J. &on.
Dis. 1967, Vol. 20, pp. 103-113. Pergamon Press Ltd. Printed in Great Britain
COMPLICATIONS
FOLLOWING
HIP FRACTURES
J. GEORGE FUREY, M.D. Division of Orthopedic
Surgery, Highland View Hospital and Western Reserve University School of Medicine, Cleveland, Ohio
(Received27 July 1966) THE HIGH incidence of hip fracture in our elder population and its attendant period of disability and mortality rate is well recognized [l-5]. The mechanical problems related to the fractured hip have been subjected to considerable study and research, and innumerable devices have been provided to produce better forms of internal fixation. Insufficient attention has been given to the frequent complications that follow in the wake of the fractured hip [6]. It is the complications in many instances that account for the relatively high rate of ultimate poor results. The hip-fracture patient’s failure to regain functional independence is as often due to a postoperative complication as to a mechanical failure of the operative procedure. Two hundred and sixty-seven consecutive hip-fracture patients were reviewed at Highland View Hospital, Cleveland, Ohio, from July 1959 to December 1962. These patients were transferred from 25 other general hospitals in the greater Cleveland area for convalescent care on an average of 39.4 days postoperative. The patients were evaluated for complications developing postfracture, and the effect of the complications on the patient’s ultimate functional outcome. These 267 patients cannot be considered the average of all hip-fracture patients in a community since this group represented the more difficult patients from either a medical or social standpoint or both. The younger and better preserved hip-fracture patients are frequently discharged to their regular home environment by 53 weeks postoperative. This fact has magnified the complications, thus providing an opportunity to study the complications in larger number and to demonstrate their effect on the ultimate end result following hip fracture. A series of events has been seen to start frequently following a hip fracture which makes a bad situation worse. Certain operative pitfalls will be reviewed that are directly responsible for specific postoperative complications. Immediate postoperative attention is required to prevent complications other than the well publicized pneumonia, thrombophlebitis and heart failure. Skin decubiti, urinary-tract infection, knee contracture and drop foot should have a high priority in the prophylactic management of these patients. Anticipation of potential complications can break the chain of untoward events, and allow the elderly hip-fracture patient to resume a life close to the functional level that existed prior to the fracture. The average age in this series was 75 yr, and 74 per cent of the patients were over the age of 70. The fragility of this group is shown by the fact that 93 per cent had an average of 2.2 other diseases to contend with in addition to the hip fracture (Table 1). Arteriosclerotic heart disease, 46 per cent, was of course the most frequent, but 103
J. GEORGEFUREY
104 TABLE1.
cerebral and was a high fracture treated.
267 HIP-FRACTURE PATIENTS
Average age Associated disease Average number of associated diseases Extracapsular fracture Intracapsular fracture
93% 2.04
75.0 yr
Complications occurred Average complications per patient
71.5% 1.2
64.4% 35.6%
arteriosclerosis, 33 per cent, produced the greatest number of overall problems, a major deterrent to rehabilitation (Table 2). It is my impression that there is incidence of permanent deterioration of cerebral function following hip which, to a large degree, is related to the manner in which the patient is It was not possible to document this point in the present study. TABLE2.
ASSOCIATED DISEASES IN 247 PATIENTS (93 per cent)
Arteriosclerotic heart disease Cerebral arteriosclerosis Cataract Diabetes Chronic alcoholism Osteoarthritis, knee Pulmonary emphysema Hemiplegia (side of hip fracture) Hypertensive cardiovascular disease Generalized arteriosclerosis Parkinsonism Deafness, total Malignancy Wrist fracture Obesity Congestive heart failure Miscellaneous
124 88 45 22 18 17 17 15 15 13 13 13 12 11 11 10 100 Total
544
There was an average of 3.8 days delay per patient before surgery was performed in the acute treatment hospital. This seems to be longer than desired as it is well recognized that early mobilization is an essential part of maintaining physical and mental capabilities. Extra-capsular fractures were seen in 64.4 per cent of the patients and 35.6 per cent had intra-capsular fractures. Primary prosthetic replacement had been performed in 61 per cent of the intra-capsular fractures and another 11.6 per cent had prostheses inserted while at Highland View Hospital giving a total of 72.6 per cent of the intracapsular fractures that ultimately were treated by prosthetic replacement. Patients were evaluated on an average of 120.4 days after hip fracture, and it was determined that of the 267 patients, 191 (71.5 per cent) had a significant postoperative complication. Each of the 191 patients had an average of 1.7 complications. From the list of complications (Table 3) note that heart failure 1.5 per cent and pneumonia 1.1 per cent were relatively infrequent. This reflects the time postoperatively when the patients were under treatment at Highland View Hospital.
