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Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 648-651

Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study

Department of Orthopaedics and Traumatology, Firat University Faculty of Medicine, Elazig, Turkey

Date of Acceptance15-Jan-2019
Date of Web Publication15-May-2019

Correspondence Address:
Dr. M Gurger
Department of Orthopaedics and Traumatology, Firat University, Faculty of Medicine, Elazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_327_18

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Background: This study aimed to evaluate risk factors that impact 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. Patients and Methods: Overall, 109 patients aged ≥65 years with nonpathological hip fractures, treated between 2015 and 2016, were included in this study. Thirty-nine patients (35.8%) were treated with primary arthroplasty, and 70 patients (64.2%) were treated with proximal femoral nail. To determine whether the risk factors affected mortality, Kaplan–Meier and log-rank analyses were conducted, and a Cox regression analysis was conducted to include the factors determined to have an impact on mortality. Results: Twelve patients (11%) died during hospitalization, and 24 patients (22%) died within 1 year after discharge from the hospital. The mortality risk was high for patients who underwent surgery 72 h after fracture, who could not independently perform their daily activities before the operation, had accompanying diseases, had an American Society of Anaesthesiologists score of 3 or 4, and had postoperative complications. There was no statistically significant difference between primary arthroplasty group and proximal femoral nail group with respect to mortality risk. Conclusion: Delayed surgery and postoperative complications may be the most important risk factors increasing 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. These two risk factors can be prevented with proper precautions, and the rate of 1-year survival for these patients can be increased.

Keywords: Aged, hip fractures, mortality, risk factors

How to cite this article:
Gurger M. Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study. Niger J Clin Pract 2019;22:648-51

How to cite this URL:
Gurger M. Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study. Niger J Clin Pract [serial online] 2019 [cited 2022 Jan 22];22:648-51. Available from:

   Introduction Top

Increase in the elderly population has resulted in an increase in the incidence of hip fractures worldwide, which imposes both a social and an economic burden for society.[1] Despite developments in surgical methods and postoperative care, the 1-year mortality rate in the elderly after hip fractures fluctuates between 20% and 30%.[2] In addition, most patients are unable to perform daily life functions on their own after a hip fracture, and their quality of life decreases.[3]

Factors related to senility such as the presence of other diseases, physical weakness, and polypharmacy adversely affect treatment outcomes.[4] Therefore, numerous studies have been conducted to investigate morbidity and fatal risk factors after hip fractures.[5],[6] Certain differences have been observed in these study results. The demographic features of these patients can change over time due to improvements in health services and increasing life expectancy, and these changes may vary by region.[7] This study aimed to evaluate risk factors that impact the 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail (PFN).

   Patients and Methods Top

Overall, 324 patients hospitalized at our hospital due to hip fracture between January 2015 and January 2016 were retrospectively analyzed after obtaining approval of the local ethics committee. The study design was based on previous studies.[4],[8] Medical charts of patients were reviewed. Of these, 109 patients were included in the study. Patients aged >65 years, who could mobilize independently or with assistance, who had nonpathological femoral neck fracture and intertrochanteric fracture, and who were treated with primary arthroplasty [Figure 1] or PFN [Figure 2] were included in this study. A similar postoperative rehabilitation protocol was implemented for all patients capable of early mobilization and tolerating weight. Factors such as additional diseases, fracture types, surgical methods, discharge status, and postoperative complications were determined via medical chart analysis. Cause of death for patients who died during the first year following surgery were determined by a review of the medical archives. Variables related to mortality, including the age of patients who died in the year following the operation (65–80 or >80 years), gender, other diseases, and number of diseases (0, 1–2, >2), American Society of Anaesthesiologists (ASA) score (1–4), patient mobility prior to the fracture (independent or assisted walking), type of fracture (femoral neck or intertrochanteric), surgical treatment used (arthroplasty or PFN), and number of postoperative complications (0 or ≥1), were recorded.
Figure 1: (a) Preoperative and (b) postoperative 6-month hip radiographs of a 76-year-old female patient with a partial hip prosthesis operation after left femoral neck fracture

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Figure 2: (a) Preoperative and (b) postoperative 12-month hip radiographs of a 65-year-old male patient with a PFN operation after left intertrochanteric femoral fracture

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Data were analyzed using SPSS 21 (IBM Corp., Armonk, NY, USA). Kaplan–Meier analyses were conducted to determine whether the variables affected mortality, and Cox regression analysis was conducted to include the variables determined to have an impact on mortality in the model. Statistical significance level was set at P = 0.05.

