Quality of life after hip fracture in the elderly: A systematic literature review

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JINJ-6689; No. of Pages 14 Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Injury journal homepage: www.elsevier.com/locate/injury

Review

Quality of life after hip fracture in the elderly: A systematic literature review Charles M.M. Peeters a, Eva Visser b, Cornelis L.P. Van de Ree a,b, Taco Gosens a,b, Brenda L. Den Oudsten d, Jolanda De Vries b,c,d,* a

Department of Orthopaedics, St. Elisabeth Hospital, Tilburg, The Netherlands Trauma TopCare, St. Elisabeth Hospital, Tilburg, The Netherlands Department of Medical Psychology, St. Elisabeth Hospital, Tilburg, The Netherlands d Center of Research on Psychological and Somatic Disorders, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands b c

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 17 April 2016

Background: With an increasing ageing population, hip fractures have become a major public health issue in the elderly. It is important to examine the health status (HS) and health-related quality of life (HRQOL) of the elderly faced with the epidemic of hip fractures. Objective: To provide an overview of reported HS and HRQOL in elderly patients with a hip fracture. Design: A systematic literature search was performed in Embase, Medline, Web of Science, Scopus, CINAHL, Cochrane, PsycINFO, Pubmed, and Google Scholar in July 2014. Studies which reported the HS or HRQOL based on standardised questionnaires in patients older than 65 years with a hip fracture were considered eligible for inclusion. Results: After inspecting the 2725 potentially eligible studies, 49 fulfilled the inclusion criteria. All included studies were randomised controlled trials or prospective cohort studies. The methodological quality of the studies was moderate. Patients’ functioning on the physical, social, and emotional domains were affected after a hip fracture. The HS and HRQOL of the majority of patients recovered in the first 6 months after fracture. However, their HS did not return to prefracture level. Mental state, prefracture functioning on physical and psychosocial domains, comorbidity, female gender, nutritional status, postoperative pain, length of hospital stay, and complications were factors associated with HS or HRQOL. Treatment with total hip arthroplasty or hemi-arthroplasty provided better HS than treatment with internal fixation with displaced femoral neck fractures. Supportive psychotherapy in ‘‘low-functioning’’ patients, (home) rehabilitation programmes and nutritional supplementation appeared to have beneficial effects on HS. Conclusions: Optimizing nutrition intake, (home) rehabilitation programmes, and the possibility for psychological counselling in patients with difficulties in the psychosocial dimensions would be recommended after hip fracture surgery. Besides HS questionnaires like EQ-5D and SF-36, adequate measurements like the WHOQOL-Bref or ICECAP-O are warranted in future studies regarding hip fracture surgery and postoperative treatment options. ß 2016 Elsevier Ltd. All rights reserved.

Keywords: Hip fracture Health-related quality of life Health status Elderly Systematic review

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . Search strategy . . . . . . . . . . . . . . Inclusion and exclusion criteria . Study selection . . . . . . . . . . . . . .

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* Corresponding author at: Center of Research on Psychological and Somatic Disorders, Department of Medical and Clinical Psychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands. E-mail address: [email protected] (J. De Vries). http://dx.doi.org/10.1016/j.injury.2016.04.018 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Peeters CMM, et al. Quality of life after hip fracture in the elderly: A systematic literature review. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.018

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2

Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . Data extraction and presentation. . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study inclusion and characteristics . . . . . . . . . . . . . Methodological quality . . . . . . . . . . . . . . . . . . . . . . . HS and HRQOL among patients with a hip fracture Factors associated with HS and HRQOL . . . . . . . . . . Type of hip fracture surgery and HS/HRQOL . . . . . . Strength training and HS/HRQOL . . . . . . . . . . . . . . . Psychological counselling and HS . . . . . . . . . . . . . . Nutritional status and HS . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Introduction

Methods

A hip fracture is a common public health problem throughout the world. The incidence increases substantially with a growing and continuously ageing population [1–3]. Due to the high mortality, morbidity, and disability rate hip fracture patients are a major challenge for the healthcare system as well as for society [4–8]. In order to assess the impact of a hip fracture and the efficacy of (surgical) interventions, a measurement of patient-based outcomes, such as health status (HS) and health-related quality of life (HRQOL), is required. These multidimensional concepts are not uniquivocally defined. In general, HRQOL focuses mainly on the physical, emotional, and social well-being after diagnosis and treatment of a disease in combination with perceived functioning (i.e., health status; HS) [9–12]. Thus, HS represents the perceived impact of a disease only on the level of a patients’ physical, emotional and social functioning [13]. In other words, HS refers to perceived functioning, while HRQOL measures internal experiences. As long as the ageing population is steadily increasing in the countries over the world, it is important to expand clinical reasearch efforts into the HRQOL of the elderly faced with the epidemic of hip fractures. Often small groups of homogeneous populations are used to obtain information about the consequences of a hip fracture. However, the elderly popultion cannot be regarded as homogeneous due to their comorbidity, social environments, and different perspectives on life, and should be understood as individuals. This is the first systematic review focusing on all published studies which reported HS or HRQOL after hip fracture in elderly patients above 65 years old to provide a rich variety of perspectives to compose a heterogenous view on the impact of this health problem. The aims of this systematic review were (i) to provide an extensive overview of reported HS and HRQOL in the elderly patients faced with the hip fracture epidemic, (ii) to describe factors of influence on HS or HRQOL, and (iii) to examine the influence of strength training, psychological counselling and nutritional care in relation to HS and HRQOL.

