Calcif Tissue Int (2006) 78:7277 DOI: 10.

1007/s00223-005-0169-6

Mortality Rates of Patients with a Hip Fracture in a Southwestern District of Greece: Ten-Year Follow-Up with Reference to the Type of Fracture
A. Karagiannis,1 E. Papakitsou,2 K. Dretakis,2 A. Galanos,2 P. Megas,1 E. Lambiris,1 G. P. Lyritis2
1 2

Orthopedic Department, University Hospital, University of Patras, Patras, Greece Laboratory for the Research of the Musculoskeletal System Th. Garofalidis, University of Athens, Kisia, Greece

Received: 5 October 2005 / Accepted: 12 October 2005 / Online publication: 6 February 2006

Abstract. Increased mortality after a hip fracture has been associated with age, sex, and comorbidity. In order to estimate the long-term mortality with reference to hip fracture type, we followed 499 patients older than 60 years who had been treated surgically for a unilateral hip fracture for 10 years. At admission, patients with femoral neck fractures (n = 172) were 2 years younger than intertrochanteric patients (77.6 7.7 [SD] vs. 79.9 7.4 [SD], P = 0.001) and had a greater prevalence of heart failure (57% vs. 40.3%, P = 0.03). Similar mortality rates were observed at 1 year in both types of fracture (17.9% vs. 11.3%, log rank test P = 0.112). Mortality rates were signicantly higher for intertrochanteric fractures at 5 years (48.8% vs. 34.7%, P = 0.01) and 10 years (76% vs. 58%, P = 0.001). Patients 6069 years old with intertrochanteric fractures had signicantly higher 10-year mortality than patients of similar age with femoral neck fractures (P = 0.008), while there was no dierence between the groups aged 7079 (P > 0.3) and 8089 (P = 0.07). Women were less likely to die in 5 years (relative risk [RR] = 0.57, 95% condence interval [CI] 0.410.79, P = 0.0007) and 10 years (RR = 0.65, 95% CI 0.490.85, P = 0.002). Age, sex, the type of fracture, and the presence of heart failure were independent predictors of 10-year mortality (Cox regression model P < 0.0001). The intertrochanteric type was independently associated with 1.37 (95% CI 1.031.83) times higher probability of death at 10 years (P = 0.002). In conclusion, the type of fracture is an independent predictor of long-term mortality in patients with hip fractures, and the intertrochanteric type yields worse prognosis. Key words: Hip fracture Long-term mortality Type of fracture

Several studies have shown that patients with hip fractures have increased mortality after the fracture compared to the general population with similar age and sex distribution [15]. According to large population-based

Correspondence to: E. Papakitsou; E-mail: eypapk@med. uoa.gr

studies of survival after osteoporotic fractures, the hip fracture-related eect on survival is maximal during the rst 36 months after the fracture and persists for several years after the event [610]. Mortality during the rst year after the fracture may be associated with a deleterious eect of surgery or trauma and their complications on the frail elderly population with hip fractures [1012], while long-term mortality may be attributed to comorbidity [11] or a progressive decline in health due to limited activity and disuse [10]. The incidence of hip fracture in Greece increased from 107.3/100,000 inhabitants in 1992 to 118.6/100,000 inhabitants in 1997, and this increase was mainly due to aging of the population. Patients older than 80 years comprised 50% of the hip fracture population in 1997 [13]. Data about mortality after a hip fracture in Greece are limited, and there are no data about long-term survival. Sex, age, and health status at admission have been well recognized factors that aect the pattern of mortality after a hip fracture [4, 1416], although previous cohort studies with considerably long follow-up (9 and 18.5 years) have shown that almost all groups of age and gender have signicant excess long-term mortality after a hip fracture [3, 17]. Intertrochanteric or femoral neck location of the hip fracture indicates dierent surgical manipulations and dierences in patient characteristics that may aect short-term or long-term mortality. However, most studies do not examine the association between the type of hip fracture and postfracture mortality. Interestingly, in a multicenter study from Baltimore and a study from two British centers with 12 months of follow-up, patients with intertrochanteric fractures had signicantly higher mortality rates than those with femoral neck fractures [18, 19]. In this study, we measured the short- and long-term mortality, up to 10 years, after a hip fracture in patients treated during a 3-year period in our department and analyzed data about gender, age, type of fracture, and mortality.

