- Email: [email protected]
Quality of life after a subtrochanteric fracture
Injury, Int. J. Care Injured 40 (2009) 371–376
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Quality of life after a subtrochanteric fracture A prospective cohort study on 87 elderly patients Wilhelmina Ekstro¨m a,*, Gunnar Ne´meth a,c, Eva Samnega˚rd d, Nils Dalen d, Jan Tidermark b,c a
Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital Solna, Sweden Karolinska Institutet, Department of Clinical Science and Education, Section of Orthopedics, So¨dersjukhuset, Stockholm, Sweden c Capio S:t Go¨rans Hospital, Stockholm, Sweden d Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 September 2008
Background: The subtrochanteric fracture constitutes approximately 5–10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures. Objective: To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL. Setting: Four university hospitals. Design: A prospective cohort study with a 2-year follow-up. Patients and methods: Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ5Dindex score). Results: The EQ-5Dindex score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months. Conclusions: A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs). ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Subtrochanteric fractures Elderly Fracture fixation Intramedullary Treatment outcome Quality of life
Introduction The subtrochanteric fracture is one of the less frequent types of fracture in the proximal femur and constitutes approximately 5– 10% of all hip fractures.8 This particular fracture type, owing to its
* Corresponding author at: Department of Orthopaedics, Karolinska University Hospital Solna, SE 171 77 Stockholm, Sweden. E-mail address: [email protected] (W. Ekstro¨m). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.09.010
configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. Although not based on scientific evidence proven in randomised controlled trials (RCTs), there has been a gradual change in the operative techniques used to stabilise these fractures, from the extramedullary devices such as the blade plate, the compression hip screw and dynamic condylar screw to the current widespread use of cephalomedullary nails. The rationale for this shift is probably the theoretical advantages of the cephalomedullary nails owing to the improved biomechanics
372
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
with a shorter lever arm leading to a more stable fracture construct and the percutaneous insertion technique which may result in less soft tissue trauma and thereby potentially facilitate fracture healing and reduce bleeding and the incidence of infection. Recent prospective studies including elderly patients with subtrochanteric fractures treated with cepahlomedullary nails also confirm comparatively good results with reoperation rates below 10%.20,24 Previous studies have focused on evaluating different surgical methods and implants with the primary aim of reducing the fracture complication and reoperation rates. In contrast to the field of research on patients with the more common femoral neck fractures1–3,30–32 and trochanteric fractures,20 few studies have evaluated the health-related quality of life (HRQoL) of patients with subtrochanteric fractures. In a recent RCT, Miedel et al.,20 reported a substantial negative influence on the quality of life after the treatment of an unstable trochanteric or subtrochanteric fracture in 217 patients. However, the HRQoL for the subgroup of 28 patients with subtrochanteric fractures was not reported separately. The aim of this study was to report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.
Patients and methods We included 87 consecutive patients with an acute subtrochanteric fracture of the femur26 treated with a cephalomedullary nail at any of the four university hospitals in Stockholm during the period from 1 January to 31 December 2003 in a prospective cohort study with a 2-year follow-up. The inclusion criteria were absence of severe cognitive dysfunction and independent walking capability with or without walking aids before the fracture. Patients with pathological fractures were not included. Fracture reduction and fixation was carried out with the patient supine on a fracture table. A short cephalomedullary nail (the gamma nail [GN]; Stryker Howmedica, Malmo¨, Sweden, or the proximal femoral nail [PFN]; Synthes, Stockholm, Sweden) was used in 37 patients and a long cephalomedullary nail (the long gamma nail [LGN] or the long PFN [LPFN]) in 50 patients. All patients received preoperative intravenous antibiotics and tromboembolic prophylaxis according to the routine at each hospital. Patients were mobilised with full weight bearing as tolerated. The assessment at baseline, data collection and follow-up were performed by research nurses. The fractures were classified by orthopaedic surgeons who were well experienced in hip fracture surgery. The American Society of Anesthesiologists (ASA) classification was made by the attending anaesthetist. The study was conducted in conformity with the Helsinki Declaration and was approved by the local Ethics Committee. Primary assessment and follow-up The primary assessment included an appraisal of cognitive function according to the Short Portable Mental Status Questionnaire (SPMSQ)23 and of general health according to the ASA classification.21 The patients were interviewed about their living conditions, walking ability, activities of daily living (ADL) status15 and HRQoL according to the EuroQol-5D (EQ-5D)6 during the last week before the fracture as baseline. The patients were interviewed by phone at 4 months (mean 4.4, S.D. 1.3), 12 months (mean 12.0, S.D. 0.9) and 24 months (mean 24.1, S.D. 1.2) and those reporting problems were scheduled for a followup visit including a radiographic examination. Reoperations including the indication for reoperation, wound complications,
Fig. 1. Flowchart for all patients included with stable trochanteric fractures: mth = month; f-u = follow-up.
pain at the hip, walking ability, ADL status, HRQoL and living conditions, were recorded. Seven out of 87 patients (8%) had died by 4 months and the corresponding figures for the 12- and 24-month follow-ups were 12 (14%) and 22 (25%), respectively. Three out of 80 patients (4%) were lost to the 4-month follow-up, 3 out of 75 (4%) at 12 months and 5 out of 65 (8%) at 24 months (Fig. 1). Methods The Jensen–Michaelsen14 and the Seinsheimer26 classification system were used by orthopaedic surgeons well experienced in hip fracture surgery to differentiate between trochanteric and subtrochanteric fractures and only patients with subtrochanteric fractures were included. The waiting time to surgery, the mean operating time, the intraoperative blood loss, type of anaesthesia and the experience of the surgeon were recorded. Deep wound infection was defined as an established infection beneath the fascia requiring surgical revision and superficial wound infection was defined as a cutaneous/subcutaneous infection requiring antibiotic therapy. The patient’s general physical health status was assessed by the attending anaesthetist. according to the ASA classification.21 ASA 1 indicates a completely healthy person; ASA 2, a person with a mild systemic disease; ASA 3, a person with a severe systemic disease that is incapacitating; ASA 4, a person with an incapacitating disease that is a constant threat to life; ASA 5, a moribund patient who is not expected to live 24 h with or without surgery. There were no ASA 5 patients in the study.
