- Email: [email protected]
Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation
G Model JINJ 7461 No. of Pages 10
Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Full length article
Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation A prospective 2-year follow-up study of 182 patients Pierre Campenfeldta,b , Margareta Hedströma,c , Wilhelmina Ekströmd , Amer N. Al-Ania,e,* a
Karolinska Institutet, Department of Clinical Science, Intervention and Technology (CLINTEC), Stockholm Sweden Norrtälje Hospital, TioHundra AB. Box 905, 761 29 Norrtälje, Sweden Department of Orthopaedics, Karolinska University Hospital, Huddinge, Stockholm, Sweden d Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Department of Orthopaedics Karolinska University Hospital Solna, Stockholm, Sweden e Orthopaedic Clinic, Vällingby-Läkarhuset, Praktikertjänst AB, 16268 Vällingby, Sweden b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 June 2016 Received in revised form 7 October 2017 Accepted 16 October 2017
Background and purpose: Prospective studies on patient related outcome in patients <70 years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation. Patients and methods: 182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations. Results: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p < 0.001). Interpretation: Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Femoral neck fracture Young Functional outcome Fracture healing HRQoL
Introduction Femoral neck fractures in younger patients are uncommon but may result in lifetime disability. The recommended treatment for patients <70 years with a femoral neck fracture is anatomic fracture reduction and internal fixation regardless of the degree of displacement [1]. The rationale behind this recommendation is the desire to preserve the native hip joint, which may facilitate the
* Corresponding author at: SE – 162 68 Vällingby, Sweden. E-mail addresses: [email protected], [email protected] (A.N. Al-Ani).
patients’ future functional demand. Furthermore, the longer life expectancy in these patients might increase the risk of surgical revisions if treated with a hip arthroplasty. However, there is currently a growing trend in Sweden to treat patients with a displaced femoral neck fracture in the age range of 60–69 years with a total hip replacement (THR) [2]. A similar trend has been reported in the USA and in other countries [3,4], yet, studies supporting this approach are missing. There is a lack of prospective studies on younger patients. A majority of the studies are retrospective, have a low sample size and are not conducted on western population. Moreover, the national registers as well as most previously published studies on
https://doi.org/10.1016/j.injury.2017.10.028 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
2
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
younger patients with femoral neck fracture focus on re-operation rates [1,5–7]. Studies analysing functional outcome and health related quality of life (HRQoL) after a femoral neck fracture in younger patients are needed [8]. The aim of this study was to investigate functional outcome, HRQoL and fracture healing complications in patients aged 20–69 with a femoral neck fracture treated with internal fixation. Materials and methods This was a prospective multicenter study with a 24 months follow-up. Patients aged 20-69 with a femoral neck fracture admitted to any of the four university hospitals in Stockholm, Sweden during a period of 3.5 years were included. Patients living independently and who were able to walk before the fracture were included in the study. Patients with psychotic disease or severe cognitive impairment according to Short Portable Mental Status Questionnaire (SPMSQ <3) [9] were excluded. Subjects with risk factors for secondary osteoporosis (chronic renal failure and hyperparathyroidism) and those with simultaneous fracture of the lower extremity were excluded. Similarly, a fracture older than 48 h before admission and patients with previous pathology in the fractured hip were not included in the study. At inclusion All assessments, except the American Society of Anaesthesiologists (ASA) classification [10] and fracture classifications were carried out by specially trained research nurses. The following variables were recorded at inclusion: age, gender, pre-fracture living conditions, walking ability, alcohol consumption, current smoking, ASA score, fracture type and mechanism of injury. Living conditions were registered as independent (i.e. own home or block of serviced flats) or as institutionalized. Walking ability was recorded as walking outdoors, walking indoors or unable to walk. Use of walking aids was recorded.
The mechanism of injury was classified as low-energy trauma (fall at the same level), sport injury (mainly cycling or ice skating) and high-energy trauma (traffic accident, riding accident and fall from a height). Alcohol consumption was evaluated with Alcohol Use Disorder Identification Test (AUDIT), which is a validated instrument that identifies hazardous and harmful alcohol use, as well as possible dependence [11]. Current smokers were coded as smokers. The ASA score was assessed by the attending anaesthesiologist. The ASA score [10] describes the physical status of the patients and classifies them according to 6 scores (ASA 1–6). The health-related quality of life was rated using the EQ-5D [12] and SF-36 [13]. In order to acquire baseline values of EQ-5D and SF36, patients were asked to report their pre-fracture quality of life from the week before the fracture. 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. [14] 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. SF-36 is a questionnaire used to measure HRQoL originally developed by RAND corporation [13]. It contains 36 items on 8 different domain scales. The scales are; physical functioning (PF), role-physical (RF), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE) and mental health (MH). By adding the scores from the first 4 scales and dividing by 4 a SF-36 physical score is calculated with a range of 0–100. The mental score is calculated in a similar fashion, by adding the scores from the last 4 scales and dividing by 4. The total score is calculated by adding the 8 scales and diving by 8. The changed score between baseline and 24-month follow up was compared to minimally important difference (MID) to evaluate whether the change was of
Fig. 1. X-ray showing the position of the screws. It was considered as good when the distal screw was introduced at the level of the lesser trochanter (A) and positioned on the inferior calcar (B). The proximal one should be parallel and at least 2 cm away from the distal one (<10 ) (C). Both screw tips should be less than 5 mm from the subchondral bone (D). On the lateral projection the screws should be parallel and lie on the central or posterior third of the femoral head and neck (E). The Garden angle is the angle formed between the shaft of the femur (F) and medial trabeculae in the neck-head of the femur (G).The reduction was categorised depending on degree of fracture displacement (H), Garden angle 16-0175 and posterior head angulation (I).
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
clinical significance. The MID was previously calculated as 8.2 for SF-36 total score [15]. All radiographs were assessed in consensus by 3 orthopaedic surgeons who are well experienced in hip fracture surgery. The femoral neck fracture was classified into non-displaced (Garden 1– 2) and displaced (Garden 3–4) [16]. All patients were operated with closed reduction and fixation with two cannulated screws (Olmed1). Surgery was performed by both consultants and residents. Fracture reduction was carried out by closed methods with the aid of image intensifier and patients on extension table and fixed with two cannulated screws (Olmed 1). The reduction was categorised into good (displacement <2 mm, Garden angle 160–175 , posterior angulation <10 ), fair (displacement 2-5 mm, Garden angle 160-175 , posterior angulation <20 ) or poor (displacement >5 mm Garden angle <160 or >175 , posterior angulation >20 ) (Fig. 1). The Garden angle is the angle formed between the shaft of the femur and medial trabeculae in the neck-head of the femur on the frontal view [16] (Fig. 1). The screw position was considered good when the distal screw was introduced at the level of the lesser trochanter and positioned on the inferior femoral calcar. The proximal screw should be placed parallel and at least 2 cm apart from the distal one (< 10 ) with both screw tips less than 5 mm from the subchondral bone. On the lateral projection the screws should be parallel and lie on the central or posterior third of the femoral head and neck. If one or more of these criteria were not fulfilled the position was considered not good [17] (Fig. 1).