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Methods and Patients During a 3-year period, from February 1989 to February 1992, we registered 541 patients older than 60 years old who were admitted with a hip fracture in the Orthopedic Department of the University Hospital of Patras, with the approval of the Ethics Committee. The hospital is centrally located in the city of Patras, a mixed urban-rural area in west southern Greece, with 300,822 permanent inhabitants. At admission, the patients or their relatives were interviewed by medical doctors of the department and gave their consent to participate in the study. Patients with subtrochanteric fractures, pathologic fractures, fractures caused by non-low-energy mechanisms (fall from height higher than ground level or trac accident), or a previous hip fracture were excluded from the study (n = 23). Finally, 144 men (27.8%) and 374 women (72.2%) with hip fractures were included in the study and followed from the date of fracture until death or February 2002. The majority of the fractures were routinely treated surgically by reduction and internal xation or hemiarthroplasty, as soon as the patient was stable to undergo the operation. Nineteen patients were treated conservatively with non-weight-bearing therapy and physiotherapy since their perioperative risk was very high. These 19 patients were not included in the mortality analysis. Dynamic hip screw (DHS) was used in 290 intertrochanteric fractures and gamma-nail in 47. Femoral neck fractures were managed by hemiarthroplasty (n = 123) or xation with cannulated screws (n = 11). In a small number of displaced femoral neck fractures (n = 28), we performed a total hip replacement. After surgery, preventive anticoagulative and antibiotic therapy was given in all patients for 10 days and 4 days, respectively. As per protocol, patients were mobilized early except if the surgeon suggested limitations due to unstable xation. During hospitalization, data on sex, age, type of fracture, coincident diseases, surgical methods of management, time from admission to surgery, time from admission to discharge, and intrahospital mortality were collected by one orthopedic surgeon of the ward. After discharge, patients were followed for 2 years in the outpatient clinic of the Orthopedic Department, and mortality was recorded at 6 months, 1 year, and 2 years after the fracture. At 5 and 10 years from the end of the recruitment period, we communicated with our cases by phone or through an appointment in order to collect data about mortality. If a subject was lost to follow-up, the censoring time was computed from the date of entry in the study to the last available phone call or visit. Sixty percent of the lost cases had censoring time lower than 1 year. At 10 years (February 2002), 389 cases responded and the date and cause of death were recorded as reported by siblings or other relatives. There was no signicant dierence in baseline age, type of fracture, sex, and presence of heart failure between these 389 patients and the lost cases. Statistics Descriptive statistics were reported by means and standard deviation (SD) of interval variables and frequency and proportions for the nominal data. The unpaired t-test and Pearsons chi-squared or Fischers exact test were used to test interval and nominal data in dierent groups. The KaplanMeier method was used to estimate the probability of survival at certain time points postfracture. Between-group comparisons of the survival distributions were performed using the log rank test. Coxs proportional hazards model was used to investigate the relationship between survival time and possible prognostic patient characteristics. The independent variables were age, gender, type of fracture, and heart failure. Patients treated conservatively were not included in the mortality analysis. All statistical analyses were performed using the SPSS software program for Windows (SPSS, Chicago, IL). Statistical signicance was dened at or below P = 0.05.

Results

The mean age of the patients was 79.01 7.72 (SD) years, and 54.9% of the patients were older than 80 years. There were 172 (33.2%) patients with a femoral neck fracture. Men and women were of similar age (P = 0.261), and there was no dierence in the type of fracture between men and women (Fischers test P = 0.141). At admission, patients with a femoral neck fracture were approximately 2 years younger than patients with intertrochanteric fractures (77.6 7.7 vs. 79.9 7.4 years, respectively; P = 0.001). On admission, 50% of patients with femoral neck and 53.7% of those with intertrochanteric fractures had at least one or more concomitant illnesses (Fischers test P = 0.25). The most common diseases found in patients with femoral neck or intertrochanteric fractures are summarized in Table 1. Heart failure had a greater prevalence in femoral neck fractures (Pearsons chi-squared P = 0.03). The mean time from admission to surgery was 2.38 1.85 days, and 29.5% of patients were operated within 24 hours of admission. There was no signicant dierence in the mean time from admission to surgery between intertrochanteric and femoral neck fractures (P = 0.24). Patients with femoral neck fractures were discharged 10.37 5.05 (SD) days after the operation, while the patients with intertrochanteric fractures were discharged earlier, 8.73 3.82 (SD) days (P = 0.005). During hospitalisation, 2.2% of patients who had been treated surgically had a lethal complication related to the fracture, e.g., pulmonary embolism. Two patients (1.2%) with femoral neck fractures and nine (2.7%) in the intertrochanteric group were dead before discharge, and there was no statistically signicant dierence in intrahospital mortality between the two groups (Fishers test P = 0.35). The median survival time in our patients was 72.5 months overall. Survival rates up to 10 years after the fracture for men and women in age decades 6069, 7079, and over 80 years are summarized in Table 2. Women had higher median postfracture survival time than men in the decade 6069 years (118 4.7 standard error [SE] vs. 85.7 12.5 (SE) months, log rank test P = 0.007), but the survival curves of men and women were parallel with respect to the older groups (log rank test P > 0.1). Mortality at 1 year was 15.7% overall. There was no signicant dierence in mortality at months 6, 12, and 24 between the two types of hip fracture. At 6 months, mortality was 10.5% for both types of fracture (log rank test P = 0.848). At month 12, mortality was 11.3% among femoral neck and 17.9% among intertrochanteric fractures, but the dierence was not statistically signicant (log rank test P = 0.112). On the contrary, longterm mortality recorded at 5 and 10 years was signicantly higher in the intertrochanteric group (log rank test