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
The patient’s cognitive function was assessed with the Short Portable Mental Status Questionnaire (SPMSQ).23 The SPMSQ is a 10-item test that categorises the patient as lucid (8–10 correct answers), as having mild to moderate cognitive dysfunction (3–7 correct answers) or as having severe (0–2 correct answers) cognitive dysfunction. Only patients without severe cognitive dysfunction (3 correct answers) were included. Living conditions were categorised as independent (living in one’s own home or in housing for the elderly) or as institutionalised (living in a nursing home or a hospital). Walking ability was based on the patient’s need for walking aids and was categorised as no need for a walking aid, need for a stick or crutches, need for a walking frame or non-ambulant. Only patients with independent walking capability with or without a walking aid before the fracture were included. The Katz ADL index15 status is based on an evaluation of the functional dependence or independence of patients in bathing, dressing, going to the toilet, transferring, continence and feeding. ADL index A indicates independence in all six functions, index B independence in all but one of the six functions. Indexes C–G indicate dependence in bathing and at least one additional function. Pain at the hip was assessed with Charnley’s numerical classification,9 which grades the pain from 1 to 6 with 1 = severe and spontaneous and 6 = no pain. The HRQoL was rated using the EQ-5D.6 The EQ-5D has five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is divided into three degrees of severity: no problem, some problems, and major problems. Dolan et al.12 used the time trade-off (TTO) method to rate these different states of health in a large UK population (UK EQ-5D Index Tariff). We used the preference scores generated from this population when calculating the scores for our study population. A value of 0 indicated the worst possible state of health and a value of 1 the best possible. Statistical methods The statistical software used was SPSS 15.0 for Windows. The Wilcoxon signed ranks test was used when comparing EQ-5D data. The tests were two-sided and the results were considered significant at p < 0.05. Results Baseline data for all patients included (n = 87) are displayed in Table 1. The mean age was 83 years and 75% of the patients were females. The vast majority, 94%, came from independent living conditions and 94% were assessed as ADL A or B, i.e. they were independent in all six functions of ADL or in all but one. According to the inclusion criteria there were no patients with severe cognitive dysfunction (SPMSQ < 3) and all patients were independent walkers with or without walking aids before the fracture. However, 56% of the patients used some form of walking aid before the fracture, mostly a walking frame. Ninety-one per cent were assessed as ASA 2 or 3. The most common co-morbidities were cardiovascular disease (55%), pulmonary disease (23%), malignancy (19%), diabetes mellitus (17%), cerebrovascular lesion (11%) and renal disease (6%). During the hospital stay 16 of the 87 patients (18%) developed a major medical complication. The most frequent major complications were cardiac failure (n = 5) and pneumonia (n = 5). As previously mentioned the mortality rate at 4 months was 8% and the corresponding figures for the 12- and 24-month followups were 14% and 25%, respectively (Fig. 1).
373
Table 1 Baseline data for all patients included (n = 87). Mean (S.D.) age in years
82.5 (7.8), range 66–101
Gender, female (%)
65 (75)
ASA, classification (%) 1 2 3 4
3 (3) 35 (40) 44 (51) 5 (6)
Mean (S.D.) cognitive function
7.8 (2.1), range 3–10
Mean (S.D.) EQ-5Dindex score prefracture
0.73 (0.27), range 0.0–1.0
Walking aids (%) None Stick or crutches Walking frame
38 (44) 17 (20) 32 (37)
ADL A and B (%)
80 (94)a
From independent living (%)
82 (94)
ADL A indicate independence in all six functions and B independence in all but one function. a Two missing values.
Surgical outcome The waiting time to surgery was 1.1 days (0–4 days). The type of anaesthesia was spinal or epidural in 79 patients (91%) and the surgeon was a certified specialist in orthopaedic surgery (postregistrar or consultant) for 59 patients (68%) and a registrar for the remaining 28 (32%). The mean intraoperative blood loss was 450 (50–6000) ml and the mean duration of surgery was 85 (15– 250) min. There were seven patients (8%) with superficial infections that healed after antibiotic therapy and one patient (1%) with a suspected deep infection who had a wound revision surgery. At surgery there were no signs of deep infection and the bacterial cultures were all negative. This patient died at 18 months after surgery from causes not related to the fracture. In total, seven patients (8%) were reoperated upon during the study period, including the patient explored for a suspected deep infection (Table 2). One patient had early revision surgery due to excessive internal malrotation. The reoperation was complicated by a deep infection and the patient underwent two subsequent wound revisions and finally extraction of the nail after the fracture was healed. Two patients had lag-screw penetrations, in one of them a total hip replacement (THR) was performed and in the other a successful reosteosynthesis with a new LGN. Two patients sustained fractures close to the tip of the nail after new falling accidents. In one of these patients the distal fracture was stabilised with a longer LGN and in the other one, the LGN was left in situ and the distal fracture was stabilised with a dynamic condylar screw (DCS, Synthes, Stockholm, Sweden). In both patients all fractures healed. Finally, in one patient there were radiological signs of delayed union indicating dynamisation, after which the fracture healed. Functional outcome and HRQoL Pain at the hip, walking ability and ADL function for all patients available at each follow-up are displayed in Table 3. At the final follow-up 80% of the patients reported no or only slight or intermittent pain at the hip (Charnley score 5–6). Forty-six per cent had regained their prefracture walking ability, 48% had the same level of ADL function and 71% of the patients living independently before the fracture were still living independently after 24 months.
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
374 Table 2 Data on all patients reoperated upon (n = 7). Implant
Indication
Reoperation/s
Time (month)
GN
1. Malrotation 2. Deep infection 3. Deep infection 4. Local pain L-S penetration L-S penetration Fx close to the tip of the nail Suspected deep infection Fx close to the tip of the nail Delayed union
Revision with new lag-screw Wound revision Wound revision Extraction of the nail New LGN THR Longer LGN Wound revision LGN left in situ, fixation with a DCS Dynamisation
0.1 0.4 1.7 12.5 1.8 1.9 2.1 3.0 3.6 8.6
LGN LGN LGN LGN LGN LPFN
Fx = fracture; time = time elapsed from the primary operation; L-S = lag-screw; GN = gamma nail; LGN = long gamma nail; LPFN = long proximal femoral nail; DCS = dynamic condylar screw; THR = total hip replacement.