3
Statistical analysis Statistical calculations were performed using SPSS version 22 for Windows (IBM, SPSS Statistics). Mean, standard deviation, median, range and percentage were used for descriptive purposes. Normally distributed independent variables were tested for differences with Student’s t test. Contingency tables were tested for differences with Pearson’s chi-square test. Exact methods were utilized wherever needed. In all analyses, a p value of less than 0.05 was considered statistically significant. Results There were 182 patients included with a median age of 59 years (range 20–69, 47% male). Demographic and baseline data are presented in Table 1. At 24-month data was available for 170 patients, (120 patients with displaced fracture and 50 patients with non-displaced fracture). Seven patients were deceased and 5 patients were not able to attend at last follow-up. Background data on these patients was previously published [15,22]. As for patients with displaced fractures, the quality of reduction was considered good in 80% (n = 101), fair or poor in 20% (n = 26). In one patient the post-operative radiographic examinations were missing. The screw position was considered good in 76% (n = 97) and not good in 24% (n = 30). In those with non-displaced fractures the position of the screws was good in 85% (n = 46) and not good in 15% (n = 8).
Follow up An orthopaedic surgeon performed the follow-ups during regular outpatient’s visits including radiographic and clinical examinations, recording of complications and evaluation of hip function as well as EQ-5D and SF-36 at 4, 12 and 24 months. Fractures were considered healed if x-ray showed trabecular bone across the fracture line. Fractures which re-displaced at 4month follow-up or showed absence of visible trabecular bone across the fracture line at 12- or 24-month follow-up were both considered non-union (NU). Only patients that were re-operated with arthroplasty were considered to be NU. Fractures healed with any position were not regarded as NU. Avascular necrosis (AVN) was defined as segmental collapse, loss of sphere of the femoral head or subchondral fracture [18]. Re-operations were registered and the reasons were categorised as NU, AVN, deep wound infection and new fracture near the implant. Extraction of the screws was recorded as a minor re-operation. General complications and mortality were recorded at each follow-up. The hip function was evaluated using Harris Hip Score (HHS) [19] at 4, 12 and 24 months. HHS is a validated instrument that evaluates pain, function, range of motion and deformity of the hip. It has a scale of 100 points in which pain constitutes 44 points. No pain gives a value of 44 and severe pain at rest gives a value of 0. Function has a maximum level of 43 points and includes evaluation of daily activities and walking ability. Absence of deformities gives 4 points and maximum range of motions gives 5 points. Harris Hip Score has 3 categories: excellent if >80, good between 70 and 80 and poor if <70 points. All patients were treated according to the protocols at the participating hospitals and the study was conducted according to the Helsinki Declaration [20]. The protocols were approved by the local Ethics Committee (Dnr. 01-427). Reporting of the study conforms to STROBE guidelines [21].
Table 1 Baseline data for all patients younger than 70 years with a femoral feck fracture (n = 182) divided by fracture type. Values are expressed as mean +/ SD for age and BMI, and N (%) for other variables. All patients
Non-displaced
Displaced
N = 182
N = 54
N = 128
57 8 24 4 N (%)
57 8 23 3 N (%)
58 9 25 4 N (%)
0.39* 0.008*
Gender n (%) Women Men
97 (53) 85 (47)
35 (65) 19 (35)
62 (48) 66 (52)
0.043x
ASA scoreb n (%) 1 2 3 4
67 (37) 81 (44) 30 (17) 4 (2)
22 (41) 25 (46) 6 (11) 1 (2)
45 (35) 56 (44) 24 (19) 3 (2)
0.66x
Alcohol AUDITc n (%) High Low
41 (23) 137 (77)
7 (13) 46 (87)
34 (27) 91 (73)
0.043x
Smoking
72 (40)
20 (37)
52 (41)
0.651x
Trauma mechanism Low-energy trauma Sport injury High-energy trauma
137 (75) 31 (17) 14 (8)
39 (72) 9 (17) 6 (11)
98 (77) 22 (17) 8 (6)
0.56x
Age mean SD BMIa mean SD, kg/m2
P-value
ASA: American Society of Anaesthesiologists classification; BMI: Body Mass Index; AUDIT: Alcohol Use Disorders Identification Test. a missing = 1. b missing = 5. c missing = 4. * = P-value for difference in mean using Student’s T-test. x = P-value for difference in chi-square distribution across groups using Pearson’s chi-square test.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
4
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Fig. 2. Chart showing number of patients at initiation of the study, and at each follow-up (4, 12 and 24 months) with summary of the results in terms of nonunion, avascular necrosis, deep wound infection, nearby fracture, and re-operation.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx Table 2 Postoperative hip function in patients younger than 70 years with a femoral neck fracture evaluated with Harris Hip Score (0–100). All
Non-displaced
Displaced
N (%)
N (%)
N (%)
4 monthsa Poor function <70 Good function 70–80 Excellent function >80
70 (41) 23 (14) 77 (45)
13 (25) 5 (10) 34 (65)
57 (48) 18 (15) 43 (37)
0.002*
12 monthsb Poor function <70 Good function 70–80 Excellent function >80
45 (27) 16 (10) 103 (63)
10 (21) 0 38 (79)
35 (30) 16 (14) 65 (56)
0.005*
24 monthsc Poor function <70 Good function 70–80 Excellent function >80
38 (24) 15 (9) 109 (67)
7 (15) 3 (6) 37 (79)
31 (27) 12 (10) 72 (63)
0.156*
P-value
Missing: an = 12, bn = 18, cn = 20. * = P-value for difference in chi-square distribution across groups using Pearson’s chi-square test.
Fracture healing complications The distribution of fracture healing complications and reoperations by type of fracture (displaced or non-displaced) is shown in Fig. 2.
5
In patients with displaced fracture, 23% had a NU and 15% AVN at 24-month follow-up. The re-operation rate was 28%, including all patients with NU and seven patients with AVN. Four patients were treated for a deep wound infection and were re-operated with Girdlestone resection arthroplasty (two of them were later reoperated with THR). One patient needed re-operation due to a new nearby fracture. A subgroup analysis of the patients with displaced fracture according to different age categories showed that 11% of the patients <50 years of age (2/19), 34% of the patients 50–59 years of age (13/39) and 31% (19/62) of the patients 60–69 years of age with a displaced femoral neck fracture had a re-operation with hip replacement because of AVN or NU, (p = 0.16). Of the patients with a non-displaced fracture at 24-month follow-up none had a NU and 12% had AVN. Four of the patients with AVN had pain that required re-operation with a THR. Functional outcome Harris Hip Score at each follow up is shown in Table 2. The analysis includes those with and without re-operation. The functional outcome favoured patients with non-displaced fracture at four- and twelve-month follow-ups; however, this levelled out at the final follow-up (Table 2). Patients with displaced fracture that healed after the index operation had good or excellent functional outcome at 24-month
Fig. 3. EQ-5D Index score before fracture and at each follow-up.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
6
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Fig. 4. SF-36 score before fracture and at each follow-up.
follow-up in 80% (n = 65/81) of cases, compared to 57% (n = 20/35) in those who required re-operation (p = 0.01). Health-related quality of life The HRQoL decreased for all patients (Fig. 3). The mean EQ5Dindex for patients with displaced fracture decreased from 0.81 (SD 0.27) to 0.59 (SD 0.26) at 4 months (p < 0.001), 0.63 (SD 0.29) at 12 months (p < 0.001) and 0.65 (SD 0.29) at 24 months (p < 0.001). The mean EQ-5Dindex in patients with non-displaced fracture decreased from 0.88 (SD 0.18) to 0.69 (SD 0.28) at 4 months (p < 0.001), 0.75 (SD 0.25) at 12 months (p < 0.001) and 0.74 (SD 0.28) at 24 months (p < 0.001). There was no statistically significant difference in HRQoL (EQ5Dindex) for patients with non-displaced fracture compared to patients with displaced fracture at each follow-up (data not shown). The HRQoL (EQ-5Dindex) in patients with displaced fracture that healed after one operation compared to those who required reoperation is shown in Fig. 3. Both patient groups showed a noticeable decrease in health-related quality of life at four-month and did not reach their pre-fracture level at final follow-up.