   Results Top

The mean age of the patients was 79.3 years (±7.8). Fifty-five patients (50.5%) were women, and 54 (49.5%) were men. All fractures were caused by simple falls. Most of the patients underwent surgery within the first 3 days after fracture (74.3%). The most frequent co-occurring diseases were hypertension (45%), diabetes (16%), cardiac diseases (14%), and respiratory diseases (13%). At least one complication developed in 41.6% of patients during their follow-up at the hospital. The most common minor complications were delirium (12.8%), decubitus ulcers (8.3%), anemia (4.6%), and electrolyte disturbance (3.7%). The most common major complications were acute kidney failure (2.8%), acute respiratory distress syndrome (ARDS) (1.8%), deep surgical site infection (1.8%), deep vein thrombosis (DVT) (1.8%), and pulmonary embolism (1.8%). Twelve patients (11%) included in this study died during follow-up at the hospital. Twenty-four patients (22%) died during the first year after discharge from the hospital. The 1-year mortality rate was 35.1% for men and 30.9% for women. The mortality rate for the 65–80 age group was 28.1%, whereas it was 36.5% for the >80 age group. When the Cox regression analysis was conducted following the Kaplan–Meier and log-rank analyses, the mortality rate was found to be high in patients who underwent surgery 72 h after the fracture, could not independently perform their daily activities, had other diseases, had an ASA score of 3 or 4, and developed a postoperative complication at the hospital [Table 1].
Table 1: Determination of factors that have an impact on mortality using Cox regression analysis

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   Discussion Top

High mortality rates following hip fractures have been reported in previous studies.[4],[8],[9],[10] A 1-year mortality rate of 27% was reported by Cenzer et al.,[6],[11] 23.2% by Folbert et al.,[4] 25.2% by Geiger et al.[9] 25.2%, and 30.8% by Jiang et al.[10] A study with 606 patients in Brazil confirmed that 130 of the patients (21.5%) died in the first year, and a great majority of these deaths occurred in the first 3 months.[12] Bass et al.[13] reported a mortality rate of 8.9% in the first month, 15.6% in the first 3 months, 21.8% in the first 6 months, and 29.9% within 12 months after fracture. In our study, the 1-year mortality rate was 33%, and 11% of patients died during follow-up at the hospital.

Although the risk of hip fracture is higher in women, mortality due to hip fracture is higher in men.[14] The increase in mortality risk related to age and male gender is discussed in detail in the literature.[6],[11] In one study, Forsen et al.[15] examined the effect of age and gender on short- and long-term mortality after hip fracture and found that male patients had a higher mortality rate. Kenzora et al.[16] found that gender did not have an impact on 1-year mortality. Beringer et al.[17] found that women fared better than men at returning to their previous living situation. In our study, no statistically significant correlation was found between 1-year mortality and gender (P = 0.678).

Age of the patient is an important risk factor in mortality after hip fracture.[15],[16] The incidence of hip fracture increases with age, and the fracture probability doubles every 10 years after the age of 50.[18] With 1.7 million hip fractures worldwide in 1990, Cooper et al.[19] calculated that the number of hip fractures will be 6.3 million by 2050. Alternatively, Pioli et al.[18] could not find any correlation between age and mortality, which is consistent with our findings (P = 0.249).

The literature suggests that lower mortality and postoperative complication rates are obtained when treatment is provided within the first 24–72 h of fracture.[20] There is consensus that an early surgery is beneficial, and it is recommended that surgery should be performed as early as possible.[21] However, how early surgery reduces mortality remains unclear.[22] Most of our patients (74.3%) underwent surgery within the first 72 h. Patients who undergo surgery 72 h after a fracture have 4.40 times higher mortality risk than those who undergo surgery within 24 h. The literature also suggests that poor mobility before surgery is strongly correlated with an increased mortality rate after the surgery.[23] Our study also demonstrates a statistically significant correlation between mobilization status before surgery and mortality rates (P < 0.001).

Aharonoff et al.[24] found that patients with ASA scores of 3 and 4 had higher mortality rates in the first year. An increased ASA score was one of the independent reasons for higher mortality rates.[25] Our study demonstrated that the 1-year mortality risk particularly increases remarkably in patients with an ASA score of 3 (P = 0.044) or 4 (P = 0.007).

Previous studies have shown that mortality risk increases in patients with hip fracture if they also have other diseases such as pulmonary system-related diseases and malignancies.[1] Our study demonstrated that 1-year survival significantly decreases in patients who have extraosseous malignancies before surgery (P = 0.021).

Roche et al.[1] found that one-fifth of patients developed postoperative complications, and the majority of these complications were pulmonary infection and cardiac failure. The same study found that 65% of patients with cardiac failure and 43% of those with pulmonary infection died within the first 30 days following surgery. In addition, it was found that 92% of patients with cardiac failure died in the first year following surgery.[1] In our study, we demonstrated that the most common postoperative major complications were acute kidney failure (2.8%), ARDS (1.8%), deep surgical site inflection (1.8%), DVT (1.8%), and pulmonary embolism (1.8%). There is a statistically significant correlation between postoperative major complications and mortality (P < 0.001).