The HRQoL (EQ-5Dindex score) decreased from 0.73 before the fracture to 0.53 at 4 months (p < 0.001) and remained at the same level at the 12- and 24-month follow-ups, 0.53 (p < 0.001) and 0.52 (p < 0.05), respectively (p values are given for the difference between follow-ups and before fracture) (Fig. 2). Table 3 Pain at the hip, walking ability and ADL function for all patients available at each follow-up (4 months, n = 77; 12 months, n = 72; 24 months, n = 60). Pain, mean (S.D.) Charnley score 4 months 12 months 24 months
4.9 (1.5)4 5.1 (1.4)2 5.4 (1.0)4
Pain, Charnley score 5 or 6, n (%) 4 months 12 months 24 months
47 (64)4 49 (70)2 45 (80)4
Walking ability at least similar to prefracture, n (%) 4 months 12 months 24 months
33 (43) 34 (47) 27 (46)1
Level of ADL function at least similar to prefracture, n (%) 4 months 12 months 24 months
35 (46)1 31 (44)1 28 (48)2
Living conditions similar to prefracture, n (%)a 4 months 12 months 24 months
58 (74) 53 (74) 42 (71)1
The figures in superscript refer to the number of missing values at each follow-up occasion. Charnley hip score: best possible score = 6 and worst possible score = 1. a The calculation is based on the number of patients available at each follow-up who were living independently before the fracture.
Fig. 2. HRQoL according to the EQ-5D for the patients with subtrochanteric fractures available at each follow-up. Best possible score = 1 and worst possible score = 0: fx = fracture; mth = months.
Discussion The results of our study confirmed an acceptable reoperation rate after subtrochanteric fractures in elderly patients treated with a cephalomedullary nail. Although the patients experienced a limited amount of pain at the hip there were obvious consequences for walking ability and ADL function reflected in a significant deterioration in both short and long-term HRQoL. The rate of revision surgery, 8%, was of the same magnitude as reported in the two major studies on elderly patients treated with the LGN, the prospective study by Robinson et al.24 and the retrospective study by van Doorn et al.,33 and better than in most larger studies using various types of extramedullary implants.16,22,34 One exception is the prospective study by Lunsjo¨ et al.18 reporting only 2% of technical failures in subtrochanteric fractures when using the Medoff sliding plate (MSP) in the uniaxial dynamisation mode. However, in clinical practice, the differentiation between low-trochanteric fractures and high-subtrochanteric fractures might be difficult and lead to erroneous uniaxial dynamisation in trochanteric fractures which may contribute to lag-screw penetration.17,19 Therefore uniaxial dynamisation requires frequent radiographic follow-up and readiness for staged dynamisation in a number of cases to prevent lag-screw penetration.8 To overcome this, the MSP may be used in the biaxial dynamisation mode, but then the problem of excessive medialisation of the shaft remains, especially in the Seinsheimer type 2C fracture (reverse oblique).20,25,26 Despite the good results reported for the MSP in clinical studies its use in clinical practice is limited probably due to problems of correctly interpreting the fracture type and selecting the correct type of dynamisation. The rate of lag-screw penetrations resulting in revision surgery in our study, 2.3%, was on par with the 1.7% reported by Robinson et al.24 But in contrast to Robinson and co-workers we found only one patient with a delayed union resulting in reoperation (dynamisation). On the other hand, three out of the eight patients (3.1%) reoperated on for suspected non-union in the study by Robinson and co-workers, had a healed fracture at the time of exploration. A finding also in conformity with this previous study was that a fracture close to the tip of the nail was another major cause of reoperation, 2.3% in our study compared to the 1.7% reported by Robinson et al.,24 all in patients with long nails. Owing to the natural antecurvation of the femur, nail impingement against the anterior cortex of the distal femur has been a problem especially with the use of earlier generations of cephalomedullary nails. This problem is less pronounced in later generations with reduced stiffness and a smaller radius of curvature. However, both our patients sustained their distal fractures after falling more than 2 months after the index operation and this particular complication probably cannot be completely eliminated. In an
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
elderly patient with a femoral implant sustaining a significant injury, the stress concentration and eventual fracture will most probably occur at the distal end of the implant regardless of its length or type, i.e. nail or plate. There were no deep infections after the index procedure. One of our patients was explored due to a suspected deep infection which could not be verified at surgery or with cultures. Infection seems to be very rare in most studies using any type of intramedullary nail,24,33,36 probably reflecting the advantages of the percutaneous technique and more limited soft tissue trauma. Although the number of fracture-related complications was limited, the subtrochanteric fracture had a substantial effect upon the patients’ quality of life. There was a clear deterioration in the HRQoL which was established as early as 4 months and persisted without any positive development during either the first or the second year after the fracture. The interpretation of the quality of life data is based on our patients’ ability to correctly recall their health status prior to the hip fracture. However, since a prospective collection of preinjury HRQoL data is not possible in trauma studies, we have to rely on preinjury recall or a comparison with population figures. The prefracture EQ-5Dindex score value, based on recall, 0.73 for our patients was in conformity with the value for the age-matched Swedish reference, 0.74.7 We have previously reported the HRQoL determined by the same instrument, the EQ5D, in a RCT20 with a 1-year follow-up comparing the MSP and the standard gamma nail in patients with unstable trochanteric fractures (J-M 3–5)14 and high-subtrochanteric fractures.26 The number of patients with subtrochanteric fractures in that study, 28, were too small to allow a separate analysis of HRQoL; however, compared to the patients with unstable trochanteric fractures in that study satisfying the same inclusion criteria as in the present study, the deterioration in the EQ-5Dindex score at 4 months was comparable, 0.20, while, in contrast to the patients with unstable trochanteric fractures, the patients with subtrochanteric fractures did not show any improvement at the 12-month follow-up. We have also recently analysed the HRQoL after a stable trochanteric fracture (J-M 1–2).13 The patients reported a more limited deterioration in the EQ-5Dindex score at 4 months, 0.12, and at 2 years the survivors had almost regained