Complications TABLE 3.
Following Hip Fractures
105
COMPLICATIONS IN 191 PATIENTS(71.5 m
Urinary tract infections AbnormaI hip position Decubiti
cent)
52.0% 24.3%
Knee contracture
23.6% 12.4%
Wound infection Drop foot
7.6% 5.2%
Thrombophlebitis Congestive heart failure Pneumonia
1.9% 1.5% 1.1%
Thirty-seven patients (13.8 per cent) died while at Highland View Hospital on an average of 107 days after the fracture (Table 4). This group had an average age of 80.8 yr ; an average of 2.8 other associated disease ; and an average of 1.9 complications per patient. All of these figures are above the average for the group as a whole. None of these 37 patients were felt to be making satisfactory progress in rehabilitation. The hip fracture was felt to be the major contributory factor in the death of all but 4 patients who died of totally unrelated diseases within 2 months of the fracture. This is a high mortality rate and should cause us to be especially diligent in the management of patients approaching the age of 80 with several associated diseases. TABLE 4.
37 DEATHSAT HIGHLAND VIEW (13.8 per cent)
Average age Average number of associated diseases Extracapsular fractures Intracapsular fractures Average complication per patient Average days after fracture, death occurred
80.8 yr 2.8 67.6% 32.4% 1.9 107
Urinary-tract infection Evaluation for urinary tract infection was determined by routine urine analysis including microscopic examination and urine culture. This was accomplished by chart review, and was not intended to be a detailed evaluation of this complication. A gross urinary tract infection was defined as one reported to be ‘loaded’ with leukocytes on microscopic examination as well as a positive urine culture. A slight infection was defined as one with fewer leukocytes than ‘loaded’ but also a positive culture. Many patients in this series arrived at the hospital with a Foley catheter in place. The exact number could not be determined. The incidence of 52 per cent urinary tract infections (11.2 per cent slight and 40.8 per cent gross infections) is largely related to the routine use of indwelling catheters at the time of admission. In spite of meticuIous catheter technique, contamination of the bladder almost always occurred following their use. It is felt that an indwelling catheter should not be a routine order following hip fracture, especially in male patients. Catheter use is a necessary evil in the majority of cases during the first week when pain from the fracture is at its highest level, and use of the bed pan would add considerably to the patient’s discomfort. Incontinency during the early phase of treatment may trigger decubitus formation due to maceration of the skin in vulnerable areas. As long as the foreign body catheter is in place in the bladder the usually
106
J. GEORGEFUREY
associated infection cannot be eradicated or prevented by antibiotics. This behoves the surgeon to try to eliminate the infection. Early removal of the catheter adds to the nursing work load, but this may prevent a chronic urinary tract infection from organisms made resistant by futile antibiotic therapy given while the catheter is in place. Abnormal hip position Abnormal hip position produced obvious deformities of the fractured extemity in 65 patients (24.3 per cent). Fifty-two patients had either shortening of at least one inch, or excessive external rotation, or both deformities. Thirteen patients had internar rotation and adduction deformities. The deformities were caused by either improper initial reduction of the fracture fragments; loss of reduction due to inadequate internal fixation; or improper placement of a hip prosthesis. Minor shortening and rotational deformities are well tolerated by elderly patients though more severe degrees are not, and will interfere significantly with ambulation and also .help promote decubiti, knee contracture, and common peroneal palsy. In most instances these complications can be prevented at the time the fracture is reduced and internal fixation carried out. The use of a fracture table and placement of the extremity in traction will easily correct shortening. Attention to the degree of internal rotation of the distal fragment is important. It is essential that the traction be maintained during surgery while internal fixation is being carried out. Cornminuted intertrochanteric fractures require special attention to re-establish proper length and rotation. There may be little or no secure bone in the trochanteric region to provide fixation; however, sufficient immobilization can be obtained in the neck and head by a properly placed nail and distally in the shaft by a long plate. In this type of fracture the nursing staff must be