   Conclusion Top

Factors that may impact mortality, such as age and gender of the patient, activity level before surgery and co-occurring diseases, are not modifiable factors. However, early surgery and postoperative complications are factors that can be addressed. Therefore, the best strategy to decrease mortality in these patients is to ensure that surgery is performed as soon as possible and that complications that may develop after the operation are prevented and effectively treated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: Prospective observational cohort study. BMJ 2005;331:1374.  Back to cited text no. 1
Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: A systematic review and meta-analysis. J Orthop Trauma 2014;28:e49-55.  Back to cited text no. 2
Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17:1726-33.  Back to cited text no. 3
Folbert EC, Hegeman JH, Vermeer M, Regtuijt EM, van der Velde D, Ten Duis HJ, et al. Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment. Osteoporos Int 2017;28:269-77.  Back to cited text no. 4
Diamantopoulos AP, Hoff M, Hochberg M, Haugeberg G. Predictors of short- and long-term mortality in males and females with hip fracture - A prospective observational cohort study. PLoS One 2013;8:e78169.  Back to cited text no. 5
Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma 2014;28:63-9.  Back to cited text no. 6
Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mortality following hip fracture: Trends and geographical variations over the last 40 years. Injury 2008;39:1157-63.  Back to cited text no. 7
Cenzer IS, Tang V, Boscardin WJ, Smith AK, Ritchie C, Wallhagen MI, et al. One-year mortality after hip fracture: Development and validation of a prognostic index. J Am Geriatr Soc 2016;64:1863-8.  Back to cited text no. 8
Geiger F, Zimmermann-Stenzel M, Heisel C, Lehner B, Daecke W. Trochanteric fractures in the elderly: The influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg 2007;127:959-66.  Back to cited text no. 9
Jiang HX, Majumdar SR, Dick DA, Moreau M, Raso J, Otto DD, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res 2005;20:494-500.  Back to cited text no. 10
Endo Y, Aharonoff GB, Zuckerman JD, Egol KA, Koval KJ. Gender differences in patients with hip fracture: A greater risk of morbidity and mortality in men. J Orthop Trauma 2005;19:29-35.  Back to cited text no. 11
Vidal EI, Coeli CM, Pinheiro RS, Camargo KR Jr. Mortality within 1 year after hip fracture surgical repair in the elderly according to postoperative period: A probabilistic record linkage study in Brazil. Osteoporos Int 2006;17:1569-76.  Back to cited text no. 12
Bass E, French DD, Bradham DD, Rubenstein LZ. Risk-adjusted mortality rates of elderly veterans with hip fractures. Ann Epidemiol 2007;17:514-9.  Back to cited text no. 13
Sullivan KJ, Husak LE, Altebarmakian M, Brox WT. Demographic factors in hip fracture incidence and mortality rates in California, 2000-2011. J Orthop Surg Res 2016;11:4.  Back to cited text no. 14
Forsen L, Sogaard AJ, Meyer HE, Edna T, Kopjar B. Survival after hip fracture: Short- and long-term excess mortality according to age and gender. Osteoporos Int 1999;10:73-8.  Back to cited text no. 15
Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res 1984:45-56.  Back to cited text no. 16
Beringer TR, Clarke J, Elliott JR, Marsh DR, Heyburn G, Steele IC. Outcome following proximal femoral fracture in Northern Ireland. Ulster Med J 2006;75:200-6.  Back to cited text no. 17
Pioli G, Barone A, Giusti A, Oliveri M, Pizzonia M, Razzano M, et al. Predictors of mortality after hip fracture: Results from 1-year follow-up. Aging Clin Exp Res 2006;18:381-7.  Back to cited text no. 18
Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int 1992;2:285-9.  Back to cited text no. 19
Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: Systematic review and meta-analysis. CMAJ 2010;182:1609-16.  Back to cited text no. 20
Gdalevich M, Cohen D, Yosef D, Tauber C. Morbidity and mortality after hip fracture: The impact of operative delay. Arch Orthop Trauma Surg 2004;124:334-40.  Back to cited text no. 21
Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004;291:1738-43.  Back to cited text no. 22
Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: An analysis of data from the scottish hip fracture audit. J Bone Joint Surg Br 2008;90:1357-63.  Back to cited text no. 23
Aharonoff GB, Koval KJ, Skovron ML, Zuckerman JD. Hip fractures in the elderly: Predictors of one year mortality. J Orthop Trauma 1997;11:162-5.  Back to cited text no. 24
Mariconda M, Costa GG, Cerbasi S, Recano P, Aitanti E, Gambacorta M, et al. The determinants of mortality and morbidity during the year following fracture of the hip: A prospective study. Bone Joint J 2015;97-B: 383-90.  Back to cited text no. 25


  [Figure 1], [Figure 2]

  [Table 1]


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