The mean SF-total score in patients with displaced fracture decreased from 76 (SD 20) to 55 (SD 23) at 4 months, 63 (SD 22) at 12 months and 65 (SD 23) at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80 (SD 26), 67 (SD 23), 74 (SD 25) and 76 (SD 23) respectively (p < 0.001). Average SF-36 physical and mental scores at baseline and at each follow-up are presented in Fig. 4. The figure shows that mental scores recovered to a greater extent compared to physical scores for all patients’ regardless of the type of femoral neck fracture. Mean SF-36 subscales at baseline and at final follow-up are shown in Table 3 and Fig. 5. In patients with non-displaced fractures the changes were significant in PF, BP, GH, VT, MH. The difference in PF and BP was 10 and 14 respectively (Table 3) which is higher than MID. On the opposite, in patients with displaced fracture the difference in all sub-scales between baseline and final follow-up were significant and higher than MID with the exception of MH and GH subscales were the differences were below MID (Table 3). Further, both patients with and without re-operation reported significantly lower values in numerous SF-36 subscales at 24 months, particularly in PF, RP, BP and RE (Table 3 and Fig. 5).
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
7
Table 3 SF-36 subscales at baseline and at 24-month follow up with change score. All values presented as mean (SD). NonDisplaced Displaced fracture displaced
Physical functioning (PF) - Before fracture
No major reoperation
With major reoperations
n = 45
n = 113
n = 79
n = 34
85 (23)
75 (29)
78 (29)
68 (31)
- 24-month
71 (31)
58 (31)
64 (30)
44 (29)
- change score
14 (23)
17 (28)
14 (22)
24 (38)
- P-value
<0.001
<0.001
<0.001
0.001
83 (34)
75 (37)
80 (34)
62 (43)
- 24-month
76 (37)
57 (44)
64 (42)
38 (43)
- change score
7 (42)
18 (42)
16 (40)
24 (48)
- P-value
0.2
<0.001
<0.001
0.008
87 (25)
80 (26)
84 (22)
72 (31)
- 24-month
77 (27)
65 (32)
70 (29)
56 (37)
- change score
10 (27)
15 (30)
14 (24)
16 (41)
- P-value
0.008
<0.001
<0.001
0.025
77 (20)
72 (23)
77 (20)
62 (27)
- 24-month
71 (24)
66 (24)
70 (23)
57 (24)
- change score
6 (18)
6 (21)
7 (18)
5 (25)
- P-value
0.04
0.001
0.002
0.2
76 (24)
71 (25)
76 (21)
60 (29)
- 24-month
68 (29)
62 (29)
67 (27)
50 (30)
- change score
8 (23)
9 (26)
9 (23)
10 (31)
- P-value
0.03
<0.001
0.002
0.09
89 (24)
85 (23)
90 (18)
75 (28)
- 24-month
86 (23)
75 (30)
80 (28)
62 (32)
- change score
3 (24)
10 (27)
10 (24)
13 (31)
- P-value
0.4
<0.001
0.001
0.023
83 (31)
80 (36)
87 (29)
64 (45)
- 24-month
74 (42)
65 (44)
74 (41)
44 (46)
- change score
9 (43)
15 (46)
13 (41)
20 (57)
- P-value
0.17
0.001
0.001
0.06
85 (20) 79 (24)
80 (20) 75 (27)
83 (19) 80 (24)
73 (23) 64 (30)
6 (18)
5 (24)
3 (23)
9 (28)
Role physical (RP) - Before fracture
Bodily Pain (BP) - Before fracture
General Health (GH) - Before fracture
Vitality (VT) - Before fracture
Social functioning (SF) - Before fracture
Role emotional (RE) - Before fracture
Mental health (MH) Before fracture - 24-month - Change score
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
8
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Table 3 (Continued) NonDisplaced Displaced fracture displaced
- P-value
Mortality and general complications Two patients had pneumonia, three patients had heart failure and 11 patients were treated for urinary tract infections. Seven patients were dead at 24-month follow-up (4%). Discussion This study showed that two-thirds of the patients with displaced fracture healed after one operation and three-quarters had good or excellent functional outcome after two years. As for patients with non-displaced fracture:- all healed after one surgery and eight percent needed reoperation due to AVN. The study further showed that patients did not regain their pre-fracture level of HRQol regardless of the type of femoral neck fracture. Furthermore, in patients with displaced fracture, no difference in re-operation rate was found between patients in the age group 50–59 and 60–69 (34% and 31% respectively). Thus, one cannot tell if the age limit for treating patients with displaced femoral neck fracture with a THR should be lowered and if so to 60 or 50 years of age. This indicates that chronological age may not be reliable when deciding treatment modality, which contradicts the ongoing trend to treat patients with a displaced femoral neck fracture in the age range of 60–69 years with a total hip replacement (THR) [2–4]. It could therefore be of interest to find risk factors other than age that are associated with increased risk for re-operation due to AVN and NU. As for patients under 50 years, further studies are needed to find the optimal surgical method in order to reduce the risk for complications related to the fracture healing [23]. All patients in our study with NU required re-operation. By contrast, only 46% (11/24) of those with AVN had symptoms that required re-operation at 24-month follow-up. A previous study made by Haidukewych et al. [5] found that half of the patients that developed AVN showed symptoms and required re-operation, which is in accordance with our results. Furthermore, Jain et al. [24] found that AVN did not affect functional outcome in younger patients with femoral neck fracture. A meta-analysis conducted by Damany et al. [1] reported that the incidence of NU was 9% and for AVN 23% in patients <50 years of age, with displaced femoral neck fracture, which is similar to our findings. However, the reported incidence of NU in younger patients varies between 0 and 59% [1,5–7,25,26]. This may be explained by several factors, such as different definitions of NU. Early complications are in some studies considered re-displacement, if it occurs 4–6 months after surgery it is instead regarded as NU [6,27]. In the present study, NU was defined as absence of healing regardless of whether it occurs before or after 4 months. Concerning type of re-operation, there is an agreement that patients over 60 years of age, who are symptomatic due to fracture healing complication, are re-operated with an arthroplasty. Younger patients are instead treated with more hip preserving methods. However, further studies are needed and the choice of the treatment modality must be decided on an individual basis and
No major reoperation
With major reoperations
n = 45
n = 113
n = 79
n = 34
0.02
0.001
0.25
0.054
discussed with the patient to achieve the most successful outcome [28]. The functional outcome in younger patients with femoral neck fracture is not well studied. In the present study, a higher proportion of patients with non-displaced fracture had a good or excellent functional outcome at four- and twelve- months follow-up compared to those with displaced fracture according to HHS. However, this statistically significant difference had disappeared at the final follow-up at 24 months. This could be explained by the fact that the majority of the patients with fracture healing complication were re-operated with hip replacement and had recovered at the time of final follow-up. However, those patients who required reoperations had inferior outcome at 24-month follow-up. These results indicate that further studies are required to find risk factors associated with fracture healing complications and re-operation in this age group. A similar decrease in functional outcome among elderly patients with fracture healing complications has been reported by Tidermark et al. [29] with a mean follow-up of 17 months. EuroQoL, as a health related quality-of-life instrument, judges favourably in terms of internal and external validity being only slightly less sensitive than SF-36 [15]. EuroQol has also been validated in elderly patients with femoral neck fracture as a reliable outcome measurement in clinical trials [30–34]. Previous studies on elderly patients have shown that those with a healed non-displaced fracture regained their pre-fracture quality of life level while patients with a healed displaced fracture did not [30]. On the contrary, this study showed that younger patients with either of the fracture types did not regain their pre-fracture level of HRQoL. One could assume that younger patients have higher functional demands and a slight functional impairment might influence their health related quality of life. A previous study suggested that a mean effect size of 0.15 is considered to be MID for EQ-5D [34]. Our study showed that patients with a displaced fracture requiring re-operation had a similar decrease of HRQoL at 4 months, with minimal improvement until 24-month follow-up compared to those with fractures that healed after a single operation. SF-36 showed similar results, the group with non-displaced as well as displaced fractures had a loss in both physical and mental scores two years after surgery. Zidén et al. [35] reported similarly “a social and existential crack” in elderly patients after a hip fracture. To our knowledge this has not been shown in younger patients and should therefore be further investigated. Consequently, one could theorize that special rehabilitation program for younger patients are required. The strengths of this study were the prospective multicentre design and the long follow-up, including clinical, radiological and functional outcomes. Another strength was the low dropout rate. One limitation of the study was the low number of patients < 50 years of age, as the incidence of femoral neck fracture in this group is low. Highly posteriorly angulated Garden I–II fractures could behave as displaced fracture but were not allocated to the displaced fracture group, and that this may represent a weakness