thoroughly warned of two things. The fractured extremity cannot be handled roughly in transferring the patient, and secondly a greater degree of pain can be expected from a cornminuted fracture than in the average hip fracture, These patients are less inclined to change position in bed making them prime candi-dates for decubiti and other complications produced by failure to move about in bed. Attention to the proper placement of the intramedullary stem hip prosthesis to reproduce the existing degree of neck antiversion is extremely important in securing a stable hip joint. Reapproximation of severed tendons and muscles, as well as the joint capsule is also important to obtain a stable hip joint and also to maintain proper alignment of the lower extremity. More rotational problems have been seen where the anterior approach to the hip joint has been used than with a posterior approach. One of the main reasons for immediate use of the prosthesis in femoral neck fractures is to provide early mobilization and weight bearing on the injured extremity. Early mobilization is the best prophylactic means of eliminating or minimizing the complications outlined in this article. If normal lower extremity alignment is not produced at the time of prosthetic insertion, the prosthesis advantage over nailing may be lost. Decubiti Decubiti were not the most common complication (63 patients or 23.6 per cent), but they did represent the most difficult problems to manage. The distribution is listed in Table 5, indicating there were 103 decubiti in 63 patients, or an average of 1.6 decubiti per patient. The size of the decubiti were either large or medium in 54.3 per cent indicating a major setback to the patient in these instances. It was a common fmding
Complications TABLE5. HeI Sacrum Trochanter Knee Other
DECUFBTIIN 63 PATIENTS 39 34 13 6 11
Total
107
Following Hip Fractures
hge Medium Small
32 24 47
103
to have the hip fracture heal before the skin defect healed in a large decubitus. In most instances this complication did not lend itself to plastic surgical reconstruction due to the patient’s age and a multitude of other medical problems. Decubiti are more likely to develop within a few days of the hip fracture when pain is the greatest and the patient is unable to change position frequently enough. This is a major reason for the earliest possible surgery so the pain is diminished and mobilization of the patient can be started. Many elderly patients are poorly nourished at the time the fracture occurs, which contributes to their propensity to skin necrosis. A high incidence of peripheral arterial insufficiency in the same group makes the occurence of decubitus a greater threat to the patient. Those patients with Parkinsonism and other chronic neurological disorders are prime targets for decubiti since by the nature of their primary disease there are varying degrees of rigidity and immobility. The heels and sacrum were involved to almost an equal degree and should be areas of major concern. The heel decubitus usually developed on the posterolateral aspect, especially if any degree of external rotation deformity was present. A common combination was found to be a shortened external rotation deformity resulting from a cornminuted intertrochanteric fracture and a posterolateral heel decubitus. The major positive factor is the failure of the patient to frequently change position and relieve the concentrated pressure over the bony prominence of the heel. It was not uncommon to find bilateral heel decubiti where the patient failed to move either lower extremity adequately. Protective heel padding, side to side positioning and early sitting in a chair with the knees flexed are the chief means of preventing this serious complication. The high incidence of sacral decubitus is understandable, and preventive measures are more difficult to apply. The first 24 hr postfracture may seal the fate of a large area of sacral skin. It is difficult to persuade the patient, as well as the nurses, that early turning from side to side is essential in the face of rather severe hip pain. Early insertion of an indwelling catheter is essential in almost all female patients to avoid incontinence and subsequent maceration of skin followed by breakdown. An overhead trapeze should be applied to the patient’s bed on admission so she can assist in moving. The incidence of decubiti over the hip and knee regions was not great and these were usually present in patients who had multiple decubiti. These patients usually had another primary disabling disease such as Parkinsonism or malnutrition. Prompt fixation of the fracture, rapid mobilization and competent nursing care are essential if decubiti are to be prevented.
