Elderly patients with two episodes of fragility hip fractures form a special subgroup

Journal of Orthopaedic Surgery, Dec 2006 by Ip, D, Ip, F K

ABSTRACT

Purpose. To identify the demographic features of patients aged 65 years or older admitted with 2 episodes of fragility hip fractures.

Methods. From July 2003 to December 2004 inclusive, 50 consecutive elderly patients underwent surgery for a second episode of hip fracture. Patients in a very poor physical condition and therefore unfit for surgery were excluded. Risk factors of fractures in both episodes and whether risk factors were corrected after the first episode were analysed. Detailed radiological assessment and charting of elderly mobility scores and Barthel index were completed and the one-year mortality rate documented. The rehabilitation periods for the 2 episodes of hip fracture were compared.

Results. Most patients were female and had trochanteric fractures. In patients aged 65 to 75 years, the incidence of femoral neck fracture occurred as often as trochanteric fracture; while trochanteric fracture was predominant in older patients. Subclinical osteomalacia and undiagnosed hyperthyroidism was found in 3 of the 7 younger patients. Only 30% of them were on treatment for osteoporosis after the first fracture, which underlines the importance of osteoporosis treatment in these patients.

Conclusion. Elderly patients with 2 episodes of fragility hip fractures form a special subgroup among geriatric hip fracture patients. Fall prevention programmes and treatment for osteoporosis are recommended.

Key words: aged; geriatrics; hip fracture; treatment outcome

INTRODUCTION

Hip fractures increase morbidity and mortality of elderly patients with multiple co-morbidities. The negative effects of low-energy fragility fractures on elderly patients resemble those of high-energy trauma to younger individuals, with the first-year mortality rates being 15 to 25%. Only 50% of elderly patients with hip fractures are able to regain their original mobility status, despite prolonged rehabilitation.

Patients with 2 episodes of fragility hip fractures seem to constitute a subgroup among elderly hip fracture patients. Characteristics of such elderly patients were recorded and compared with those of elderly persons with a single episode of hip fracture documented in the literature.

MATERIALS AND METHODS

Between the period July 2003 and December 2004 inclusive, consecutive patients aged ≥65 years with a history of hip fractures requiring surgery admitted to the Pamela Youde Nethersole Eastern Hospital or the Ruttonjee Hospital for second hip fracture surgery were included and their details obtained from hospital logs. Patients in a very poor physical condition and therefore unfit for surgery were excluded.

The injury mechanisms/risk factors for fall of the first and second episodes of hip fractures were recorded, as per patients' recollections, eyewitness accounts of relatives or attending staff of nursing homes. Co-morbidities (especially cardiopulmonary or endocrine disorders), and treatment methods used for the previous hip fracture were noted, as was any treatment for osteoporosis. Any history of previous fragility fractures in other parts of the body were documented, particularly of the wrist and the spine. For each patient, initial mobility status and ability to manage activities of daily living were also assessed.

The patients' cardiopulmonary fitness and orthopaedic condition were assessed, with particular emphasis on the ipsilateral and contralateral lower extremities and the neuromuscular status of the upper and lower extremities. Preoperative and postoperative radiography, fracture classification of both episodes, assessment of the hips, and laboratory blood work (including the calcium and phosphate levels) were undertaken for each patient. Relevant blood investigations were ordered, depending on preliminary test results, such as for endocrine screening.

Rehabilitation began immediately after surgery and consisted of posture, balance retraining, as well as strength and gait training. Muscular retraining involved both strength and, later, endurance exercises. Elderly mobility and Barthel index scores were assessed before and after hospital discharge. The time required to reach maximum improvement in function and mobility was defined as 2 identical serial Barthel index and/or elderly mobility scores. The times required for rehabilitation after the first and second episodes of hip fracture were analysed using Student's t test. The rehabilitation protocol and the multidisciplinary care team was essentially the same for both episodes.

RESULTS

Patient characteristics including age, gender, interval between the first and second hip fracture, injury mechanisms, and types of injury are shown in Table 1: the mean age was 85 (range, 65-96) years, the male to female ratio was about 1:6 (8 males, 42 females). Of the 50 patients, 7 were aged 65 to 75 years, 23 were between 76 and 85 years, and 20 were ≥86 years old. Regarding the second episode of hip fracture, 40 (80%) were trochanteric (3 patients were aged 65-75, 17 were aged 76-85, and 20 ≥86 years). The 10 patients having femoral neck fractures were in the younger age-groups (4 aged 65 to 75 years, 6 aged 76 to 85 years, and none ≥86 years).