectively in patients aged 45 and over attending private and public hospitals in Fortaleza from July 2001 to June 2002. The study identified 673 patients with hip fractures, 382 of whom from Fortaleza. Annual hip fracture incidence in Fortaleza for patients over 60 years was 21.7/10,000 inhabitants (13.0/10,000 for men and 27.7/10,000 for women). Hip fractures were more frequent among women and with advancing age. Hip fracture incidence in Fortaleza was very low compared to rates reported from other parts of the world.