Knee contracture A total of 33 patients (12.4 per cent) had a significant loss of knee joint motion
J. GEORGEFUREY
108
which produced a serious deterrent to successful rehabilitation (Table 6). Though a hip fracture may be sufficiently healed in 4 months, the patient’s ability to ambulate independently can be permanently jeopardized by the secondary knee joint deformity. TABLE 6.
KNEE CONTRACTURE IN
33 PATIENTS
Flexion contracture, fracture side Flexion contracture, opposite Extension contracture, fracture side
23 6 10 Total
39
The functional inter-relationship of the hip joint and knee joint is essential for ambulation. The natural tendency with a painful hip is to maintain the joint in a flexed attitude which in turn causes the knee joint to be placed in flexion. Twenty-three patients in this series developed a significant degree of knee flexion contracture on the side of the hip fracture, and 6 of the 23 demonstrated a flexion contracture of the opposite knee also. Ten patients developed extension contracture on the side of the hip fracture. The occurrence of extension contracture, as well as flexion contracture, indicates the primary causative factor was prolonged immobilization of the knee joint and a lack of either active or passive motion. A significant degree of osteoarthritis of the knee predisposes the hip fracture patient to this problem, and calls for special precautions to avoid loss of knee-joint motion. A pillow placed under the knee to provide temporary comfort post-operatively should be avoided as this may initiate a permanent flexion contracture. The best prophylaxis against either flexion or extension contractures is to maintain the knees in extension in bed and flexed to 90 degrees when the patient is up in a chair. In addition, it is inadvisable to maintain the knee extended when the patient is up in a chair as this produces a longer lever arm which adds unnecessary strain on the fractured hip. The value of range of motion exercises for the knees cannot be better exemplified than in the elderly postoperative hip-fracture patient. In the presence of pain in the hip region, patients are reluctant to move the knee, which makes them susceptible to permanent loss of motion. The same sequence that produced decubiti is apt to develop unless the patient is encouraged to change positions frequently in bed and is mobilized within a few days of surgery. These factors cannot be left to the nursing staff to initiate, but must be specifically ordered by the surgeon. Wound infection An overall incidence of operative wound infection was 7.6 per cent (20 patients) which is quite high, but this reflects the type of patient frequently referred to this institution. Seven patients had superficial infections and 13 had deep, serious infections. It is significant that 40 per cent of the infections (8 patients) occurred in prosthetic operations which represented a 13.8 per cent infection incidence in 58 patients. Hip nailing operations had an incidence of only 5.9 per cent infections. The magnitude of the prosthetic operation probably accounts for this higher incidence. Six of the 20 infected patients died while hospitalized, and it was felt that the infection was a contributing cause in all 6 patients. This complication represents a serious threat to the patient’s physical ability, and may also jeopardize his life. MURRAY [7] reported a similar high mortality rate in infected hip fracture patients.