Search strategy

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A systematic search of the literature was carried out in July 2014. Electronic databases (EMBASE, Medline (OvidSP), Web-ofScience, Scopus, CINAHL, Cochrane, PsycInFO (OvidSP), Pubmed, Google scholar) were used to identify relevant studies since their inception up to July 2014. An overview of the search strategy is presented in Table 1 and Appendix 1. Inclusion and exclusion criteria Studies were included in this systematic review if the following inclusion criteria were fulfilled: (i) the study describes HRQOL after hip fracture treatment with or without surgery in the elderly (65 years); (ii) patients are diagnosed with high- or low-energy traumatic per- or intertrochanteric femur fracture or (supcapital) femoral neck fracture; (iii) HS or HRQOL was measured with a standardised questionnaire, which contained at least a physical, psychological and social dimension, reflecting the World Health Organization’s definition of health [14]; (iv) a full text of the article is available; (v) the study is published in English, Dutch or German. Comments, editorials, case reports, reviews, letters, guidelines and protocols were excluded. Study selection One reviewer (CP) examined article titles and abstracts for eligibility. Subsequently, the full texts of potential studies were screened to determine final eligibility for inclusion in this review. Uncertainty concerning the inclusion of the studies was solved in a single consensus meeting with a second reviewer (JV). In addition, reference lists of included articles were screened for eligible studies that were not found in the search. The selection of studies is shown in Fig. 1.

Table 1 Search strategy in Medline. ((hip[tiab] OR intertrochant*[tiab] OR femur neck*[tiab] OR femur head*[tiab] OR femoral neck*[tiab] OR femoral head*[tiab] OR subcapital[tiab] OR intracapsular[tiab] OR pertrochant*[tiab] OR subtrochant*[tiab] OR trochant*[tiab] OR proximal femoral*[tiab] OR collum[tiab]) AND fracture*[tiab]) AND (quality of life*[tiab] OR QoL[tiab] OR HRQoL[tiab] OR HRQL[tiab] OR mental health*[tiab] OR well being*[tiab] OR wellbeing[tiab] OR satisf*[tiab]) AND (inventor*[tiab] OR questionnair*[tiab] OR scale*[tiab] OR score*[tiab] OR scoring[tiab] OR rating[tiab] OR checklist*[tiab] OR instrument*[tiab] OR tool*[tiab] OR measur*[tiab] OR collect*[tiab] OR index*[tiab] OR indice*[tiab])

Please cite this article in press as: Peeters CMM, et al. Quality of life after hip fracture in the elderly: A systematic literature review. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.04.018

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Fig. 1. Study selection.

Quality assessment Two authors (CP and EV) independently assessed the methodological quality of each included study, using a standardised

checklist of 17 predefined criteria (Table 2). The checklist was developed for reviewing QOL studies and based on established criteria lists for systematic reviews [9,10,15–18]. Each item was assigned zero or one point. If an item was described insufficiently,

Table 2 Methodological quality criteria.

A) B) C) D) E) F) G) H) I) J) K) L) M) N) O) P) Q)

Item

Score

A description is given of (HR)QOL and/or HS by describing at least the domains and/or the importance of the subjective experience of the patient. A reason is given for choosing a certain questionnaire. A distinction is made between (HR)QOL and HS. A description is included of at least two socio-demographic variables (e.g., age, sex, ambulatory status). A description is present of at least two clinical variables (e.g., type of hip fracture, postoperative complications). Inclusion and/or exclusion criteria are provided. The study describes potential prognostic factors by using multivariate analyses or structural equation modeling. Participation rates for patient groups are described and these rates are exceeding 75%. Information is given about the ratio non-responders versus responders. The study size is consisting of at least 50 patients (arbitrarily chosen). The collection of data is prospectively gathered. The design is longitudinal. The process of data collection is described (e.g. interview or self-report). The follow-up period is at least 6 months. The loss to follow-up is mentioned and <20%. The results are compared between two groups or more (e.g., health population, groups with hip fracture patients) and/or results are compared with at least two time points (e.g., longitudinally or pre- versus post-treatment). A psychometrically sound (health-related) QOL or health status questionnaire is used.

0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1 0/1

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no point was assigned. Disagreements were solved by consensus. In case of persistent disagreement, consultation of a third reviewer (JV) was required. This was, however, unnecessary. Studies were classified as ‘‘high quality’’ when at least 70% of the 17 criteria was assigned with one point (i.e. 12 points), as ‘‘moderate quality’’ when between 50% and 70%, and as ‘‘low quality’’ when less than 50% of the total attainable points was assessed. The level of evidence was classified into the following levels [15,16,18,19]: (1) Strong evidence: consistent findings (75%) in at least two high-quality studies or one high-quality study and at least three moderate studies. (2) Moderate evidence: consistent findings (75%) in one highquality study and at least one low-quality study or at least three moderate studies. (3) Weak evidence: findings of two moderate studies or consistent findings (75%) in at least 3 low-quality studies. (4) Inconclusive evidence: inconsistent findings irrespective of study quality, or less than 3 low-quality studies available. Data extraction and presentation One author (CP) extracted the data of the included studies. Information was collected on study design, study population, outcome measures, follow-up period, and results. Studies with 36-item Short Form (SF-36) or European Quality of Life-5 Dimensions (EQ-5D) as outcome measurement are presented in figures with their mean scores and standard deviation (SD) at each follow-up moment until one year. The SF-36 and EQ5D are widely used measures of HS. The SF-36 contains 36 items covering eight health concepts: physical function, role limitation (physical and emotional), body pain, general health, vitality, social functioning, and mental health. The EQ5D has five domains: mobility, self-care, usual activities, pain/ discomfort, and anxiety/depression. The patients’ health state can be converted to a single summary index, a scale from 0 to 1, based on values from general population samples. The reliability and validity of both measures have been well evaluated [20–23]. In case of absence of the mean scores or SD’s, we contacted the corresponding authors. Subsequently, all included studies are listed in a table and potential factors associated with HS or HRQOL are documented in the results.