the same level of quality of life as before the fracture. The quality of life instrument used in this study is brief and easy to use in elderly patients5,31 and has been validated in hip fracture patients.10,28,29 Another major advantage of this particular instrument is that it also allows combining different dimensions of health to form an overall index (utility score), as required for health care evaluations4 and for constructing quality-adjusted lifeyears (QALYs),35 a measure frequently used in cost-effectiveness analyses. Despite relatively uneventful fracture healing, patients with subtrochanteric fractures do not regain their prefracture functional level and HRQoL. Compared with patients with stable trochanteric fractures satisfying the same inclusion criteria and displaying nearly identical baseline data besides the fracture type,13 the percentages of patients reporting no or only limited pain at the hip were equal, 80% and 81%, respectively, but the percentage of patients who regained their prefracture walking ability and ADL function was lower, 46%, compared with 55%, and 48%, compared with 66%, respectively. This is probably a reflection of the fracture type being more complex and associated with a more severe soft tissue injury and thereby resulting in a more difficult rehabilitation for these elderly patients. The magnitude of the mortality rate is highly dependent on the inclusion criteria and therefore it is not easy to compare between individual trials. Our 1-year mortality rate of 14% is lower than the 25% reported in the prospective study by Robinson et al.,24 which
375
may partly be explained by the fact that only patients without severe cognitive dysfunction were included in our study. We opted not to include patients with severe cognitive dysfunction and patients who had already been unable to walk before the fracture because they are difficult to evaluate, especially regarding HRQoL,11,27 and their quality of life is strongly influenced by the cognitive dysfunction and other co-morbidities.3 One limitation of the study is that at each follow-up the patients were interviewed by phone and only patients reporting problems were scheduled for a follow-up visit including a radiographic control. Another limitation was that we did not use the long nails in all patients. Individual surgeons opted to use the short cephalomedullary nails in patients with high-subtrochanteric fractures. However, short nails have been shown to be successful in previous studies on patients with high-subtrochanteric fractures. Miedel et al.20 reported no reoperation in 16 patients with highsubtrochanteric fractures treated with the short gamma nail and, in the present study, none of the fracture-related complications were in patients operated upon with short nails. The only reoperation after fixation with a short nail was due to a primary malrotation. Therefore, we believe that our results are representative of cephalomedullary nails in general. The strength of the study is the relatively large number of patients, the prospective design, appropriate follow-up period and the fact that data were assessed with validated instruments. The dropout rates at the various follow-ups were acceptable in this fragile age group and not of such a magnitude that the validity of the conclusions would be jeopardised. In conclusion, a subtrochanteric fracture in elderly patients had a substantial negative effect on the patient’s short and long-term HRQoL. Although pain at the hip was not a major problem, there was an obvious detoriation in walking ability and ADL function. However, the rate of revision surgery was comparatively low, which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to QALYs. Conflict of interest statement All authors state that there are no conflicts of interest. Acknowledgements Special thanks are due to the Stockholm Hip Fracture Group for running the study during the course of years: i.e. Paul Ackerman, Amer Al-Ani, Richard Blomfeldt, Tommy Cederholm, Margareta Hedstro¨m, Paula Kelly-Pettersson, Kristina Ka¨llbom, Gustaf Neander, A˚sa Norling, Sari Ponzer, Bodil Samuelsson, Maria Sa¨a¨f, Anita So¨derqvist and K.-G. Thorngren. Funding: The study was supported by the Stockholm County Council Research Fund for clinical studies (EXPO 1999). References 1. Blomfeldt R, To¨rnkvist H, Eriksson K, et al. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br 2007;89:160–5. 2. Blomfeldt R, To¨rnkvist H, Ponzer S, et al. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am 2005;87:1680–8. 3. Blomfeldt R, To¨rnkvist H, Ponzer S, et al. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. J Bone Joint Surg Br 2005;87:523–9. 4. Borgstro¨m F, Zethraeus N, Johnell O, et al. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 2006;17:637– 50.
376
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
5. Brazier JE, Walters SJ, Nicholl JP, Kohler B. Using the SF-36 and EuroQol on an elderly population. Qual Life Res 1996;5:195–204. 6. Brooks R. EuroQol: the current state of play. Health Policy 1996;37:53–72. 7. Burstro¨m K, Johannesson M, Diderichsen F. Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 2001;10:621–35. 8. Ceder L, Lunsjo¨ K, Olsson O, et al. Different ways to treat subtrochanteric fractures with the Medoff sliding plate. Clin Orthop 1998;348:101–6. 9. Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61–76. 10. Coast J, Peters TJ, Richards SH, Gunnell DJ. Use of the EuroQoL among elderly acute care patients. Qual Life Res 1998;7:1–10. 11. Coucill W, Bryan S, Bentham P, et al. EQ-5D in patients with dementia: an investigation of inter-rater agreement. Med Care 2001;39:760–71. 12. Dolan P, Gudex C, Kind P, Williams A. The time trade-off method: results from a general population study. Health Econ 1996;5:141–54. 13. Ekstro¨m W, Miedel R, Ponzer S, et al. Quality of life after a stable trochanteric fracture. A prospective cohort study on 148 patients. J Orthop Trauma, in press. 14. Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthop Scand 1975;46:795–803. 15. Katz S, Ford A, Moskowitz R, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 1963;185:94–9. 16. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res 1989;238:122–30. 17. Lunsjo¨ K, Ceder L, Stigsson L, Hauggaard A. One-way compression along the femoral shaft with the Medoff sliding plate. The first European experience of 104 intertrochanteric fractures with a 1-year follow-up. Acta Orthop Scand 1995;66:343–6. 18. Lunsjo¨ K, Ceder L, Tidermark J, et al. Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems. Acta Orthop Scand 1999;70:459–66. 19. Lunsjo¨ K, Ceder L, Thorngren KG, et al. Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Acta Orthop Scand 2001;72:133–40. 20. Miedel R, Ponzer S, To¨rnkvist H, et al. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. J Bone Joint Surg Br 2005;87:68–75. 21. Owens WD, Felts JA, Spitznagel Jr EL. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–43.
