Elsevier

Bone

Volume 41, Issue 6, December 2007, Pages 958-964
Bone

Survival and functional outcome according to hip fracture type: A one-year prospective cohort study in elderly women with an intertrochanteric or femoral neck fracture

https://doi.org/10.1016/j.bone.2007.08.026Get rights and content

Abstract

We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome and to determine whether outcomes differ by fracture type.

The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures were survival and functional outcome, both at hospital discharge and 1 year later. Functional outcome was assessed using the Rapid Disability Rating Scale version-2.

Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significant differences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities and prefracture residence at the time of injury. At hospital discharge, intertrochanteric hip fracture patients had a higher mortality (p = 0.006) and were functionally more impaired (p = 0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (relative risk 2.5; 95% confidence interval: 1.3 to 5.1; p = 0.008), but functional outcome among surviving patients was similar in both groups.

We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcome differs according to fracture type at hospital discharge, but these differences do not persist over time. These differences cannot be explained by differences in age or comorbidity. To address the mechanism(s) by which intertrochanteric fractures carry excess mortality compared to femoral neck fractures, future studies in hip fracture patients should include a comprehensive assessment of the degree of frailty, vitamin D status, and fall dynamics.

Introduction

Hip fractures are classified according to the anatomic location of fracture into fractures of the femoral neck (cervical, intracapsular) or intertrochanteric (extracapsular) regions [38], [46]. However, most survival studies in hip fracture patients have not analyzed these different fracture types separately [7], [9], [13], [21], [22], [23], [33], [35], [39], [47], [48]. In those survival studies that did focus on fracture type, women with an intertrochanteric fracture were found to be almost twice as likely to die than those with a femoral neck fracture [1], [3], [6], [8], [12], [15], [24], [25], [29], [34], [43], [45], [49], but it remains unclear if and to what extent these differences in mortality might be due to differences in comorbidity.

Data on potential differences in long-term functional outcome between both hip fracture types are even more sparse and conflicting, with some studies reporting less functional recovery 1 year after injury among patients with an intertrochanteric fracture [24] and other studies reporting similar functional outcomes [3], [15], [26], [28], [36], [37], [45]. Moreover, differences in baseline characteristics between intertrochanteric and femoral neck fracture patients in these studies make it difficult to interpret these results. More specifically, differences in age and comorbidity – known determinants of mortality and functional outcome after hip fracture [5] – may have confounded the results.

In a one-year prospective cohort study conducted among unselected, consecutively recruited elderly women with a first hip fracture [4], [5], [17], we observed no differences in age and pre-fracture comorbidities between our patients with an intertrochanteric or a femoral neck fracture. In this regard, this cohort provides an opportunity to address the question as to whether mortality and functional outcome are affected directly by hip fracture type.

Section snippets

Study design and source of study population

The current paper is based on a large observational study undertaken between November 1995 and July 1996 with the aim to collect data on risk factors for hip fracture, current surgical practice, mortality, clinical outcome, and costs of care after hip fractures in women aged 50 years and older. A detailed description of the study design, recruitment strategy, participant characteristics, outcome assessment, and statistical analysis has been previously published [4], [5], [17].

Briefly, at four

Participants’ characteristics

All eligibility criteria were met by a total of 184 hip fracture patients, of which 170 (92.4%) accepted to participate. Patients or their relatives who declined to participate typically did so because they did not want to participate in a long-term study. Of the 170 women originally enrolled, 84 (49%) and 86 (51%) women had a femoral neck fracture or an intertrochanteric fracture, respectively, with a corresponding ratio of femoral neck to intertrochanteric fracture patients of 0.98.

Table 1

Discussion

Our findings provide evidence that mortality and functional outcome following a hip fracture vary according to fracture type. At hospital discharge, women who sustained an intertrochanteric hip fracture had a higher mortality and were less able to walk independently than women with a femoral neck fracture. One year later, mortality was still higher after intertrochanteric fracture, but functional outcome among surviving patients was not different between both groups.

An increase in mortality in

Acknowledgments

We are indebted to the participating women and their families. We would also like to thank Health Management Creative (Brussels) for the professional way they ensured the interviews and the follow-up of patients.

S. Boonen and D. Vanderschueren are both Senior Clinical Investigator of the Fund for Scientific Research-Flanders, Belgium (F.W.O.-Vlaanderen) and holders of the Leuven University Chair in Metabolic Bone Diseases, supported by Roche & GSK.

This paper was selected for oral presentation

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    All members of the study group are listed in the Acknowledgments section.

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