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Table 1. Frequency of the most common illnesses within each type of hip fracture in admission Frequency of illness within fracture type (%) Femoral neck Type of disease Heart failure Diabetes mellitus Arterial hypertension Other 57 8.1 22.1 12.8 Intertrochanteric 40.3 17.6 21.6 20.5

Table 2. The survival rates up to 10 years after the fracture for men and women in age decades 6069, 7079 and over 80 years Survival percentage (%) Age (years) Men 6069 7079 80+ Women 6069 7079 80+ 6 months 86 93 80 100 88 84 1 year 81 83 73 100 82 76 2 years 67 73 59 97 79 64 5 years 57 60 29 90 66 44 10 years 50 40 12 85 42 15

Pearson Chi-Square, P = 0.03

P = 0.01 and P = 0.001, respectively). The median survival time was 85 months (95% condence interval [CI] 77.897.9) for femoral neck and 60 months (95% CI 50.769.3) for intertrochanteric fractures (Fig. 1). Five-year mortality was 48.8% in patients who had been admitted with intertrochanteric fractures compared to 34.7% in those with femoral neck fractures (log rank test P = 0.01). In Cox regression analysis of the model of survival at 5 years after the fracture, age, sex, and the presence of heart failure on admission were signicant predictors (Table 3), while any other particular illness did not seem to contribute signicantly to mortality (P = 0.49). Women were less likely to die within 5 years after the fracture (relative risk [RR] = 0.57, 95% CI 0.410.79, P = 0.0007). At 10 years, the type of fracture was found to be a signicant predictor of mortality in the Cox multiple regression analysis (Table 3), and patients with intertrochanteric fractures had a 1.37 (95% CI 1.031.83) times relatively higher risk of death than patients with femoral neck fractures (P = 0.03). After adjustment for age, 10-year mortality was still higher in the intertrochanteric group (log rank test P = 0.0072). In particular, patients 6069 years old with intertrochanteric fractures had signicantly higher 10-year mortality than patients of similar age with femoral neck fractures (P = 0.008), while there was no dierence between the groups aged 7079 (P = 0.349) and 8089 (P = 0.07) years (Fig. 2). Women had a lower risk of dying within 10 years compared to men (RR = 0.65, 95% CI 0.490.85, P = 0.002). Sex-adjusted 10-year mortality was also higher after an intertrochanteric fracture (log rank test P = 0.019), and women with intertrochanteric fractures had higher mortality than women with subcapital fractures (log rank test P = 0.008). Survival at 10 years postfracture was signicantly associated with the type of fracture in patients with no chronic disease on admission and in patients with at least one illness (log rank test P = 0.0015).
Discussion

Fig. 1. Kaplan-Meier survival analysis of 499 patients with intertrochanteric and femoral neck fractures.

In a study of international variations in hip fracture probabilities, Greece was ranked as a high-risk country

along with Germany, Switzerland, Finland, The Netherlands, Hungary, Italy, and Portugal in Europe [20]. About 13,611 persons aged 50 years and older fractured a hip in Greece in 2002 [21]. Data about mortality are rare, and there are no published data on excess mortality of patients with hip fractures compared to matched controls. According to our results, the median survival time in patients admitted with a hip fracture was 85 months for femoral neck fractures and 60 months for intertrochanteric fractures. In 1990, the life expectancy in the general population of Greece older than 60 years was 111.84 months [22]. While the dierence between the two groups was partially aected by a dierence in age of 2 years at admission, it is obvious that the median survival time of hip fracture patients was much shorter than the average survival time of the inhabitants of Greece of similar age category. Among 10,953 hip fractures that occurred in Greece during 1992 [13], 198 (1.8%) were admitted to our hospital. There were no major dierences in the distribution of hip fractures in Greece [13]. In our study, mortality

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Table 3. Model of mortality from Coxs regression model by enter of predictors of survival at 5 and 10 years after a hip fracture 5 yearsa Relative risk (95% CI) Increase (per year) in age Sex Male Female Type of fracture Femoral neck Intertrochanteric No heart failure Heart failure Other illness
a b