Results Study inclusion and characteristics A primary search of databases yielded 5585 records (Fig. 1). After duplicates removal, 2725 potentially eligible articles were identified. Finally, 49 articles fulfilled the inclusion criteria and were included in this systematic review [24–72]. See Tables 3–5 for an overview of the included studies. All included studies were randomised controlled trials (RCT’s) or prospective cohort studies. The overall sample size of the included papers ranged from 38 [43] to 1569 patients [54]. The mean age of the cohorts ranged from 74 [51] to 93 years old [33] and the length of follow-up ranged from 30 days [44] to 7 years [32]. Twenty-five studies included only patients with femoral neck fractures (FNF’s), three studies included only patients with pertrochanteric fractures, and 21 studies made no distinction between different types of hip fractures or included all of them. The majority of the studies (88%) used the SF-12, SF-36, or EQ-5D questionnaire as measurements of HS.

Methodological quality According to the quality assessment (Table 2), the overall quality of included studies was moderate (Table 6). The mean quality score was 11 (SD = 2.1) with a range of 6 (low quality) to 15 (high quality). The methodological shortcomings mainly concerned items A–C, G–I, and O. Twenty-three studies (47%) did not describe any of the QOL-specific criteria (items A–C). Only one study made a distinction between HRQOL and HS (item C) [63]. HS and HRQOL among patients with a hip fracture All studies confirmed that a hip fracture has a negative impact on HS and/or HRQOL for the majority of the patients [24–72]. In particular, physical functioning was seriously affected in the first months after hip fracture. In addition, high evidence was found for the incomplete recovery of HRQOL and HS. Only five studies reported recovery, based on population reference scores or prefracture status of HRQOL or HS [28,34,36,42,57]. Eight studies, of which 5 high quality, showed that the majority of the recovery takes place in the first 2–6 months [26,31,34,43,50,63,69,72]. Figs. 2 and 3 present the studies with the SF-36 and EQ-5D as outcome measures. The SF-36 scores and EQ-5D scores were compared to a Canadian reference population and a Swedish reference population, respectively, with the age of 75+ [20,22]. Only one of the contacted authors of two included papers responded to our request and provided the missing data [30,35]. Since the majority of the recovery has taken place within 6 months, we do not present data exceeding one-year follow-up [28,32,45,47,50,56,57,65,67]. Factors associated with HS and HRQOL The following factors were negatively associated with HS and/ or HRQOL. Strong evidence was found for low physical or psychosocial functioning before hip fracture, comorbidity, female sex, poor nutritional status, severe post-surgical pain perception, longer duration of hospital stay and postoperative complications [24,31,33,34,37,44,45,48,50,52,56,59,62,65,68,70]. Moderate evidence was found for cognitive dysfunction (e.g. dementia) [24,33,52,62]. One high quality and two moderate quality studies reported that cognitive dysfunctioning had a negative impact on HS and/or HRQOL [33,52,62]. A low quality study which included only women could not confirm this predictive value [24]. Tidermark et al. [52] showed that type of fracture was a predictor for HS. Patients with healed undisplaced FNF’s with internal fixation (IF) regained their prefracture HS level. In contrast, patients with healed displaced FNF showed a significantly worse HS at all moments in the two-year follow-up in comparison with their prefracture status [68]. Inconclusive evidence was found for the predictive value of living in an institution before hip fracture and older age [24,31,33,38,48,50,52,59,60]. Type of hip fracture surgery and HS/HRQOL Twelve studies compared different surgical treatment options for displaced FNF [37,42,45,47,51,53–58,65–67]. One high quality study showed better HS in the total hip arthroplasty (THA) compared to the IF group at four months (p < 0.005) and one year (p < 0.05) follow-up, probably due to the lower complication rate in de THA group (4% vs 34%) [45]. However, at two and four years follow-up no significant difference was found between these groups [65]. Hemiarthroplasty was considered as a superior treatment for displaced FNF compared to IF in three moderate quality studies with a significance difference on HS

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Table 3 Overview of studies comparing different surgical treatment options. % Male

HRQOL or HS question-naire

Follow-up period

Conclusions

24%

EQ-5D

1

–

4 year

28%

SF-36

1 year

74.1  4.2 (65–79)

25%

NHP

6 months

128

85.4  4.2 (80 + )

13%

NHP

6 months

No significant difference on HS between the U-HA and B-HA group was established at 4 months (p = 0.06) and 1 year of follow-up (p = 0.51). Significant better HS was established in the BHA group at 4 years of follow-up (p = 0.04), possibly due to the later onset of acetabular erosion in the B-HA group. No significant difference on HS between the U-HA and B-HA group was established at 3 months and 1 year of follow-up. No significant difference on HS between U-HA and B-HA group was found at 6 months of follow-up. No significant difference on HS between U-HA and B-HA group was reported at 6 months of follow-up.