Complications Following Hip Fractures
109
The cause of wound infection is in the operative technique. Special attention to aseptic technique, and the time the operative wound is open to contamination are especially important. The large number of persons and equipment involved in hip pinning operations make this procedure vulnerable to breaks in technique. The results of the deep infections were disastrous in 10 out of our 13 cases. In all three prosthetic cases the prosthesis was removed, and of the remaining 7 cases femoral head and neck resection was necessary in four cases to control the infection and provide a movable and less painful hip joint. Resection of the femoral head and neck produces several inches of shortening and varying degrees of instability depending on the amount of scarring that has developed. It is felt that this procedure is frequently the most practical solution to a severe problem in an elderly poor risk patient. The infection was eliminated in all cases of resection. An insidious problem of infection presented in one case in which the wound healed per primum and the femoral neck fracture healed within 4 months. This patient continued to experience severe hip pain, and serial X-rays demonstrated loss of the joint space. A staphylococcus infection of the hip joint was discovered and the patient was ultimately treated by an arthrodesis of the hip joint. Postoperatively, wounds should be watched closely, as early and vigorous treatment of the infection may be the only chance of salvaging a functional hip or preserving the patient’s life. Drop foot
Prolonged common peroneal nerve pressure in a bed-fast patient results in a drop foot, and can be seen as a complication in any prolonged debilitating illness. A hip fracture usually produces an external rotation deformity, and varying degrees of this frequently persist after surgery which exposes the common peroneal nerve to unusual pressure. A slender person is more prone to develop this complication as the common peroneal nerve lies directly on the posterolateral aspect of the fibular neck, and has only a thin layer of peroneus longus muscle between it and the skin. Pressure from elastic bandages or excessive traction on the fracture table have also been implicated as causative factors [8]. Fourteen patients (5.2 per cent) were found to have this problem, while three patients had bilateral drop feet. One patient developed a drop foot only on the side opposite from the hip fracture. Four of the 14 patients had been treated by prosthetic replacement. It was not felt that the operative approach was the usual causative factor as two patients had the problem bilaterally, and one patient had the drop foot on the opposite side. The causative factors were again basically the same as listed for the other complications. One half of the patients showed spontaneous return of muscle function by the time weight bearing was permitted, and the remainder required bracing to permit satisfactory ambulation on discharge. X-ray evaluation on discharge
One hundred and seventy-five out of the 267 patients could be evaluated by X-ray examination on discharge to determine the degree of healing on an average of 120 days post-fracture (Tables 7 and 8). At the time of discharge 119 patients (68 .O per cent) demonstrated a satisfactory degree of healing for full weight bearing, while 20 patients (11.4 per cent) were judged to have shown only a moderate degree of healing.
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J. GJDRGE FUREY
TABLE 7.
X-RAYEVALUATION OF 175 PATIENTSAT AVERAGE
120 DAYS POSTFRACTURE
68.0%
Satisfactory healing Moderate healing Early healing Non-union
11.4% 10.3% 10.3%
Eighteen patients (10.3 per cent) were noted to have only early signs of healing, and in the remaining 18 patients (10.3 per cent) there was definite evidence on non-union. Comparison of X-rays taken at the time of admission with those at the time of discharge in 175 patients revealed partial loss of reduction in 141 patients (80.5 per cent), and a gross loss of reduction in 20 patients (11.5 per cent). Only 14 patients (8.0 per cent) demonstrated no change in the position of reduction. It is felt that the loss of reduction was due to a combination of too early weight bearing as well as normal muscle forces in play about the hip joint in the activities of transferring and ambulation.
TABLE 8.
X-RAY EVALUATION
Partial loss reduction from admission Gross Ioss reduction from admission No loss reduction from admission
80.5% 11.5% 8.0%
There was evidence of aseptic necrosis occurring in only two patients, both of whom had femoral neck fractures. The low incidence of this complication noted was due to the relatively short follow-up and high incidence of prosthetic replacement.
RESULTS It was not possible to evaluate 17 patients (6.5 per cent) at the time of discharge due to the short period of care at Highland View Hospital. The remaining 250 patients were rated as either satisfactory or unsatisfactory on an average of 120.4 days after the fracture. A satisfactory result was defined as a patient experiencing only minor hip pain, who was ambulatory and able to perform activities of daily living close to the functional level existing prior to the fracture. One hundred and sixty-three patients (61 .O per cent) were felt to have satisfactory results. An unsatisfactory result occurred in 87 patients (32.5 per cent), and was defined as a patient with moderate hip pain who failed to ambulate for practical purposes and was grossly dependent in activities of daily living in contrast to the pre-fracture functional level. Comparing the groups of satisfactory results (61 .O per cent) and unsatisfactory results (32.5 per cent), Tables 9 and 10, it is seen that the unsatisfactory result patients averaged 6 yr older; had a somewhat greater number of associated diseases, but most significantly, were found to have two and one-half times as many complications. The unsatisfactory results in many instances were related to the secondary complications rather than the hip fracture per se. When a patient with a hip fracture is 75 yr of age or older and has more than one associated disease, the surgeon should be especially on guard for the complications just reviewed.