10 yearsb P <0.0005 0.0007 0.12 0.0009 0.49 Relative risk (95% CI) 1.1 (1.071.12) 1 0.65 (0.490.85) 1 1.37 (1.031.83) 1 1.66 (1.22.28) 1.3 (0.961.76) P < 0.0005 0.002 0.03 0.002 0.09

1.09 (1.061.12) 1 0.57 (0.410.79) 1 1.32 (0.931.88) 1 1.87 (1.292.72) 1.14 (0.781.68)

P-value model <0.0001 P-value model <0.0001

during the rst year after a hip fracture was 15.7%, which is consistent with a previous study in a Greek cohort from the urban area of Athens with a mortality rate of 18% [23] and data from the rural area of Crete with 1-year mortality rates of 17% for women and 23% for men [24]. If we extrapolate the results of our study (15.7%), about 1,792 deaths among persons older than 60 years could have been attributed to hip fractures and their consequences during 1992, while the total number of deaths within the general Greek population of that age was 98,231 [22]. The 1-year mortality rates in our study are comparable to similar rates reported for Caucasian patients from Baltimore (17.4%) [25], New York (12.7%) [26], Norway (12.921%) [16, 17], Sweden (1322%) [7, 27], Denmark (1925%) [3], Spain (22.5%) [28], and Italy (23%) [29], although comparisons must be made with caution because dierent patients age, race, lifestyle, management, and discharge programs may aect the results. The rate of mortality after a hip fracture in certain hospital districts may serve as an index of the total quality of care and may be used to develop multidisciplinary pathways for hip fracture patients. The recognition of predictive factors of short-term or longterm mortality by orthopedic surgeons may be useful in promoting postsurgical care through these pathways in health services. In our study, male gender was an independent predictor of long-term mortality. Men were twice as likely to die within 5 years than women. Men have higher mortality in the general population, and male gender is a well-recognized factor associated with higher mortality in patients with a hip fracture [1, 9, 14, 15, 17, 28] even after consideration of their higher mortality rate in the general population [3, 30]. Studies on survival after hip fractures do not usually focus on the type of fracture and consider patients with intertrochanteric and femoral neck fractures as a homogeneous group. A few studies that examine the

role of the type of fracture in postfracture recovery and mortality up to 1 year have found that patients with intertrochanteric (extracapsular) fractures have greater mortality than those with femoral neck (intracapsular) fractures [18, 19, 31], and it has been suggested that fracture type is a predictor of ambulatory recovery and mortality [32]. The dierent mortality rates between the two types of hip fracture have been attributed to intrinsic variations in prefracture comorbidity and functional status [18, 33]. In a previous study with 10 years follow-up, the type of fracture was no more associated with survival when a correction for age was made [34]. In our study, type of fracture was not a signicant predictor of survival up to 2 years after the fracture. However, patients with femoral neck fractures had signicantly better age-adjusted and sexadjusted 5-year and 10-year survival than patients with intertrochanteric fractures. Our results are in accordance with separate long-term studies on the outcomes of surgical treatment after certain types of hip fracture, which show dierent mortality curves after intertrochanteric and femoral neck fractures. In particular, patients with femoral neck fractures managed by hemiarthroplasty show an initially marked increase in excess mortality during the rst year, which gradually declines to result in an identical rate to that of controls after 5 years [35], while patients with surgically treated intertrochanteric fractures show a gradual increase in excess mortality from 4% at 1 year to 9% at 6 years [36]. Patients with intertrochanteric fractures usually are older, are more frail, have worse functional capacity [3739], and are more osteoporotic [4042] than patients with femoral neck fractures. Unfortunately, our study did not examine the role of functional ability or osteoporosis in survival between intertrochanteric and femoral neck fractures, but it is noteworthy that in our cohort diabetes mellitus was more common in intertrochanteric fractures and heart failure prevailed in femoral neck fractures. More

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Categorizing geriatric patients by prefracture comorbidity may only modestly reect health status since disease stage and compliance to therapy are important predictors of the following deterioration. A few studies have measured the severity of comorbidity using the American Society of Anesthesiologists grading system, and they found that this score was an important predictor of mortality after a hip fracture [4345]; however, these studies are limited in short-term survival analysis (up to 2 years). Heart failure, which is a devastating disease, was an important predictor of mortality in our study. The prevalence of heart failure in the femoral neck group may have obscured the contribution of the intertrochanteric type of fracture in the multiple regression model of 5 year mortality in our results. In conclusion, in our study, age, gender, type of fracture, and presence of heart failure on admission were independent predictors of long-term mortality in patients with a hip fracture. While the type of fracture had no signicant correlation with mortality during the rst 2 years after surgery, intertrochanteric fractures were associated with a higher probability of death within 5 and 10 years compared to femoral neck fractures.

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Fig. 2. Kaplan-Meier mortality curves in patients with intertrochanteric or femoral neck fractures for each age category.

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