102

80.3  5.9 (70–96)

20%

EQ-5D

2 year

–

4 year

Treatment (study population)

First author, year of publication

Design

U-HA vs B-HA (displaced FNF)

Hedbeck et al. [66]

RCT

Inngul et al. [67]a

–

Raia et al. [42]

Prospective randomised trial

115

82.1 (65–101)

Calder et al. [51]

RCT

110

IF vs THA (displaced FNF)

IF vs HA (displaced FNF)

HA vs THA (displaced FNF)

Tidermark et al. [45]

RCT

Blomfeldt et al. [65]b

–

Hedbeck et al. [58]

RCT

Gjertsen et al. [54]

Prospective observational study

Gjertsen et al. [55]c

Prospective observational study

Calder et al. [51]

RCT

Blomfeldt et al. [37]

RCT

Hedbeck et al.d [47]

–

Number of subjects 120

–

–

60

Age at surgery (years) Mean  SD (range) 86.4 (80–100)

–

–

–

–

year

84.5  5.4

17%

EQ-5D

1 year

1569

82.3  6.2 (70–100)

22%

EQ-5D

4 months

1031

82.0 (70+)

22%

EQ-5D

1 year

110

74.1  4.2 (65–79)

25%

NHP

6 months

120

80.6 (70–90)

16%

EQ-5D

1 year

–

4 year

–

–

–

Significant better HS was established in the THA group at 4 months (p < 0.005) and 1 year (p < 0.05) of follow-up. No significant difference on HS between IF and THA group was established at 2 years and 4 years of follow-up. Significant better HS was established in the HA group at 1 year of follow-up (p = 0.03) for patients with severe cognitive dysfunction. Significant better HS was established in the HA group at 4 months of follow-up (p < 0.001). Significant better HS was established in the HA group at 4 months (p < 0.001) and 1 year of follow-up (p < 0.001). Significant better HS was established in the HA group at 4 months (p < 0.001) and 1 year of follow-up (p < 0.001). Significant better score on the social index score (p = 0.049) in the HA group at 6 months of follow-up. No significant difference on HS between HA and THA group was established at 4 months and 1 year of follow-up. Significant better HS was established in the THA group at 4 years of follow-up (p = 0.039).

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6 Table 3 (Continued ) Treatment (study population)

First author, year of publication

Design

C-HA vs NC-HA (displaced FNF)

Taylor et al. [53]

RCT

160

GN vs SHS (OTA: 31-A2.2/ 31-A2.3)

Aktselis et al. [36]

RCT

80

Number of subjects

Age at surgery (years) Mean  SD (range) 85.2  6.8

83  6.2

% Male

HRQOL or HS question-naire

Follow-up period

Conclusions

31%

SMFA

2 year

No significant difference on HRQOL between CHA and NC-HA group was established at 6 weeks, 6 months, 1 year and 2 years of follow-up.

19%

EQ-5D

1 year

Significant better HS was established in the GN group at 1 year of follow-up (p = 0.018).

a

This study is a four-year follow-up of the 120 patients from Hedbeck et al. [47]. This study is a four-year follow-up of the 102 patients from Tidermark et al. [68]. c This study included also patients from Gjertsen et al. [54] who fulfilled both 4 and 12 months of follow-up questionnaire. d This study is a four-year follow-up of the 120 patients from Blomfeldt et al. [37]. Abbreviations: U-HA, unipolar hemiarthroplasty; B-HA, bipolar hemiarthroplasty; FNF, femoral neck fracture; IF, internal fixation; THR, total hip arthroplasty; HA, hemiarthroplasty; C-HA, cemented hemiarthroplasty; NC-HA, non-cemented hemiarthroplasty; GN, gamma nail; SHS, Sliding hip screw; OTA, Orthopaedic Trauma Association; RCT, randomised controlled trial; NHP, Nottingham Health Profile; SMFA, Short Muscoskeletal Function Assessment. b

[51,54,55]. Treatment with bipolar hemiarthroplasty (B-HA) does not lead to significant differences on HRQOL or HS in comparison with unipolar hemiarthroplasty (U-HA) according to three studies of moderate quality [42,51,66,67]. However, the follow-up study of Hedbeck et al. [47] found that the B-HA group had significantly better HS compared to the U-HA group at 4 years of follow-up (p = 0.04). A significant difference on HS were found between the HA and THA group at 4 years of follow-up (p < 0.039) and implied that a THA should be a preferred method of treatment for displaced FNF’s in an active elderly patient with a long life expectancy [47]. Another study compared intramedullary nails with sliding hip screws for intertrochanteric fractures of the femur and established a significant difference on HS in the benefit of the intramedullary nails (p < 0.0018) [36]. Strength training and HS/HRQOL Nine RCT’s investigated the influence of strength training and supportive counselling on HRQOL or HS [25,26,29,30,34, 35,39,40,46]. Five studies reported significant improvements of components of HS contributed to (home) rehabilitation programmes containing different types of strength training [26,29,34,39,40]. Two studies found no significant improvements of HS after a 4 months or one year home exercise programme [25,46]. According to Ryan et al. a more intensive regime of community-based multidisciplinary therapy, with six or more face-to-face contacts per week, did not result in improved HS at three months of follow-up in comparison with three or less visits per week [30,35]. Psychological counselling and HS A high quality study reported that psychosocial factors can increase pain severity and emotional distress. The application of counselling throughout the perioperative period to influence a patient’s psychosocial condition and self-perceptions improved the patients’ pain perception and their HS, in particular for patients with a low score on the SF-36 scale at baseline [44]. Nutritional status and HS Two studies investigated HS in combination with nutritional intake. One compared a control group with multidisciplinary nutritional care and showed that the intervention group experienced better EQ-5D scores after three months of follow-up