Complications TABLE9.
Following Hip Fractures
111
SATJSFACT~RY RFXJLTS IN 163 PATIENTS (61 .O per cent)
Average age Average number of associated diseases Extracapsular fractures Intracapsular fractures Average complication per patient Deaths in Highland View
73.1 yr 6::& 32.3% 1.0 1
The level of the fracture being intracapsular or extracapsular did not have much effect on the satisfactory or unsatisfactory outcome. There were 4.5 per cent more satisfactory results in the extracapsular group (172 patients). Those intracapsular fractures treated by primary prosthetic replacement (58 patients) showed a significantly greater number of satisfactory results (69.1 per cent) than similar fractures treated by hailing operation (37 patients, 50 per cent satisfactory results). TABLE10.
UNSATBFACTORY RESULTS IN 87 PATIENTS (32.5 per cent)
Average age Average number of associated diseases Extracapsular fractures Intracapsular fractures Average complications per patient Deaths in Highland View
79.1 yr 2.4 63.2% 36.8% 2.5 33
The group of 76 patients that did not develop complications had 91.4 per cent satisfactory results as compared to the 191 patients with complications who had only 55.2 per cent satisfactory results. The other statistic that stands out is four deaths (5.3 per cent) in the no complication group as compared with 33 deaths (17.3 per cent) in the complication group. Again, the complication group’s average age is 6.7 yr older, and there was a higher incidence of associated diseases, The figures demonstrate the great adverse effect that complications have, not only on the patient’s functional result, but also on the survival rate. DISCUSSION
It is apparent after review of the material collected that most of the poor end results were in patients over 75 yr who had more than one associated disease and developed one of the complications reviewed. It is in this group that mortality is high during hospitalization, and in the remaining patients the hip fracture frequently marked the beginning of a gradual and painful deterioration with total dependence in activities of daily living. The patients in the younger age group frequently do not have much difficulty regaining their pre-fracture functional level once the fracture has healed. When an elderly patient with these poor prognostic signs sustains a hip fracture, surgical stabilization of the fracture or prosthetic replacement should be carried out at the earliest time after fracture that the patient’s general condition permits. These patients are usually in the best condition on admission to the hospital that they will be in for a considerable period of time. Secure fixation of the fracture or insertion of a prosthesis considerably diminishes the pain, and makes it possible to get the patient up in a chair within one or two days after the fracture, Initially the patient may have
112
J. GEORGE FUREY
to be lifted into a chair, but as soon as possible the patient should work herself into the dangle position, then transfer to a chair beside the bed by bearing weight on the sound extremity. ‘Hi-Lo’ beds have greatly aided in this manoeuver. An overhead trapeze is also essential in making it possible for the patient to move about in bed as well as getting in and out of bed with minimal assistance. The exercise derived from these activities may be all the patient gets in the course of a day. Frequent changes in position in bed are necessary to prevent decubit, peroneal palsy and knee-joint contractures. It is common practice of nursing and medical staffs to rely on devices such as an air mattress or sheep skin to prevent decubiti. Reliance on these aids cannot be substituted for conscientious nursing care. In the early postoperative period the patient must be turned onto the side at regular intervals and special care given to skin of the back and heels. This also gives the skin a chance to be thoroughly dried and thus prevent maceration. Bulky prophylactic heel dressings or special props under the calf should be used to prevent heel decubiti. Ankle and calf edema frequently occur when the patient first sits up. Inactivity and dependency are more frequent causes of this problem than phlebothrombosis. Prophylactic use of elastic stockings or elastic bandages are recommended for the first few weeks