22. Parker MJ, Dutta BK, Sivaji C, Pryor GA. Subtrochanteric fractures of the femur. Injury 1997;28:91–5. 23. Pfeiffer E. A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23: 433–41. 24. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am 2005;87:2217–26. 25. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am 2002;84:372–81. 26. Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg Am 1978;60:300–6. 27. Selai C. Assessing quality of life in dementia. Med Care 2001;39:753–5. 28. Tidermark J, Bergstro¨m G. Responsiveness of the EuroQol (EQ-5D) and the Nottingham Health Profile (NHP) in elderly patients with femoral neck fractures. Qual Life Res 2007;16:321–30. 29. Tidermark J, Bergstro¨m G, Svensson O, et al. Responsiveness of the EuroQol (EQ5D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12:1069–79. 30. Tidermark J, Ponzer S, Svensson O, et al. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br 2003;85:380–8. 31. Tidermark J, Zethraeus N, Svensson O, et al. Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 2002;11:473–81. 32. Tidermark J, Zethraeus N, Svensson O, et al. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma 2002;16:34–8. 33. van Doorn R, Stapert JW. The long gamma nail in the treatment of 329 subtrochanteric fractures with major extension into the femoral shaft. Eur J Surg 2000;166:240–6. 34. Warwick DJ, Crichlow TP, Langkamer VG, Jackson M. The dynamic condylar screw in the management of subtrochanteric fractures of the femur. Injury 1995;26:241–4. 35. Williams A. The role of the EuroQol Instrument in QUALY calculations. Great Britain: Centre for Health Economics, The University of York; 1995. 36. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res 1992;283:231–6.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Quality of life after a subtrochanteric fracture A prospective cohort study on 87 elderly patients Wilhelmina Ekstro¨m a,*, Gunnar Ne´meth a,c, Eva Samnega˚rd d, Nils Dalen d, Jan Tidermark b,c a
Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital Solna, Sweden Karolinska Institutet, Department of Clinical Science and Education, Section of Orthopedics, So¨dersjukhuset, Stockholm, Sweden c Capio S:t Go¨rans Hospital, Stockholm, Sweden d Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 24 September 2008
Background: The subtrochanteric fracture constitutes approximately 5–10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures. Objective: To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL. Setting: Four university hospitals. Design: A prospective cohort study with a 2-year follow-up. Patients and methods: Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ5Dindex score). Results: The EQ-5Dindex score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months. Conclusions: A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs). ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Subtrochanteric fractures Elderly Fracture fixation Intramedullary Treatment outcome Quality of life
Introduction The subtrochanteric fracture is one of the less frequent types of fracture in the proximal femur and constitutes approximately 5– 10% of all hip fractures.8 This particular fracture type, owing to its
* Corresponding author at: Department of Orthopaedics, Karolinska University Hospital Solna, SE 171 77 Stockholm, Sweden. E-mail address: [email protected] (W. Ekstro¨m). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.09.010
configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. Although not based on scientific evidence proven in randomised controlled trials (RCTs), there has been a gradual change in the operative techniques used to stabilise these fractures, from the extramedullary devices such as the blade plate, the compression hip screw and dynamic condylar screw to the current widespread use of cephalomedullary nails. The rationale for this shift is probably the theoretical advantages of the cephalomedullary nails owing to the improved biomechanics
372
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
with a shorter lever arm leading to a more stable fracture construct and the percutaneous insertion technique which may result in less soft tissue trauma and thereby potentially facilitate fracture healing and reduce bleeding and the incidence of infection. Recent prospective studies including elderly patients with subtrochanteric fractures treated with cepahlomedullary nails also confirm comparatively good results with reoperation rates below 10%.20,24 Previous studies have focused on evaluating different surgical methods and implants with the primary aim of reducing the fracture complication and reoperation rates. In contrast to the field of research on patients with the more common femoral neck fractures1–3,30–32 and trochanteric fractures,20 few studies have evaluated the health-related quality of life (HRQoL) of patients with subtrochanteric fractures. In a recent RCT, Miedel et al.,20 reported a substantial negative influence on the quality of life after the treatment of an unstable trochanteric or subtrochanteric fracture in 217 patients. However, the HRQoL for the subgroup of 28 patients with subtrochanteric fractures was not reported separately. The aim of this study was to report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.
Patients and methods We included 87 consecutive patients with an acute subtrochanteric fracture of the femur26 treated with a cephalomedullary nail at any of the four university hospitals in Stockholm during the period from 1 January to 31 December 2003 in a prospective cohort study with a 2-year follow-up. The inclusion criteria were absence of severe cognitive dysfunction and independent walking capability with or without walking aids before the fracture. Patients with pathological fractures were not included. Fracture reduction and fixation was carried out with the patient supine on a fracture table. A short cephalomedullary nail (the gamma nail [GN]; Stryker Howmedica, Malmo¨, Sweden, or the proximal femoral nail [PFN]; Synthes, Stockholm, Sweden) was used in 37 patients and a long cephalomedullary nail (the long gamma nail [LGN] or the long PFN [LPFN]) in 50 patients. All patients received preoperative intravenous antibiotics and tromboembolic prophylaxis according to the routine at each hospital. Patients were mobilised with full weight bearing as tolerated. The assessment at baseline, data collection and follow-up were performed by research nurses. The fractures were classified by orthopaedic surgeons who were well experienced in hip fracture surgery. The American Society of Anesthesiologists (ASA) classification was made by the attending anaesthetist. The study was conducted in conformity with the Helsinki Declaration and was approved by the local Ethics Committee. Primary assessment and follow-up The primary assessment included an appraisal of cognitive function according to the Short Portable Mental Status Questionnaire (SPMSQ)23 and of general health according to the ASA classification.21 The patients were interviewed about their living conditions, walking ability, activities of daily living (ADL) status15 and HRQoL according to the EuroQol-5D (EQ-5D)6 during the last week before the fracture as baseline. The patients were interviewed by phone at 4 months (mean 4.4, S.D. 1.3), 12 months (mean 12.0, S.D. 0.9) and 24 months (mean 24.1, S.D. 1.2) and those reporting problems were scheduled for a followup visit including a radiographic examination. Reoperations including the indication for reoperation, wound complications,
Fig. 1. Flowchart for all patients included with stable trochanteric fractures: mth = month; f-u = follow-up.
pain at the hip, walking ability, ADL status, HRQoL and living conditions, were recorded. Seven out of 87 patients (8%) had died by 4 months and the corresponding figures for the 12- and 24-month follow-ups were 12 (14%) and 22 (25%), respectively. Three out of 80 patients (4%) were lost to the 4-month follow-up, 3 out of 75 (4%) at 12 months and 5 out of 65 (8%) at 24 months (Fig. 1). Methods The Jensen–Michaelsen14 and the Seinsheimer26 classification system were used by orthopaedic surgeons well experienced in hip fracture surgery to differentiate between trochanteric and subtrochanteric fractures and only patients with subtrochanteric fractures were included. The waiting time to surgery, the mean operating time, the intraoperative blood loss, type of anaesthesia and the experience of the surgeon were recorded. Deep wound infection was defined as an established infection beneath the fascia requiring surgical revision and superficial wound infection was defined as a cutaneous/subcutaneous infection requiring antibiotic therapy. The patient’s general physical health status was assessed by the attending anaesthetist. according to the ASA classification.21 ASA 1 indicates a completely healthy person; ASA 2, a person with a mild systemic disease; ASA 3, a person with a severe systemic disease that is incapacitating; ASA 4, a person with an incapacitating disease that is a constant threat to life; ASA 5, a moribund patient who is not expected to live 24 h with or without surgery. There were no ASA 5 patients in the study.