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
9
Fig. 5. Spider diagram showing mean SF-36 subscores before fracture and at 24-months follow-up.
of the study. However, we did not use posterior angulation on the axial view to allocate fracture as displaced or non-displaced as this is not stated in the original criterion of displacement [16]. Further, patients with severe cognitive impairment, multiple fractures, chronic renal failure or hyperparathyroidism and patients unable to walk or living in institutions were not included, which limits the generalizability of our results.
In conclusion, this study has shown that two-thirds of the patients with displaced femoral neck fracture healed after one operation and three-quarters had good or excellent functional outcome. In patients with non-displaced fracture only eight percent were re-operated due to AVN. The study further showed that patients did not regained their pre-fracture level of HRQol irrespective of fracture type. The study suggests that internal
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
fixation for femoral neck fracture in patients <70 years of age may still be recommended for the majority of these patients. Yet, further studies are needed to identify patients at risk of NU and AVN.
[16] [17]
Conflict of interest [18]
No competing interests declared. Funding Supported by grants provided by the Stockholm County Council (ALF project). The funding source did not play any role in the running of the study. References [1] Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults: a meta-analysis of 18 published studies involving 564 fractures. Injury 2005;36:131–41. [2] Rikshöft. The Swedish National Hip Fracture Registry. Rikshöft; 2017. . (Last Accessed May 2017) http://wwwrikshoftse/se/indexphp. [3] Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database. J Bone Joint Surg Am 2014;96:e149. [4] Lee YK, Ha YC, Park C, Koo KH. Trends of surgical treatment in femoral neck fracture: a nationwide study based on claim registry. J Arthroplasty 2013;28:1839–41. [5] Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;(86-A):1711–6. [6] Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res 1995;238–46. [7] Swiontkowski MF, Winquist RA, Hansen Jr. ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984;66:837–46. [8] Sprague S, Slobogean GP, Scott T, Chahal M, Bhandari M. Young femoral neck fractures: are we measuring outcomes that matter. Injury 2015;46:507–14. [9] 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. [10] American Society of Anesthesiologists. ASA physical status classification system. 2017. . (last accessed July 2017) https://www.asahq.org/resources/ clinical-information/asa-physical-status-classification-system. [11] Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol Consumption–II. Addiction 1993;88:791–804. [12] Brooks R. EuroQol: the current state of play. Health Policy 1996;37:53–72. [13] Sullivan MKJ, Taft C, Ware JE. SF-36 health survey: Swedish manual and interpretation guide. Gothenburg: Sahlgrenska University Hospital; 2002. [14] 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. [15] Honkavaara N, Al-Ani A, Campenfeldt P, Ekström W, Hedström M. Good responsiveness with EuroQol 5-dimension questionnaire and short form (36)
[19]
[20] [21]
[22]
[23] [24]
[25] [26] [27]
[28]
[29]
[30]
[31]
[32]
[33] [34]
[35]
health survey in 20–69 years old patients with a femoral neck fracture. A 2year prospective follow-up study in 182 patients. Injury 2016 injury.2016.05.021. Garden R. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br) 1961;43:647. Lindequist S, Tornkvist H. Quality of reduction and cortical screw support in femoral neck fractures: an analysis of 72 fractures with a new computerized measuring method. J Orthop Trauma 1995;9:215–21. DeSmet AA, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, el-Khoury GY, et al. Diagnostic imaging of avascular necrosis of the hip. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215(Suppl):247–54. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737–55. World Medical Association. Helsinki Declaration 1964. 2017. . Last Accessed May 2017 http.//http://www.wma.net/e/policy/b3.htm. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the reporting of observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495–9. Al-Ani AN, Neander G, Samuelsson B, Blomfeldt R, Ekstrom W, Hedstrom M. Risk factors for osteoporosis are common in young and middle-aged patients with femoral neck fractures regardless of trauma mechanism. Acta Orthop 2013;84:54–9. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury 2015;46:484–91. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am 2002;(84-A):1605–12. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am 2008;90:2254–66. Slobogean GP, Sprague SA, Scott T, McKee M, Bhandari M. Management of young femoral neck fractures: is there a consensus. Injury 2015;46:435–40. Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br 2011;93:811–6. Hoskinson S, Morison Z, Shahrokhi S, Schemitsch EH. Managing AVN following internal fixation: treatment options and clinical results. Injury 2015;46:497– 506. Tidermark J, Zethraeus N, Svensson O, Tornkvist H, Ponzer S. Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 2002;11:473–81. Tidermark J, Zethraeus N, Svensson O, Tornkvist H, Ponzer S. 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. Tidermark J, Bergstrom G, Svensson O, Tornkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12:1069–79. Frihagen F, Grotle M, Madsen JE, Wyller TB, Mowinckel P, Nordsletten L. Outcome after femoral neck fractures: a comparison of Harris Hip score, Eq-5d and Barthel index. Injury 2008;39:1147–56. Parsons N, Griffin XL, Achten J, Costa ML. Outcome assessment after hip fracture: is EQ-5D the answer. Bone Joint Res 2014;3:69–75. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res 2005;14:1523–32. Ziden L, Wenestam CG, Hansson-Scherman M. A life-breaking event: early experiences of the consequences of a hip fracture for elderly people. Clin Rehabil 2008;22:801–11.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Full length article
Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation A prospective 2-year follow-up study of 182 patients Pierre Campenfeldta,b , Margareta Hedströma,c , Wilhelmina Ekströmd , Amer N. Al-Ania,e,* a
Karolinska Institutet, Department of Clinical Science, Intervention and Technology (CLINTEC), Stockholm Sweden Norrtälje Hospital, TioHundra AB. Box 905, 761 29 Norrtälje, Sweden Department of Orthopaedics, Karolinska University Hospital, Huddinge, Stockholm, Sweden d Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Department of Orthopaedics Karolinska University Hospital Solna, Stockholm, Sweden e Orthopaedic Clinic, Vällingby-Läkarhuset, Praktikertjänst AB, 16268 Vällingby, Sweden b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 June 2016 Received in revised form 7 October 2017 Accepted 16 October 2017
Background and purpose: Prospective studies on patient related outcome in patients <70 years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation. Patients and methods: 182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations. Results: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p < 0.001). Interpretation: Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Femoral neck fracture Young Functional outcome Fracture healing HRQoL
Introduction Femoral neck fractures in younger patients are uncommon but may result in lifetime disability. The recommended treatment for patients <70 years with a femoral neck fracture is anatomic fracture reduction and internal fixation regardless of the degree of displacement [1]. The rationale behind this recommendation is the desire to preserve the native hip joint, which may facilitate the
* Corresponding author at: SE – 162 68 Vällingby, Sweden. E-mail addresses: [email protected], [email protected] (A.N. Al-Ani).