[48]. Another study examined protein-rich liquid supplementation in combination with nandrolone given for 6 months, which positively affected the HS in lean elderly women with a FNF [70]. Discussion The aims of this systematic review were (i) to provide an extensive overview of reported HS and HRQOL in the elderly patients (>65 years old) faced with the hip fracture epidemic, (ii) to describe factors of influence on HS or HRQOL, and (iii) to examine the influence of strength training, psychological counselling and nutritional care in relation to HS and HRQOL. In general, HS is seriously affected by a hip fracture in the physical, psychological, and social domain. The prefracture physical and psychosocial functioning, psychological state, comorbidity, female gender, nutritional status, type of fracture, postoperative pain, length of hospital stay, and complications seem associated with worse outcome. Also the method of surgical treatment, postoperative strength training, psychological counselling and nutritional supplementation probably influence patients’ self-perceived HS. This review included 49 studies and the overall methodological quality was moderate. Seventeen studies (35%) had a high quality score. A meta-analysis was not performed because of diverse outcome measures and other clinical heterogeneity. In addition, many of the included papers actually reported results on HS instead of HRQOL according to the definitions used in this review. For example, the EQ-5D was claimed in 25 studies as measurement of HRQOL instead of a questionnaire for HS [26,27,30,32,35– 37,45,47,48,50,54,55–58,61,65–72]. The EQ-5D score gives only an indication of a patients’ level of physical, emotional, and social functioning, but does not measure patients’ internal experiences or satisfaction with their functioning. Therefore, the EQ-5D score should be used as an generic instrument for HS. The same applies to SF-12, SF-36, Dartmouth COOP Functional Health Assessment Charts (DCFHAC), Swedish Health-Related Quality of Life questionnaire (SWED-QUAL), the Osteoporosis Assessment Questionnaire (OPAQ2), Health Utilities Index (HUI) and Nottingham Health Profile (NHP) scores. Only one study used an adequate measurement of HRQOL: the Short Muscoskeletal Function (SMFA) [53]. Not reported but adequate measurements for hip fracture patients could be the World Health Organization QOL assessment instrument-Bref (WHOQOL-Bref) and the ICEpop CAPability measure for Older people (ICECAP-O) [73–75]. Although the WHOQOLBref is not validated in trauma patients, this generic 26-item has

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Table 4 Overview of studies investigating the influence of strength training, psychological counselling, and nutritional care. Treatment (study population)

First author, year of publication

Design

Number of subjects

Age at surgery (years) Mean  SD (range)

% Male

HRQOL or HS questionnaire

Follow-up period

Conclusions

Geriatic hospital based HR vs CC

Ziden et al. [26]a

RCT

102

81.9  6.8 (65–99)

30%

SF-36

1 year

Supervised progressive ST vs CC

Orwig et al. [25]

RCT

180

82.4  7.0

0%

SF-36

1 year

Accelerated discharge and HR vs CC

Sylliaas et al. [40]c

RCT

150

82.4  6.3 (65–94)

17%

SF-12

3 months

Individualised OT vs CC

Sylliaas et al. [39]c

RCT

95

82.3  5.8 (65–97)

17%

SF-12

6 months

High intensity ST and SC vs CC

Crotty et al. [46]

RCT

66

32%

SF-36

4 months

Patient-centered counselling vs CC

Hagsten et al. [34]

RCT

85

79.4 (65–93)

22%

SWED-QUAL

2 months

Allegrante et al. [29]

RCT

59

77.0  8.0

24%

SF-36

6 months

Gambatesa et al. [44]

RCT

40

80.2  6.5

8%

SF-36

1 month

Significant better PF and less BP was established in the HR group at 6 months (PF: p = 0.003, BP: p = 0.002) and 1 year (PF: p = 0.001, BP: p = 0.042) of follow-up. No significant differences on SF-36 subscales between HR and CC group were reported at 1 year of follow-up. No significant difference on PCS or MCS between ST and CC group was established at 3 months of follow-up. Significant better scores on PCS and MCS were found in the ST group at 6 months of followup. No significant difference on PCS or MCS between HR and CC group was found at 4 months of follow-up. Individualised OT appeared to speed up both mental and social recovery postoperatively, but no significant difference was established at 2 months of follow-up. Significant better scores for role-physical were established in the intervention group at 6 months of follow-up (p = 0.01). Significant increased scores for VT, PF, RP, RE, and MH were established in the intervention group at one month of followup compared to baseline scores (p < 0.05). In the CC group, all items remained unmodified, except for PF (p < 0.05).