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
The patient’s cognitive function was assessed with the Short Portable Mental Status Questionnaire (SPMSQ).23 The SPMSQ is a 10-item test that categorises the patient as lucid (8–10 correct answers), as having mild to moderate cognitive dysfunction (3–7 correct answers) or as having severe (0–2 correct answers) cognitive dysfunction. Only patients without severe cognitive dysfunction (3 correct answers) were included. Living conditions were categorised as independent (living in one’s own home or in housing for the elderly) or as institutionalised (living in a nursing home or a hospital). Walking ability was based on the patient’s need for walking aids and was categorised as no need for a walking aid, need for a stick or crutches, need for a walking frame or non-ambulant. Only patients with independent walking capability with or without a walking aid before the fracture were included. The Katz ADL index15 status is based on an evaluation of the functional dependence or independence of patients in bathing, dressing, going to the toilet, transferring, continence and feeding. ADL index A indicates independence in all six functions, index B independence in all but one of the six functions. Indexes C–G indicate dependence in bathing and at least one additional function. Pain at the hip was assessed with Charnley’s numerical classification,9 which grades the pain from 1 to 6 with 1 = severe and spontaneous and 6 = no pain. The HRQoL was rated using the EQ-5D.6 The EQ-5D has five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is divided into three degrees of severity: no problem, some problems, and major problems. Dolan et al.12 used the time trade-off (TTO) method to rate these different states of health in a large UK population (UK EQ-5D Index Tariff). We used the preference scores generated from this population when calculating the scores for our study population. A value of 0 indicated the worst possible state of health and a value of 1 the best possible. Statistical methods The statistical software used was SPSS 15.0 for Windows. The Wilcoxon signed ranks test was used when comparing EQ-5D data. The tests were two-sided and the results were considered significant at p < 0.05. Results Baseline data for all patients included (n = 87) are displayed in Table 1. The mean age was 83 years and 75% of the patients were females. The vast majority, 94%, came from independent living conditions and 94% were assessed as ADL A or B, i.e. they were independent in all six functions of ADL or in all but one. According to the inclusion criteria there were no patients with severe cognitive dysfunction (SPMSQ < 3) and all patients were independent walkers with or without walking aids before the fracture. However, 56% of the patients used some form of walking aid before the fracture, mostly a walking frame. Ninety-one per cent were assessed as ASA 2 or 3. The most common co-morbidities were cardiovascular disease (55%), pulmonary disease (23%), malignancy (19%), diabetes mellitus (17%), cerebrovascular lesion (11%) and renal disease (6%). During the hospital stay 16 of the 87 patients (18%) developed a major medical complication. The most frequent major complications were cardiac failure (n = 5) and pneumonia (n = 5). As previously mentioned the mortality rate at 4 months was 8% and the corresponding figures for the 12- and 24-month followups were 14% and 25%, respectively (Fig. 1).
373
Table 1 Baseline data for all patients included (n = 87). Mean (S.D.) age in years
82.5 (7.8), range 66–101
Gender, female (%)
65 (75)
ASA, classification (%) 1 2 3 4
3 (3) 35 (40) 44 (51) 5 (6)
Mean (S.D.) cognitive function
7.8 (2.1), range 3–10
Mean (S.D.) EQ-5Dindex score prefracture
0.73 (0.27), range 0.0–1.0
Walking aids (%) None Stick or crutches Walking frame
38 (44) 17 (20) 32 (37)
ADL A and B (%)
80 (94)a
From independent living (%)
82 (94)
ADL A indicate independence in all six functions and B independence in all but one function. a Two missing values.
Surgical outcome The waiting time to surgery was 1.1 days (0–4 days). The type of anaesthesia was spinal or epidural in 79 patients (91%) and the surgeon was a certified specialist in orthopaedic surgery (postregistrar or consultant) for 59 patients (68%) and a registrar for the remaining 28 (32%). The mean intraoperative blood loss was 450 (50–6000) ml and the mean duration of surgery was 85 (15– 250) min. There were seven patients (8%) with superficial infections that healed after antibiotic therapy and one patient (1%) with a suspected deep infection who had a wound revision surgery. At surgery there were no signs of deep infection and the bacterial cultures were all negative. This patient died at 18 months after surgery from causes not related to the fracture. In total, seven patients (8%) were reoperated upon during the study period, including the patient explored for a suspected deep infection (Table 2). One patient had early revision surgery due to excessive internal malrotation. The reoperation was complicated by a deep infection and the patient underwent two subsequent wound revisions and finally extraction of the nail after the fracture was healed. Two patients had lag-screw penetrations, in one of them a total hip replacement (THR) was performed and in the other a successful reosteosynthesis with a new LGN. Two patients sustained fractures close to the tip of the nail after new falling accidents. In one of these patients the distal fracture was stabilised with a longer LGN and in the other one, the LGN was left in situ and the distal fracture was stabilised with a dynamic condylar screw (DCS, Synthes, Stockholm, Sweden). In both patients all fractures healed. Finally, in one patient there were radiological signs of delayed union indicating dynamisation, after which the fracture healed. Functional outcome and HRQoL Pain at the hip, walking ability and ADL function for all patients available at each follow-up are displayed in Table 3. At the final follow-up 80% of the patients reported no or only slight or intermittent pain at the hip (Charnley score 5–6). Forty-six per cent had regained their prefracture walking ability, 48% had the same level of ADL function and 71% of the patients living independently before the fracture were still living independently after 24 months.
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
374 Table 2 Data on all patients reoperated upon (n = 7). Implant
Indication
Reoperation/s
Time (month)
GN
1. Malrotation 2. Deep infection 3. Deep infection 4. Local pain L-S penetration L-S penetration Fx close to the tip of the nail Suspected deep infection Fx close to the tip of the nail Delayed union
Revision with new lag-screw Wound revision Wound revision Extraction of the nail New LGN THR Longer LGN Wound revision LGN left in situ, fixation with a DCS Dynamisation
0.1 0.4 1.7 12.5 1.8 1.9 2.1 3.0 3.6 8.6
LGN LGN LGN LGN LGN LPFN
Fx = fracture; time = time elapsed from the primary operation; L-S = lag-screw; GN = gamma nail; LGN = long gamma nail; LPFN = long proximal femoral nail; DCS = dynamic condylar screw; THR = total hip replacement.