patients’ future functional demand. Furthermore, the longer life expectancy in these patients might increase the risk of surgical revisions if treated with a hip arthroplasty. However, there is currently a growing trend in Sweden to treat patients with a displaced femoral neck fracture in the age range of 60–69 years with a total hip replacement (THR) [2]. A similar trend has been reported in the USA and in other countries [3,4], yet, studies supporting this approach are missing. There is a lack of prospective studies on younger patients. A majority of the studies are retrospective, have a low sample size and are not conducted on western population. Moreover, the national registers as well as most previously published studies on
https://doi.org/10.1016/j.injury.2017.10.028 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
2
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
younger patients with femoral neck fracture focus on re-operation rates [1,5–7]. Studies analysing functional outcome and health related quality of life (HRQoL) after a femoral neck fracture in younger patients are needed [8]. The aim of this study was to investigate functional outcome, HRQoL and fracture healing complications in patients aged 20–69 with a femoral neck fracture treated with internal fixation. Materials and methods This was a prospective multicenter study with a 24 months follow-up. Patients aged 20-69 with a femoral neck fracture admitted to any of the four university hospitals in Stockholm, Sweden during a period of 3.5 years were included. Patients living independently and who were able to walk before the fracture were included in the study. Patients with psychotic disease or severe cognitive impairment according to Short Portable Mental Status Questionnaire (SPMSQ <3) [9] were excluded. Subjects with risk factors for secondary osteoporosis (chronic renal failure and hyperparathyroidism) and those with simultaneous fracture of the lower extremity were excluded. Similarly, a fracture older than 48 h before admission and patients with previous pathology in the fractured hip were not included in the study. At inclusion All assessments, except the American Society of Anaesthesiologists (ASA) classification [10] and fracture classifications were carried out by specially trained research nurses. The following variables were recorded at inclusion: age, gender, pre-fracture living conditions, walking ability, alcohol consumption, current smoking, ASA score, fracture type and mechanism of injury. Living conditions were registered as independent (i.e. own home or block of serviced flats) or as institutionalized. Walking ability was recorded as walking outdoors, walking indoors or unable to walk. Use of walking aids was recorded.
The mechanism of injury was classified as low-energy trauma (fall at the same level), sport injury (mainly cycling or ice skating) and high-energy trauma (traffic accident, riding accident and fall from a height). Alcohol consumption was evaluated with Alcohol Use Disorder Identification Test (AUDIT), which is a validated instrument that identifies hazardous and harmful alcohol use, as well as possible dependence [11]. Current smokers were coded as smokers. The ASA score was assessed by the attending anaesthesiologist. The ASA score [10] describes the physical status of the patients and classifies them according to 6 scores (ASA 1–6). The health-related quality of life was rated using the EQ-5D [12] and SF-36 [13]. In order to acquire baseline values of EQ-5D and SF36, patients were asked to report their pre-fracture quality of life from the week before the fracture. 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. [14] 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. SF-36 is a questionnaire used to measure HRQoL originally developed by RAND corporation [13]. It contains 36 items on 8 different domain scales. The scales are; physical functioning (PF), role-physical (RF), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE) and mental health (MH). By adding the scores from the first 4 scales and dividing by 4 a SF-36 physical score is calculated with a range of 0–100. The mental score is calculated in a similar fashion, by adding the scores from the last 4 scales and dividing by 4. The total score is calculated by adding the 8 scales and diving by 8. The changed score between baseline and 24-month follow up was compared to minimally important difference (MID) to evaluate whether the change was of
Fig. 1. X-ray showing the position of the screws. It was considered as good when the distal screw was introduced at the level of the lesser trochanter (A) and positioned on the inferior calcar (B). The proximal one should be parallel and at least 2 cm away from the distal one (<10 ) (C). Both screw tips should be less than 5 mm from the subchondral bone (D). On the lateral projection the screws should be parallel and lie on the central or posterior third of the femoral head and neck (E). The Garden angle is the angle formed between the shaft of the femur (F) and medial trabeculae in the neck-head of the femur (G).The reduction was categorised depending on degree of fracture displacement (H), Garden angle 16-0175 and posterior head angulation (I).
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
clinical significance. The MID was previously calculated as 8.2 for SF-36 total score [15]. All radiographs were assessed in consensus by 3 orthopaedic surgeons who are well experienced in hip fracture surgery. The femoral neck fracture was classified into non-displaced (Garden 1– 2) and displaced (Garden 3–4) [16]. All patients were operated with closed reduction and fixation with two cannulated screws (Olmed1). Surgery was performed by both consultants and residents. Fracture reduction was carried out by closed methods with the aid of image intensifier and patients on extension table and fixed with two cannulated screws (Olmed 1). The reduction was categorised into good (displacement <2 mm, Garden angle 160–175 , posterior angulation <10 ), fair (displacement 2-5 mm, Garden angle 160-175 , posterior angulation <20 ) or poor (displacement >5 mm Garden angle <160 or >175 , posterior angulation >20 ) (Fig. 1). The Garden angle is the angle formed between the shaft of the femur and medial trabeculae in the neck-head of the femur on the frontal view [16] (Fig. 1). The screw position was considered good when the distal screw was introduced at the level of the lesser trochanter and positioned on the inferior femoral calcar. The proximal screw should be placed parallel and at least 2 cm apart from the distal one (< 10 ) with both screw tips less than 5 mm from the subchondral bone. On the lateral projection the screws should be parallel and lie on the central or posterior third of the femoral head and neck. If one or more of these criteria were not fulfilled the position was considered not good [17] (Fig. 1).