Intensive vs nonintensive HR

Ryan et al. [35]

RCT

71

80.9  6.9

–

EQ-5D

3 months

Multidisciplinary nutritional care vs CC

Ryan et al. [30]b

Controlled prospective cohort study

–

–

1 year

NS vs NS + nandrolone vs CC

Hoekstra et al. [48]

RCT

Tidermark et al. [70]

127

59

–

–

80.3  8.4

24%

EQ-5D

3 months

82.9  5.4

0%

EQ-5D

1 year

Six or more face-to-face contacts per week did not result in improved HS at 3 months of follow-up in comparison with three or less visits per week. Six or more face-to-face contacts per week did not result in improved HS at 1 year of follow-up in comparison with three or less visits per week. Significant lower decline in HS after hip fracture was established in the intervention group at 3 months of follow-up (p = 0.004). The decline in HS was least pronounced in the NS + nandrolone group at 6 and 12 months of follow-up.

a

This study is a one-year follow-up of the 102 patients from Zide´n et al. [93]. This study is a one-year follow-up of the 71 patients from Ryan et al. [35]. c This study started from 3 months postoperative. Sylliaas et al. [63] is a follow-up study of the 100 patients in the intervention group of Sylliaas et al. [40] with new randomization at 6 months postoperative. Abbreviations: HR, home rehabilitation; vs, versus; CC, conventional care; PCS, physical component summary scale; MCS, mental component summary scale; ST, strength training; OT, occupational training; SWED-QUAL, Swedish Health-Related Quality of Life questionnaire; SC, supportive counselling; VT, vitality; PF, physical function; RP, role-physical; RE, role-emotional; MH, mental health; NS, nutrition supplementation. b

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Design

Number of subjects

Age at surgery (years) Mean  SD (range)

% Male

HRQOL or HS question-naire

Follow-up period

Conclusions

Postoperative HDU stay vs OPW (FNF)

Turner et al. [27]

Pragmatic RCT

180

82.6 (65–103)

18%

SF-12, EQ-5D

1 year

Turner et al. [32]a

–

37

82.7 (72–100)

22%

–

7 years

No significant difference on HS was established between HDU and OPW group at 1 year of followup. No significant difference on HS and mortality was found between HDU and OPW group at 7 years of follow-up.

Thompson’s HA (displaced FNF)

Chikude et al. [38]

Cohort study

30

83 (70–95)

20%

SF-36

11 months

Good scores were established for 6/8 components of SF-36 scale (pain, overall HS, and social, emotional, mental health and physical aspects), medium scores for vitality, and low scores for functional capacity at 11 months of follow-up.

Primary THR vs secondary THR after failed IF (displaced FNF)

Blomfeldt et al. [56]

Cohort study

84

79.5  5.2 (70–90)

11%

EQ-5D

2 year

Secondary THR would give an inferior outcome on HS compared to primary THR. However, secondary THR seemed to be a safe salvage procedure after failed IF.

To evaluate responsiveness of EQ-5D and SF-36 scale in patients with FNF

Tidermark et al. [61]

RCT

110

80.0  5.8 (70–96)

19%

EQ-5D, SF-36

4 months

Good responsiveness was established for both instruments in the multifaceted domains of physical, psychological and social functioning.

Comprehensive discharge planning vs CC after hip fracture

Lin et al. [64]

RCT

50

78.8  7.0

64%

SF-36

3 months

Significant better social functioning (p = 0.028), vitality (p = 0.004), bodily pain (p = 0.009), and general health perceptions (p = 0.029) were reported in the experimental group at 3 months of follow-up.

Impact of postoperative pain on HS after hip fracture

Shyu et al. [59]

Descriptive, correlational design

87

79.8  7.2

36%

SF-36

1 year

Experienced pain during the first month after discharge significantly impacted patients’ HS throughout the remaining year.

THR with uncemented hydroxyapatite-coated femoral component (displaced FNF)

Sko¨ldenberg et al. [57]

Prospective single-series study

50

80 (70–92)

28%

EQ-5D

2 year

No significant difference on HS was established at 2 years of follow-up compared to pre-fracture status (p = 0.112).

Nonagenarians vs control cohort (FNF treated with HA)

Sanz-Reig et al. [33]

Prospective cohort study

66

93 (90–98) vs 82 (75–89)

39%

SF-12

1 year

Significant worse scores on PCS (p = 0.001) and MCS (p = 0.001) were established in the nonagenarians cohort group for the survivors at 1 year of follow-up.

To explore prognostic factors for HS after hip fracture

Sylliaas et al. [62]

Prospective cohort study

277

82.4  6.5 (65–96)

18%

SF-12

3 months

Significant and independent risk factors for low HS at 3 months of follow-up were prefracture use of walking aids, prefracture PCS or MCS score, and cognitive dysfunction. Being female demonstrated borderline significance for a low MCS-score.

Impact of cognitive problems on HS after hip fracture

Karni et al. [24]

Prospective cohort study

60

83.0  6.5

0%

SF-12

1 month

No significant difference on PCS or MCS between cognitively unimpaired and impaired women was established at 1 month of follow-up.

Platelet-rich therapy vs CC (intracapsular hip fracture)

Gryphon et al. [71]b

RCT

200

83.0  8.0

29%

EQ-5D

1 year

No significant difference on HS was established between platelet-rich therapy group and CC group at 1 year of follow-up.

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First author, year of publication

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Purpose/treatment (study population)

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Table 5 Other included studies reporting information about HRQOL/HS.

% Male

HRQOL or HS question-naire

Follow-up period

Conclusions

38

78  7

16%

SF-36

1 year

Prospective cohort study

60

86.9  8.1 (62–104)

30%

EQ-5D

1 year

All SF-36 subscales scores were lower than prefracture scores compared with at 1 year of follow-up, except for PH. The majority of the recovery has taken place in 6 months postoperative. Significant loss in HS was found at 3, 6, and 12 months postoperatively (p = 0.003). Most of the reported recovery occurred within 3 months of the hip fracture.

Jones et al. [63]

Prospective cohort study

245

80.5  7.5

27%

HUI2 and HUI3

6 months

Moderate to good agreement of the change scores was established between patients and proxy respondents. Agreement was higher during more stable periods of recovery.