The HRQoL (EQ-5Dindex score) decreased from 0.73 before the fracture to 0.53 at 4 months (p < 0.001) and remained at the same level at the 12- and 24-month follow-ups, 0.53 (p < 0.001) and 0.52 (p < 0.05), respectively (p values are given for the difference between follow-ups and before fracture) (Fig. 2). Table 3 Pain at the hip, walking ability and ADL function for all patients available at each follow-up (4 months, n = 77; 12 months, n = 72; 24 months, n = 60). Pain, mean (S.D.) Charnley score 4 months 12 months 24 months
4.9 (1.5)4 5.1 (1.4)2 5.4 (1.0)4
Pain, Charnley score 5 or 6, n (%) 4 months 12 months 24 months
47 (64)4 49 (70)2 45 (80)4
Walking ability at least similar to prefracture, n (%) 4 months 12 months 24 months
33 (43) 34 (47) 27 (46)1
Level of ADL function at least similar to prefracture, n (%) 4 months 12 months 24 months
35 (46)1 31 (44)1 28 (48)2
Living conditions similar to prefracture, n (%)a 4 months 12 months 24 months
58 (74) 53 (74) 42 (71)1
The figures in superscript refer to the number of missing values at each follow-up occasion. Charnley hip score: best possible score = 6 and worst possible score = 1. a The calculation is based on the number of patients available at each follow-up who were living independently before the fracture.
Fig. 2. HRQoL according to the EQ-5D for the patients with subtrochanteric fractures available at each follow-up. Best possible score = 1 and worst possible score = 0: fx = fracture; mth = months.
Discussion The results of our study confirmed an acceptable reoperation rate after subtrochanteric fractures in elderly patients treated with a cephalomedullary nail. Although the patients experienced a limited amount of pain at the hip there were obvious consequences for walking ability and ADL function reflected in a significant deterioration in both short and long-term HRQoL. The rate of revision surgery, 8%, was of the same magnitude as reported in the two major studies on elderly patients treated with the LGN, the prospective study by Robinson et al.24 and the retrospective study by van Doorn et al.,33 and better than in most larger studies using various types of extramedullary implants.16,22,34 One exception is the prospective study by Lunsjo¨ et al.18 reporting only 2% of technical failures in subtrochanteric fractures when using the Medoff sliding plate (MSP) in the uniaxial dynamisation mode. However, in clinical practice, the differentiation between low-trochanteric fractures and high-subtrochanteric fractures might be difficult and lead to erroneous uniaxial dynamisation in trochanteric fractures which may contribute to lag-screw penetration.17,19 Therefore uniaxial dynamisation requires frequent radiographic follow-up and readiness for staged dynamisation in a number of cases to prevent lag-screw penetration.8 To overcome this, the MSP may be used in the biaxial dynamisation mode, but then the problem of excessive medialisation of the shaft remains, especially in the Seinsheimer type 2C fracture (reverse oblique).20,25,26 Despite the good results reported for the MSP in clinical studies its use in clinical practice is limited probably due to problems of correctly interpreting the fracture type and selecting the correct type of dynamisation. The rate of lag-screw penetrations resulting in revision surgery in our study, 2.3%, was on par with the 1.7% reported by Robinson et al.24 But in contrast to Robinson and co-workers we found only one patient with a delayed union resulting in reoperation (dynamisation). On the other hand, three out of the eight patients (3.1%) reoperated on for suspected non-union in the study by Robinson and co-workers, had a healed fracture at the time of exploration. A finding also in conformity with this previous study was that a fracture close to the tip of the nail was another major cause of reoperation, 2.3% in our study compared to the 1.7% reported by Robinson et al.,24 all in patients with long nails. Owing to the natural antecurvation of the femur, nail impingement against the anterior cortex of the distal femur has been a problem especially with the use of earlier generations of cephalomedullary nails. This problem is less pronounced in later generations with reduced stiffness and a smaller radius of curvature. However, both our patients sustained their distal fractures after falling more than 2 months after the index operation and this particular complication probably cannot be completely eliminated. In an
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
elderly patient with a femoral implant sustaining a significant injury, the stress concentration and eventual fracture will most probably occur at the distal end of the implant regardless of its length or type, i.e. nail or plate. There were no deep infections after the index procedure. One of our patients was explored due to a suspected deep infection which could not be verified at surgery or with cultures. Infection seems to be very rare in most studies using any type of intramedullary nail,24,33,36 probably reflecting the advantages of the percutaneous technique and more limited soft tissue trauma. Although the number of fracture-related complications was limited, the subtrochanteric fracture had a substantial effect upon the patients’ quality of life. There was a clear deterioration in the HRQoL which was established as early as 4 months and persisted without any positive development during either the first or the second year after the fracture. The interpretation of the quality of life data is based on our patients’ ability to correctly recall their health status prior to the hip fracture. However, since a prospective collection of preinjury HRQoL data is not possible in trauma studies, we have to rely on preinjury recall or a comparison with population figures. The prefracture EQ-5Dindex score value, based on recall, 0.73 for our patients was in conformity with the value for the age-matched Swedish reference, 0.74.7 We have previously reported the HRQoL determined by the same instrument, the EQ5D, in a RCT20 with a 1-year follow-up comparing the MSP and the standard gamma nail in patients with unstable trochanteric fractures (J-M 3–5)14 and high-subtrochanteric fractures.26 The number of patients with subtrochanteric fractures in that study, 28, were too small to allow a separate analysis of HRQoL; however, compared to the patients with unstable trochanteric fractures in that study satisfying the same inclusion criteria as in the present study, the deterioration in the EQ-5Dindex score at 4 months was comparable, 0.20, while, in contrast to the patients with unstable trochanteric fractures, the patients with subtrochanteric fractures did not show any improvement at the 12-month follow-up. We have also recently analysed the HRQoL after a stable trochanteric fracture (J-M 1–2).13 The patients reported a more limited deterioration in the EQ-5Dindex score at 4 months, 0.12, and at 2 years the survivors had almost regained the same level of quality of life as before the fracture. The quality of life instrument used in this study is brief and easy to use in elderly patients5,31 and has been validated in hip fracture patients.10,28,29 Another major advantage of this particular instrument is that it also allows combining different dimensions of health to form an overall index (utility score), as required for health care evaluations4 and for constructing quality-adjusted lifeyears (QALYs),35 a measure frequently used in cost-effectiveness analyses. Despite relatively uneventful fracture healing, patients with subtrochanteric fractures do not regain their prefracture functional level and HRQoL. Compared with patients with stable trochanteric fractures satisfying the same inclusion criteria and displaying nearly identical baseline data besides the fracture type,13 the percentages of patients reporting no or only limited pain at the hip were equal, 80% and 81%, respectively, but the percentage of patients who regained their prefracture walking ability and ADL function was lower, 46%, compared with 55%, and 48%, compared with 66%, respectively. This is probably a reflection of the fracture type being more complex and associated with a more severe soft tissue injury and thereby resulting in a more difficult rehabilitation for these elderly patients. The magnitude of the mortality rate is highly dependent on the inclusion criteria and therefore it is not easy to compare between individual trials. Our 1-year mortality rate of 14% is lower than the 25% reported in the prospective study by Robinson et al.,24 which