3
Statistical analysis Statistical calculations were performed using SPSS version 22 for Windows (IBM, SPSS Statistics). Mean, standard deviation, median, range and percentage were used for descriptive purposes. Normally distributed independent variables were tested for differences with Student’s t test. Contingency tables were tested for differences with Pearson’s chi-square test. Exact methods were utilized wherever needed. In all analyses, a p value of less than 0.05 was considered statistically significant. Results There were 182 patients included with a median age of 59 years (range 20–69, 47% male). Demographic and baseline data are presented in Table 1. At 24-month data was available for 170 patients, (120 patients with displaced fracture and 50 patients with non-displaced fracture). Seven patients were deceased and 5 patients were not able to attend at last follow-up. Background data on these patients was previously published [15,22]. As for patients with displaced fractures, the quality of reduction was considered good in 80% (n = 101), fair or poor in 20% (n = 26). In one patient the post-operative radiographic examinations were missing. The screw position was considered good in 76% (n = 97) and not good in 24% (n = 30). In those with non-displaced fractures the position of the screws was good in 85% (n = 46) and not good in 15% (n = 8).
Follow up An orthopaedic surgeon performed the follow-ups during regular outpatient’s visits including radiographic and clinical examinations, recording of complications and evaluation of hip function as well as EQ-5D and SF-36 at 4, 12 and 24 months. Fractures were considered healed if x-ray showed trabecular bone across the fracture line. Fractures which re-displaced at 4month follow-up or showed absence of visible trabecular bone across the fracture line at 12- or 24-month follow-up were both considered non-union (NU). Only patients that were re-operated with arthroplasty were considered to be NU. Fractures healed with any position were not regarded as NU. Avascular necrosis (AVN) was defined as segmental collapse, loss of sphere of the femoral head or subchondral fracture [18]. Re-operations were registered and the reasons were categorised as NU, AVN, deep wound infection and new fracture near the implant. Extraction of the screws was recorded as a minor re-operation. General complications and mortality were recorded at each follow-up. The hip function was evaluated using Harris Hip Score (HHS) [19] at 4, 12 and 24 months. HHS is a validated instrument that evaluates pain, function, range of motion and deformity of the hip. It has a scale of 100 points in which pain constitutes 44 points. No pain gives a value of 44 and severe pain at rest gives a value of 0. Function has a maximum level of 43 points and includes evaluation of daily activities and walking ability. Absence of deformities gives 4 points and maximum range of motions gives 5 points. Harris Hip Score has 3 categories: excellent if >80, good between 70 and 80 and poor if <70 points. All patients were treated according to the protocols at the participating hospitals and the study was conducted according to the Helsinki Declaration [20]. The protocols were approved by the local Ethics Committee (Dnr. 01-427). Reporting of the study conforms to STROBE guidelines [21].
Table 1 Baseline data for all patients younger than 70 years with a femoral feck fracture (n = 182) divided by fracture type. Values are expressed as mean +/ SD for age and BMI, and N (%) for other variables. All patients
Non-displaced
Displaced
N = 182
N = 54
N = 128
57 8 24 4 N (%)
57 8 23 3 N (%)
58 9 25 4 N (%)
0.39* 0.008*
Gender n (%) Women Men
97 (53) 85 (47)
35 (65) 19 (35)
62 (48) 66 (52)
0.043x
ASA scoreb n (%) 1 2 3 4
67 (37) 81 (44) 30 (17) 4 (2)
22 (41) 25 (46) 6 (11) 1 (2)
45 (35) 56 (44) 24 (19) 3 (2)
0.66x
Alcohol AUDITc n (%) High Low
41 (23) 137 (77)
7 (13) 46 (87)
34 (27) 91 (73)
0.043x
Smoking
72 (40)
20 (37)
52 (41)
0.651x
Trauma mechanism Low-energy trauma Sport injury High-energy trauma
137 (75) 31 (17) 14 (8)
39 (72) 9 (17) 6 (11)
98 (77) 22 (17) 8 (6)
0.56x
Age mean SD BMIa mean SD, kg/m2
P-value
ASA: American Society of Anaesthesiologists classification; BMI: Body Mass Index; AUDIT: Alcohol Use Disorders Identification Test. a missing = 1. b missing = 5. c missing = 4. * = P-value for difference in mean using Student’s T-test. x = P-value for difference in chi-square distribution across groups using Pearson’s chi-square test.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
4
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Fig. 2. Chart showing number of patients at initiation of the study, and at each follow-up (4, 12 and 24 months) with summary of the results in terms of nonunion, avascular necrosis, deep wound infection, nearby fracture, and re-operation.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx Table 2 Postoperative hip function in patients younger than 70 years with a femoral neck fracture evaluated with Harris Hip Score (0–100). All
Non-displaced
Displaced
N (%)
N (%)
N (%)
4 monthsa Poor function <70 Good function 70–80 Excellent function >80
70 (41) 23 (14) 77 (45)
13 (25) 5 (10) 34 (65)
57 (48) 18 (15) 43 (37)
0.002*
12 monthsb Poor function <70 Good function 70–80 Excellent function >80
45 (27) 16 (10) 103 (63)
10 (21) 0 38 (79)
35 (30) 16 (14) 65 (56)
0.005*
24 monthsc Poor function <70 Good function 70–80 Excellent function >80
38 (24) 15 (9) 109 (67)
7 (15) 3 (6) 37 (79)
31 (27) 12 (10) 72 (63)
0.156*
P-value
Missing: an = 12, bn = 18, cn = 20. * = P-value for difference in chi-square distribution across groups using Pearson’s chi-square test.
Fracture healing complications The distribution of fracture healing complications and reoperations by type of fracture (displaced or non-displaced) is shown in Fig. 2.
5
In patients with displaced fracture, 23% had a NU and 15% AVN at 24-month follow-up. The re-operation rate was 28%, including all patients with NU and seven patients with AVN. Four patients were treated for a deep wound infection and were re-operated with Girdlestone resection arthroplasty (two of them were later reoperated with THR). One patient needed re-operation due to a new nearby fracture. A subgroup analysis of the patients with displaced fracture according to different age categories showed that 11% of the patients <50 years of age (2/19), 34% of the patients 50–59 years of age (13/39) and 31% (19/62) of the patients 60–69 years of age with a displaced femoral neck fracture had a re-operation with hip replacement because of AVN or NU, (p = 0.16). Of the patients with a non-displaced fracture at 24-month follow-up none had a NU and 12% had AVN. Four of the patients with AVN had pain that required re-operation with a THR. Functional outcome Harris Hip Score at each follow up is shown in Table 2. The analysis includes those with and without re-operation. The functional outcome favoured patients with non-displaced fracture at four- and twelve-month follow-ups; however, this levelled out at the final follow-up (Table 2). Patients with displaced fracture that healed after the index operation had good or excellent functional outcome at 24-month
Fig. 3. EQ-5D Index score before fracture and at each follow-up.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
6
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Fig. 4. SF-36 score before fracture and at each follow-up.
follow-up in 80% (n = 65/81) of cases, compared to 57% (n = 20/35) in those who required re-operation (p = 0.01). Health-related quality of life The HRQoL decreased for all patients (Fig. 3). The mean EQ5Dindex for patients with displaced fracture decreased from 0.81 (SD 0.27) to 0.59 (SD 0.26) at 4 months (p < 0.001), 0.63 (SD 0.29) at 12 months (p < 0.001) and 0.65 (SD 0.29) at 24 months (p < 0.001). The mean EQ-5Dindex in patients with non-displaced fracture decreased from 0.88 (SD 0.18) to 0.69 (SD 0.28) at 4 months (p < 0.001), 0.75 (SD 0.25) at 12 months (p < 0.001) and 0.74 (SD 0.28) at 24 months (p < 0.001). There was no statistically significant difference in HRQoL (EQ5Dindex) for patients with non-displaced fracture compared to patients with displaced fracture at each follow-up (data not shown). The HRQoL (EQ-5Dindex) in patients with displaced fracture that healed after one operation compared to those who required reoperation is shown in Fig. 3. Both patient groups showed a noticeable decrease in health-related quality of life at four-month and did not reach their pre-fracture level at final follow-up.