postoperatively. If the hip-fracture patient had sufficient strength for a minimum of activity of daily living before the injury, great effort should be made to maintain this functional level by rapid mobilization from bed and subsequent ambulation. This is especially helpful in eliminating the need for a catheter whether by using a bedside commode or by using a walker to go the bathroom. The earlier the catheter is removed, the less chance there is of developing a urinary-tract infection which will further weaken the patient who may be in a bare equilibrium with the simplest demands of life to begin with. Many elderly fracture patients subsequently become disoriented and lack co-operation to be successfully rehabilitated. It was impossible to determine the degree of this complication in the present study though cerebral deterioration certainly was one of the hardest problems to cope with. It is felt that speed in management of the fracture and subsequent mobilization of the patient are the essential prophylactic features to follow if this problem is to be minimized. Cerebral function can also be jeopardized by inexpertly administered anesthesia. The fragility of these elderly patients and the potential postoperative problems should be uppermost in the mind of the anesthesiologist at the time of surgery. The nutritional state of many elderly patients is not good at the time of fracture which makes them prime candidates for many complications. It is felt that blood replacement at the time of surgery is most important so not to add further to their deficiency. Arrangements for a preferential diet as well as special assistance in feeding is frequently necessary during the first 7-10 days postoperatively. Vitamin and iron supplements should be given to these patients as a routine until they are back to normal eating habits and a normal hemoglobin level. Close co-operation with. an internal medicine consultant is almost always required due to the high incidence of associated diseases and the precarious state of the general health of the average elderly hip-fracture patient. Consultation pre-operatively is important to aid in diagnosing unsuspected problems as well as ensuring adequate control of these conditions prior to surgery.
Complications
Following Hip Fractures
113
SUMMARY
of 267 hip fracture patients revealed 71.5 per cent had significant postoperative complications which effected their rehabilitation potential. Urinary tract infection, hip deformity, decubiti, knee contracture, wound infection and drop foot were seen in this order of frequency. Thirty-two and one-half per cent had unsatisfactory results judged at 4 months post-fracture. This group had two and one-half times as many complications as the 61 per cent with satisfactory results. The group of patients with complications had a 17.3 per cent mortality rate while hospitalized compared to the group of patients without complications whose mortality rate was only 5.3 per cent. Patients over 75 yr of age who sustain a hip fracture, and have more than one associated disease are prime candidates for the complications reviewed. They frequently are in a precarious equilibrium with their environment before fracture, and considerable prophylactic care is required to get these older patients back to functional independence. Review
REFERENCES 1. BANKS, H. H. : Factors influencing the result in fractures of the femoral neck, J. Bone Jt Surg. 44-A, 931-964, 1962. 2. DENA~, M. B. : Fractures in the elderly, Geront. clin. 6,347-359,1964. 3. MIKK~~N, 0. A. and LANGHOLM,0. : Life expectancy after hip fractures in the aged, Actu chir. scund. 127,46-56, 1964. 4. NICHOLSON,J. T.: Symposium surgical care of the elderly patient in different, J. Bone Jt Surg. 47-A, 103%1059,1965. 5. TAYUIR, G. M., NEUFELD,A. J. and NICKEL, V. L.: Complications and failures in the operative treatment of intertrochantric fracture of the femur, J. Bone Jt Surg. 37-A, 306316, 1955. 6. COZEN, L.: Postoperative care of hip fractures, Am. J. Orthopedics. 4, 20-21, 1962. 7. MURRAY, D. G.: Wound infections after surgery for fractured hip, J. Am. med. Ass. 190, 505508, 1964. 8. MILLER, D. S. and STERN, M.: Drop foot from trauma to common peroneal nerve associated with fractures of the hip, Am. J. Orthopedics. 4, 12-15,1962.