375
may partly be explained by the fact that only patients without severe cognitive dysfunction were included in our study. We opted not to include patients with severe cognitive dysfunction and patients who had already been unable to walk before the fracture because they are difficult to evaluate, especially regarding HRQoL,11,27 and their quality of life is strongly influenced by the cognitive dysfunction and other co-morbidities.3 One limitation of the study is that at each follow-up the patients were interviewed by phone and only patients reporting problems were scheduled for a follow-up visit including a radiographic control. Another limitation was that we did not use the long nails in all patients. Individual surgeons opted to use the short cephalomedullary nails in patients with high-subtrochanteric fractures. However, short nails have been shown to be successful in previous studies on patients with high-subtrochanteric fractures. Miedel et al.20 reported no reoperation in 16 patients with highsubtrochanteric fractures treated with the short gamma nail and, in the present study, none of the fracture-related complications were in patients operated upon with short nails. The only reoperation after fixation with a short nail was due to a primary malrotation. Therefore, we believe that our results are representative of cephalomedullary nails in general. The strength of the study is the relatively large number of patients, the prospective design, appropriate follow-up period and the fact that data were assessed with validated instruments. The dropout rates at the various follow-ups were acceptable in this fragile age group and not of such a magnitude that the validity of the conclusions would be jeopardised. In conclusion, a subtrochanteric fracture in elderly patients had a substantial negative effect on the patient’s short and long-term HRQoL. Although pain at the hip was not a major problem, there was an obvious detoriation in walking ability and ADL function. However, the rate of revision surgery was comparatively low, which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to QALYs. Conflict of interest statement All authors state that there are no conflicts of interest. Acknowledgements Special thanks are due to the Stockholm Hip Fracture Group for running the study during the course of years: i.e. Paul Ackerman, Amer Al-Ani, Richard Blomfeldt, Tommy Cederholm, Margareta Hedstro¨m, Paula Kelly-Pettersson, Kristina Ka¨llbom, Gustaf Neander, A˚sa Norling, Sari Ponzer, Bodil Samuelsson, Maria Sa¨a¨f, Anita So¨derqvist and K.-G. Thorngren. Funding: The study was supported by the Stockholm County Council Research Fund for clinical studies (EXPO 1999). References 1. Blomfeldt R, To¨rnkvist H, Eriksson K, et al. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br 2007;89:160–5. 2. Blomfeldt R, To¨rnkvist H, Ponzer S, et al. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am 2005;87:1680–8. 3. Blomfeldt R, To¨rnkvist H, Ponzer S, et al. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. J Bone Joint Surg Br 2005;87:523–9. 4. Borgstro¨m F, Zethraeus N, Johnell O, et al. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 2006;17:637– 50.
376
W. Ekstro¨m et al. / Injury, Int. J. Care Injured 40 (2009) 371–376
5. Brazier JE, Walters SJ, Nicholl JP, Kohler B. Using the SF-36 and EuroQol on an elderly population. Qual Life Res 1996;5:195–204. 6. Brooks R. EuroQol: the current state of play. Health Policy 1996;37:53–72. 7. Burstro¨m K, Johannesson M, Diderichsen F. Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 2001;10:621–35. 8. Ceder L, Lunsjo¨ K, Olsson O, et al. Different ways to treat subtrochanteric fractures with the Medoff sliding plate. Clin Orthop 1998;348:101–6. 9. Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61–76. 10. Coast J, Peters TJ, Richards SH, Gunnell DJ. Use of the EuroQoL among elderly acute care patients. Qual Life Res 1998;7:1–10. 11. Coucill W, Bryan S, Bentham P, et al. EQ-5D in patients with dementia: an investigation of inter-rater agreement. Med Care 2001;39:760–71. 12. Dolan P, Gudex C, Kind P, Williams A. The time trade-off method: results from a general population study. Health Econ 1996;5:141–54. 13. Ekstro¨m W, Miedel R, Ponzer S, et al. Quality of life after a stable trochanteric fracture. A prospective cohort study on 148 patients. J Orthop Trauma, in press. 14. Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthop Scand 1975;46:795–803. 15. Katz S, Ford A, Moskowitz R, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA 1963;185:94–9. 16. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res 1989;238:122–30. 17. Lunsjo¨ K, Ceder L, Stigsson L, Hauggaard A. One-way compression along the femoral shaft with the Medoff sliding plate. The first European experience of 104 intertrochanteric fractures with a 1-year follow-up. Acta Orthop Scand 1995;66:343–6. 18. Lunsjo¨ K, Ceder L, Tidermark J, et al. Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems. Acta Orthop Scand 1999;70:459–66. 19. Lunsjo¨ K, Ceder L, Thorngren KG, et al. Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Acta Orthop Scand 2001;72:133–40. 20. Miedel R, Ponzer S, To¨rnkvist H, et al. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. J Bone Joint Surg Br 2005;87:68–75. 21. Owens WD, Felts JA, Spitznagel Jr EL. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–43.
22. Parker MJ, Dutta BK, Sivaji C, Pryor GA. Subtrochanteric fractures of the femur. Injury 1997;28:91–5. 23. Pfeiffer E. A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23: 433–41. 24. Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am 2005;87:2217–26. 25. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am 2002;84:372–81. 26. Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg Am 1978;60:300–6. 27. Selai C. Assessing quality of life in dementia. Med Care 2001;39:753–5. 28. Tidermark J, Bergstro¨m G. Responsiveness of the EuroQol (EQ-5D) and the Nottingham Health Profile (NHP) in elderly patients with femoral neck fractures. Qual Life Res 2007;16:321–30. 29. Tidermark J, Bergstro¨m G, Svensson O, et al. Responsiveness of the EuroQol (EQ5D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12:1069–79. 30. Tidermark J, Ponzer S, Svensson O, et al. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br 2003;85:380–8. 31. Tidermark J, Zethraeus N, Svensson O, et al. Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 2002;11:473–81. 32. Tidermark J, Zethraeus N, Svensson O, et al. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma 2002;16:34–8. 33. van Doorn R, Stapert JW. The long gamma nail in the treatment of 329 subtrochanteric fractures with major extension into the femoral shaft. Eur J Surg 2000;166:240–6. 34. Warwick DJ, Crichlow TP, Langkamer VG, Jackson M. The dynamic condylar screw in the management of subtrochanteric fractures of the femur. Injury 1995;26:241–4. 35. Williams A. The role of the EuroQol Instrument in QUALY calculations. Great Britain: Centre for Health Economics, The University of York; 1995. 36. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res 1992;283:231–6.