The mean SF-total score in patients with displaced fracture decreased from 76 (SD 20) to 55 (SD 23) at 4 months, 63 (SD 22) at 12 months and 65 (SD 23) at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80 (SD 26), 67 (SD 23), 74 (SD 25) and 76 (SD 23) respectively (p < 0.001). Average SF-36 physical and mental scores at baseline and at each follow-up are presented in Fig. 4. The figure shows that mental scores recovered to a greater extent compared to physical scores for all patients’ regardless of the type of femoral neck fracture. Mean SF-36 subscales at baseline and at final follow-up are shown in Table 3 and Fig. 5. In patients with non-displaced fractures the changes were significant in PF, BP, GH, VT, MH. The difference in PF and BP was 10 and 14 respectively (Table 3) which is higher than MID. On the opposite, in patients with displaced fracture the difference in all sub-scales between baseline and final follow-up were significant and higher than MID with the exception of MH and GH subscales were the differences were below MID (Table 3). Further, both patients with and without re-operation reported significantly lower values in numerous SF-36 subscales at 24 months, particularly in PF, RP, BP and RE (Table 3 and Fig. 5).
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
7
Table 3 SF-36 subscales at baseline and at 24-month follow up with change score. All values presented as mean (SD). NonDisplaced Displaced fracture displaced
Physical functioning (PF) - Before fracture
No major reoperation
With major reoperations
n = 45
n = 113
n = 79
n = 34
85 (23)
75 (29)
78 (29)
68 (31)
- 24-month
71 (31)
58 (31)
64 (30)
44 (29)
- change score
14 (23)
17 (28)
14 (22)
24 (38)
- P-value
<0.001
<0.001
<0.001
0.001
83 (34)
75 (37)
80 (34)
62 (43)
- 24-month
76 (37)
57 (44)
64 (42)
38 (43)
- change score
7 (42)
18 (42)
16 (40)
24 (48)
- P-value
0.2
<0.001
<0.001
0.008
87 (25)
80 (26)
84 (22)
72 (31)
- 24-month
77 (27)
65 (32)
70 (29)
56 (37)
- change score
10 (27)
15 (30)
14 (24)
16 (41)
- P-value
0.008
<0.001
<0.001
0.025
77 (20)
72 (23)
77 (20)
62 (27)
- 24-month
71 (24)
66 (24)
70 (23)
57 (24)
- change score
6 (18)
6 (21)
7 (18)
5 (25)
- P-value
0.04
0.001
0.002
0.2
76 (24)
71 (25)
76 (21)
60 (29)
- 24-month
68 (29)
62 (29)
67 (27)
50 (30)
- change score
8 (23)
9 (26)
9 (23)
10 (31)
- P-value
0.03
<0.001
0.002
0.09
89 (24)
85 (23)
90 (18)
75 (28)
- 24-month
86 (23)
75 (30)
80 (28)
62 (32)
- change score
3 (24)
10 (27)
10 (24)
13 (31)
- P-value
0.4
<0.001
0.001
0.023
83 (31)
80 (36)
87 (29)
64 (45)
- 24-month
74 (42)
65 (44)
74 (41)
44 (46)
- change score
9 (43)
15 (46)
13 (41)
20 (57)
- P-value
0.17
0.001
0.001
0.06
85 (20) 79 (24)
80 (20) 75 (27)
83 (19) 80 (24)
73 (23) 64 (30)
6 (18)
5 (24)
3 (23)
9 (28)
Role physical (RP) - Before fracture
Bodily Pain (BP) - Before fracture
General Health (GH) - Before fracture
Vitality (VT) - Before fracture
Social functioning (SF) - Before fracture
Role emotional (RE) - Before fracture
Mental health (MH) Before fracture - 24-month - Change score
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
8
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Table 3 (Continued) NonDisplaced Displaced fracture displaced
- P-value
Mortality and general complications Two patients had pneumonia, three patients had heart failure and 11 patients were treated for urinary tract infections. Seven patients were dead at 24-month follow-up (4%). Discussion This study showed that two-thirds of the patients with displaced fracture healed after one operation and three-quarters had good or excellent functional outcome after two years. As for patients with non-displaced fracture:- all healed after one surgery and eight percent needed reoperation due to AVN. The study further showed that patients did not regain their pre-fracture level of HRQol regardless of the type of femoral neck fracture. Furthermore, in patients with displaced fracture, no difference in re-operation rate was found between patients in the age group 50–59 and 60–69 (34% and 31% respectively). Thus, one cannot tell if the age limit for treating patients with displaced femoral neck fracture with a THR should be lowered and if so to 60 or 50 years of age. This indicates that chronological age may not be reliable when deciding treatment modality, which contradicts the ongoing trend to treat patients with a displaced femoral neck fracture in the age range of 60–69 years with a total hip replacement (THR) [2–4]. It could therefore be of interest to find risk factors other than age that are associated with increased risk for re-operation due to AVN and NU. As for patients under 50 years, further studies are needed to find the optimal surgical method in order to reduce the risk for complications related to the fracture healing [23]. All patients in our study with NU required re-operation. By contrast, only 46% (11/24) of those with AVN had symptoms that required re-operation at 24-month follow-up. A previous study made by Haidukewych et al. [5] found that half of the patients that developed AVN showed symptoms and required re-operation, which is in accordance with our results. Furthermore, Jain et al. [24] found that AVN did not affect functional outcome in younger patients with femoral neck fracture. A meta-analysis conducted by Damany et al. [1] reported that the incidence of NU was 9% and for AVN 23% in patients <50 years of age, with displaced femoral neck fracture, which is similar to our findings. However, the reported incidence of NU in younger patients varies between 0 and 59% [1,5–7,25,26]. This may be explained by several factors, such as different definitions of NU. Early complications are in some studies considered re-displacement, if it occurs 4–6 months after surgery it is instead regarded as NU [6,27]. In the present study, NU was defined as absence of healing regardless of whether it occurs before or after 4 months. Concerning type of re-operation, there is an agreement that patients over 60 years of age, who are symptomatic due to fracture healing complication, are re-operated with an arthroplasty. Younger patients are instead treated with more hip preserving methods. However, further studies are needed and the choice of the treatment modality must be decided on an individual basis and
No major reoperation
With major reoperations
n = 45
n = 113
n = 79
n = 34
0.02
0.001
0.25
0.054
discussed with the patient to achieve the most successful outcome [28]. The functional outcome in younger patients with femoral neck fracture is not well studied. In the present study, a higher proportion of patients with non-displaced fracture had a good or excellent functional outcome at four- and twelve- months follow-up compared to those with displaced fracture according to HHS. However, this statistically significant difference had disappeared at the final follow-up at 24 months. This could be explained by the fact that the majority of the patients with fracture healing complication were re-operated with hip replacement and had recovered at the time of final follow-up. However, those patients who required reoperations had inferior outcome at 24-month follow-up. These results indicate that further studies are required to find risk factors associated with fracture healing complications and re-operation in this age group. A similar decrease in functional outcome among elderly patients with fracture healing complications has been reported by Tidermark et al. [29] with a mean follow-up of 17 months. EuroQoL, as a health related quality-of-life instrument, judges favourably in terms of internal and external validity being only slightly less sensitive than SF-36 [15]. EuroQol has also been validated in elderly patients with femoral neck fracture as a reliable outcome measurement in clinical trials [30–34]. Previous studies on elderly patients have shown that those with a healed non-displaced fracture regained their pre-fracture quality of life level while patients with a healed displaced fracture did not [30]. On the contrary, this study showed that younger patients with either of the fracture types did not regain their pre-fracture level of HRQoL. One could assume that younger patients have higher functional demands and a slight functional impairment might influence their health related quality of life. A previous study suggested that a mean effect size of 0.15 is considered to be MID for EQ-5D [34]. Our study showed that patients with a displaced fracture requiring re-operation had a similar decrease of HRQoL at 4 months, with minimal improvement until 24-month follow-up compared to those with fractures that healed after a single operation. SF-36 showed similar results, the group with non-displaced as well as displaced fractures had a loss in both physical and mental scores two years after surgery. Zidén et al. [35] reported similarly “a social and existential crack” in elderly patients after a hip fracture. To our knowledge this has not been shown in younger patients and should therefore be further investigated. Consequently, one could theorize that special rehabilitation program for younger patients are required. The strengths of this study were the prospective multicentre design and the long follow-up, including clinical, radiological and functional outcomes. Another strength was the low dropout rate. One limitation of the study was the low number of patients < 50 years of age, as the incidence of femoral neck fracture in this group is low. Highly posteriorly angulated Garden I–II fractures could behave as displaced fracture but were not allocated to the displaced fracture group, and that this may represent a weakness
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
9
Fig. 5. Spider diagram showing mean SF-36 subscores before fracture and at 24-months follow-up.