Van Balen et al. [41]

Prospective cohort study

102

83

16%

NHP

4 months

Compared with reference values at 4 months, significant differences were found in physical mobility (p < 0.001), social isolation (p = 0.001), sleep (p = 0.008), emotional reactions (p = 0.02). Compared with reference values at 4 months, significant differences were found in daily housekeeping and physical condition (p < 0.001). Compared with reference values at 4 months, lower scores of health were found in physical mobility, emotional reactions and social isolation. Compared with reference values at 4 months, lower appreciation of health was found in physical fitness, feelings, daily activities and overall health. Compared to a control group at 3 months of follow-up, significant reduction in PF (p < 0.0003), vitality (p < 0.02) and SF (p < 0.01) was established after hip fracture. Compared to a control group at 3 months of follow-up, significant reduction in PF (p < 0.001), SA (p < 0.0001) and GH (p < 0.01) was established after hip fracture. All SF-36 subscale scores were worse than reference values at 1 month of follow-up, except for GH. The largest differences were found for PF en RP. At 4 months and 1 year of follow-up, the subscales did not differ from the reference values, except for SF, PF, and RP.

First author, year of publication

Design

To measure recovery after hip fracture surgery.

Peterson et al. [43]

Prospective cohort study

Beaupre et al. [72]

To examine agreement between patient and proxy respondents on HRQOL after hip fracture.

To investigate HS after hip fracture.

Number of subjects

DCFHAC

Van Balen et al. [52]c

–

208

83

21%

NHP

–

DCFHAC

Randell et al. [49]

Prospective case–control study

61

84  7 (68–98)

30%

SF-36

3 months

OPAQ2

Shyu et al. [31]

Prospective cohort study

Undisplaced vs displaced FNF treated with IF

Tidermark et al. [68]

Prospective clinical study

HS after FNF treated with IF

Tidermark et al. [50]d

–

110

90

–

79.4  7.5 (65–96)

80  7.3 (66–92)

–

39.1%

27%

–

SF-36

1 year

EQ-5D

2 years

Significant better HS was established in the undisplaced fracture group at 1 year (p < 0.005) and 2 years (p < 0.005) of follow-up.

–

17 months

The EQ-5D index scores increased between 1 week and 4 months, and then decreased up to 17 months after the fracture. Prefracture HS level was not regained.

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Age at surgery (years) Mean  SD (range)

Purpose/treatment (study population)

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Table 5 (Continued )

9

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This study is a seven years follow-up of the 180 patients from Turner et al. [27]. The EQ-5D scores of the 200 included patients at 6, 12, and 52 weeks of follow-up is presented in the study of Parsons et al. [92]. c This study also included 102 patients of Van Balen et al. [41]. d This study included the same patients as the study of Tidermark et al. [50]. Abbreviations: HDU, high dependency unit; OPW, orthopaedic ward; HA, hemiarthroplasty; THR, total hip arthroplasty; IF, internal fixation; FNF, femoral neck fracture; CC, conventional care; PCS, physical component summary scale; MCS, mental component summary scale; CC, conventional care; HUI, Health Utilities Index; NHP, Nottingham Health Profile; DCFHAC, Dartmouth COOP Functional Health Assessment Charts; OPAQ2, Osteoporosis Assessment Questionnaire; PF, physical function; SF, social function; SA, social activity; GH, general health; TF, trochanteric fracture; CN, cephalomedullary nail; SHS, Sliding hip screw; NA, not available; RP, role-physical. b

Brenneman et al. [60] HS after hip fracture in postmenopausal women.

a

Significant worse scores on PCS (p < 0.0001) and MCS (p < 0.004) were established for women with fractures compared to women without fractures at a follow-up moment varied between 8–39 months. NA SF-12 (66–99)

Prospective cohort study Ekstro¨m et al. [28] HS after stable TF treated with SHS

Longitudinal observational study

257

0%

Significant worse HS was established after TF at 4 months (p < 0.001) and 1 year (p < 0.05) of follow-up compared to pre-fracture level. No significant difference on HS was established at 2 years of follow-up (p = 0.522). 2 year EQ-5D 26% 83.2  6.5 (68–101) 148

2 year EQ-5D 25% 82.5  7.8 (66–101) Prospective cohort study Ekstro¨m et al. [69] HS after sub-TF fracture treated with CN

87

Follow-up period HRQOL or HS question-naire % Male Age at surgery (years) Mean  SD (range) Number of subjects Design First author, year of publication Purpose/treatment (study population)

Table 5 (Continued )

Significant worse HS was established after sub-TF at 4 months (p < 0.001), 1 year (p < 0.001), and 2 years (p < 0.05) of follow-up compared to prefracture level. HS remained at the same level between 4 months and 2 years of follow-up.

