The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly
Introduction
Hip fractures are among the major causes of morbidity and mortality in geriatric population. The elderly, falls more frequently and most hip fractures result from relatively minor traumas, such as falls out of bed or from a standing height or lower (Hagino et al., 2004). The reflexes are weaker to cushion the impact of a fall and bones weakened by osteoporosis require less mechanical force to break (Melton et al., 1997). These factors act together to make elderly more susceptible to hip fractures. An estimated 1.3 million such fractures occurred globally in 1990, and the annual rate of hip fracture worldwide is expected to rise considerably as life expectancy and age-specific rates of hip fracture increase (Gullberg et al., 1997). The main goals of management of hip fractures are restoring the anatomic arrangement and bringing back the function of the limb, and rehabilitating the patient effectively. The incidence of post-operative complications is high, and rehabilitation is difficult and long-lasting. Largely as a result of diminished mobility and independence, patients with hip fracture experience a rapid and major deterioration in health-related quality of life. One in five people die in the first year after a hip fracture and one in four elderly requires a higher level of long term care after a fracture (Schurch et al., 1996). Treatment of patients with hip fracture accounts for most of the healthcare spending associated with osteoporosis (about US$ 14 billion annually in the United States) (Ray et al., 1997).
Many factors are reported to affect the post-operative mortality and quality of life. Comorbid conditions, age, mental status, operation type and early mobilization are among these factors (Nather et al., 1995, Poor et al., 1995). Some reports indicate that the post-operative quality of life and mortality is related with the early surgical time (Schurch et al., 1996). Surgery is advised as soon as the medical condition of the patient allows, provided that appropriate staffing and facilities are available (Bredahl et al., 1992, Holt et al., 1994, Hamlet et al., 1997). However, there is also data which indicate that there is no association with the early repair and mortality (Grimes et al., 2002, Stoddart et al., 2002). Again it has been reported that surgical repair may be delayed up to 7 days from the fracture episode with no adverse effect on outcome (Kenzora et al., 1984).
Most of these controversial data are from the retrospective analyses, performed through databases. Thus, the delayed operations due to poor health conditions were possibly involved in these investigation groups. Preexisting medical problems in the elderly is the most important cause of post-operative complications (Seymour, 1999). In order to prevent any bias between the early and late surgical operation groups, a prospective follow up study was designed by recruiting elderly people with similar health statuses on early and late surgical groups. The aim of this study was to investigate the relation between the frequency of post-operative complications, mortality, quality of life and the timing of surgical repair.
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Patients and methods
The consecutive admissions for hip fractures to the Orthopedics and Traumatology Department of Gülhane Military Medical Academy were prospectively screened from August 2000 to May 2002.
Sixty five patients (42 females, 23 males, mean age=76.02±7.20 years) who met the criteria were enrolled in the study. The admission criteria of the patients were as follows: (1) patients older than 65 years; (2) hip fractures were not pathological (i.e. not secondary to metastasis); and (3) ambulatory patients
Results
The mean age and gender distribution of the patient groups were not different. The weight bearing times after the operation and the total hospitalization periods were significantly longer in the late group (P<0.05 for both). The baseline characteristics of the patients are shown in Table 1.
The ADL scores before the fracture and on the 12th month of the operation were not different between the two groups. The ADL scores on the 1st, 3rd and 6th month were significantly lower in the late group (P
Discussion
Hip fractures cause significant mortality in the elderly as compared with normal population (Poor et al., 1995). The intractable pain, loss of mobility and independent life are the most important problems meaning to exhaustion or death for the elderly patient (Lyons, 1997). The optimal timing of the surgery is said to be essential in order to prevent mortality and morbidity of the hip fractures. The reports indicate that 4 week mortality rate decreases from 12 to 8% when the operation is done
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