of the study. However, we did not use posterior angulation on the axial view to allocate fracture as displaced or non-displaced as this is not stated in the original criterion of displacement [16]. Further, patients with severe cognitive impairment, multiple fractures, chronic renal failure or hyperparathyroidism and patients unable to walk or living in institutions were not included, which limits the generalizability of our results.
In conclusion, this study has shown that two-thirds of the patients with displaced femoral neck fracture healed after one operation and three-quarters had good or excellent functional outcome. In patients with non-displaced fracture only eight percent were re-operated due to AVN. The study further showed that patients did not regained their pre-fracture level of HRQol irrespective of fracture type. The study suggests that internal
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
G Model JINJ 7461 No. of Pages 10
10
P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
fixation for femoral neck fracture in patients <70 years of age may still be recommended for the majority of these patients. Yet, further studies are needed to identify patients at risk of NU and AVN.
[16] [17]
Conflict of interest [18]
No competing interests declared. Funding Supported by grants provided by the Stockholm County Council (ALF project). The funding source did not play any role in the running of the study. References [1] Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults: a meta-analysis of 18 published studies involving 564 fractures. Injury 2005;36:131–41. [2] Rikshöft. The Swedish National Hip Fracture Registry. Rikshöft; 2017. . (Last Accessed May 2017) http://wwwrikshoftse/se/indexphp. [3] Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database. J Bone Joint Surg Am 2014;96:e149. [4] Lee YK, Ha YC, Park C, Koo KH. Trends of surgical treatment in femoral neck fracture: a nationwide study based on claim registry. J Arthroplasty 2013;28:1839–41. [5] Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;(86-A):1711–6. [6] Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res 1995;238–46. [7] Swiontkowski MF, Winquist RA, Hansen Jr. ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984;66:837–46. [8] Sprague S, Slobogean GP, Scott T, Chahal M, Bhandari M. Young femoral neck fractures: are we measuring outcomes that matter. Injury 2015;46:507–14. [9] 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. [10] American Society of Anesthesiologists. ASA physical status classification system. 2017. . (last accessed July 2017) https://www.asahq.org/resources/ clinical-information/asa-physical-status-classification-system. [11] Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol Consumption–II. Addiction 1993;88:791–804. [12] Brooks R. EuroQol: the current state of play. Health Policy 1996;37:53–72. [13] Sullivan MKJ, Taft C, Ware JE. SF-36 health survey: Swedish manual and interpretation guide. Gothenburg: Sahlgrenska University Hospital; 2002. [14] 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. [15] Honkavaara N, Al-Ani A, Campenfeldt P, Ekström W, Hedström M. Good responsiveness with EuroQol 5-dimension questionnaire and short form (36)
[19]
[20] [21]
[22]
[23] [24]
[25] [26] [27]
[28]
[29]
[30]
[31]
[32]
[33] [34]
[35]
health survey in 20–69 years old patients with a femoral neck fracture. A 2year prospective follow-up study in 182 patients. Injury 2016 injury.2016.05.021. Garden R. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br) 1961;43:647. Lindequist S, Tornkvist H. Quality of reduction and cortical screw support in femoral neck fractures: an analysis of 72 fractures with a new computerized measuring method. J Orthop Trauma 1995;9:215–21. DeSmet AA, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, el-Khoury GY, et al. Diagnostic imaging of avascular necrosis of the hip. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215(Suppl):247–54. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737–55. World Medical Association. Helsinki Declaration 1964. 2017. . Last Accessed May 2017 http.//http://www.wma.net/e/policy/b3.htm. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the reporting of observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495–9. Al-Ani AN, Neander G, Samuelsson B, Blomfeldt R, Ekstrom W, Hedstrom M. Risk factors for osteoporosis are common in young and middle-aged patients with femoral neck fractures regardless of trauma mechanism. Acta Orthop 2013;84:54–9. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury 2015;46:484–91. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am 2002;(84-A):1605–12. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am 2008;90:2254–66. Slobogean GP, Sprague SA, Scott T, McKee M, Bhandari M. Management of young femoral neck fractures: is there a consensus. Injury 2015;46:435–40. Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br 2011;93:811–6. Hoskinson S, Morison Z, Shahrokhi S, Schemitsch EH. Managing AVN following internal fixation: treatment options and clinical results. Injury 2015;46:497– 506. Tidermark J, Zethraeus N, Svensson O, Tornkvist H, Ponzer S. Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 2002;11:473–81. Tidermark J, Zethraeus N, Svensson O, Tornkvist H, Ponzer S. 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. Tidermark J, Bergstrom G, Svensson O, Tornkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12:1069–79. Frihagen F, Grotle M, Madsen JE, Wyller TB, Mowinckel P, Nordsletten L. Outcome after femoral neck fractures: a comparison of Harris Hip score, Eq-5d and Barthel index. Injury 2008;39:1147–56. Parsons N, Griffin XL, Achten J, Costa ML. Outcome assessment after hip fracture: is EQ-5D the answer. Bone Joint Res 2014;3:69–75. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res 2005;14:1523–32. Ziden L, Wenestam CG, Hansson-Scherman M. A life-breaking event: early experiences of the consequences of a hip fracture for elderly people. Clin Rehabil 2008;22:801–11.
Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028