C.M.M. Peeters et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Conclusions

10

good psychometric properties as prior research showed that the WHOQOL-Bref is a reliable and valid instrument for the assessment of QOL [76–79]. Grewal et al. reported that individual’s quality of life in older people, like a hip fracture population, was limited by individual’s loss of ability to pursue the different attributes [80]. Coast et al. developed an index of capability when evaluating interventions aimed at older people: the ICECAP-O. It measures capability with regard to attachment, role, enjoyment, security and control. The ICECAP-O is validated in older people in different settings (e.g., post-hospitalised [81] or post-acute persons [82]). Utility scores can be calculated, allowing use in economic evaluations [81–90]. Due to the high mortality in the first few months after a hip fracture, HS was probably presented more favourable than reality [7,58,72]. At the first follow-up moment all included studies which compared HS scores with baseline, showed an increase in perceived health [30,35,41,43,44,48,50,52,59,63]. However, it is reasonable to assume that the increase in HS scores was probably elevated due to the selection of survivors, who were capable to complete the measures multiple times. Patients with the lowest scores at baseline were probably the patients who died shortly after the hip fracture and thus dropped out of the study. Therefore, they could not be included in further research. Subsequently, there were also studies which included only survivors in their analysis, who had filled in all follow-up questionnaires. This may have caused publication bias [48,50,54,55,68]. So, overall HS after a hip fracture in elderly is probably worse than presented in this review, in particular for the first few months postoperative. The use of correction of mortality for loss to follow-up according to ‘‘MC = (1 r)  MNL + r  ML’’ would be the preferred method to present data in hip fracture studies [91]. In most included studies, follow-up data was compared with preinjury data as assessed by patients within the first week after hip fracture [25,27–29,34,36,37,42,45,47,49,50,54–58,61,62,64– 70,72]. This may have caused recall bias. As it is not possible to prospectively collect HRQOL/HS prefracture data, the use of population values would be recommended. However, there are studies who have questioned this recall bias. For instance, the rated prefracture HS score of the patients of the study of Tidermark et al. [50] was shortly studied after the injury (within 12–48 h). It showed good correspondence with an age-matched reference population [50]. Moreover, patients’ HS or HRQOL before the hip fracture could be worse in reality in comparison with a reference population norm, for instance due to comorbidity. Fourteen studies did not present data exceeding six months follow-up [24,29,34,41,44,46,48,49,51,52,61–64]. This might be too short, considering that within this period most patients are not recovering completely. The study of Brenneman et al. [60] was used to provide an impression of HS in hip fracture patients in relation to other fractures in elderly; 2257 hip, spine, rib and wrist fractures in postmenopausal women were included, subdivided in an age group beneath and above 65 years. Spine fractures caused most impairment of PCS and MCS of the SF-12 scale, followed by a hip fracture. In the age group beneath 65 years, patients with spine fractures had significantly lower PCS than hip fracture patients, but this association was not found in women older than 65 years. The MCS scores of hip fracture patients was not significantly different from other types of fractures. So hip fractures in elderly patients have at least a comparable impact on HS as spine fractures [60]. We have extracted the data and made an overview of different surgical treatment options for hip fractures and their impact on HRQOL or HS. In particular, the treatment options of displaced FNF’s are compared with each other [37,42,45,47,51,53–55,58,65– 67]. In all studies, treatment with IF had the worst outcome in HS, probably due to the high fracture healing problems and other

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Item A B

Raia et al. [42] Tidermark et al. [61] Tidermark et al. [45] Blomfeldt et al. [65] Blomfeldt et al. [56] Hagsten et al. [34] Turner et al. [27] Turner et al. [32] Blomfeldt et al. [37] Chikude et al. [38] Gjertsen et al. [54] Lin et al. [64] Shyu et al. [59] Gjertsen et al. [55] Ziden et al. [26] Hedbeck et al. [66] Hedbeck et al. [47] Hoekstra et al. [48] Sko¨ldenberg et al. [57] Sanz-Reig et al. [33] Sylliaas et al. [39] Sylliaas et al. [62] Taylor et al. [53] Gambatesa et al. [44] Hedbeck et al. [58] Inngul et al. [67] Aktselis et al. [36] Karni et al. [24] Calder et al. [51] Peterson et al. [43] Ryan et al. [30] Allegrante et al. [29] Orwig et al. [25] Jones et al. [63] Griffin et al. [71] Tidermark et al. [70] Ryan et al. [35] Sylliaas et al. [40] Crotty et al. [46] Ekstro¨m et al. [69] Beaupre et al. [72] Randell et al. [49] Van Balen et al. [41] Tidermark et al. [50] Tidermar et al. [68] Van Balen et al. [52] Shyu et al. [31] Brenneman et al. [60] Ekstro¨m et al. [28]

0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 0 0 1 1 0 0 0 0 1 0 0 0 0 1 1 0 1 0 1 0 1 0 0 0 0 1 1 0 1 1 1 1 0 1

0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 1 0

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

Total score

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 0 0 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 1

1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0 1 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 1 0 1 0 0 1 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 1 0 0 0

0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 0 0 1 1 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 0

0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 0 0 1 1 0 0 0 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 1 0 0 0 0 1 0 0 1 1 0 0

1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 0 1 0 1 1 1 0 0 1 1 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1

1 0 1 1 1 0 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 0 1 0 1 1 1 0 1 1 0 1 1 1 1 1 0 0 0 1 1 0 0 1 1 0 1 1 1

0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 1 0 0 1 0 0 0

1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

10 13 13 11 11 12 9 8 11 7 10 11 14 11 14 10 9 15 14 10 10 11 11 12 10 10 11 8 11 12 7 11 10 15 14 13 6 10 9 10 11 12 13 12 11 15 13 11 11

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Table 6 Quality assessment.

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Fig. 2. SF-36 scores. Mean scores with SD of the eight domains of the SF-36 scores of nine included studies [29,31,38,42–44,59,61,64]. The size of the circle around the mean score is related to the number of patients included in the study. Studies which compared more than one patient group were aggregated to form one group with mean scores of the SF-36 domains for each individual study. The vertical line presents SF-36 scores of a Canadian reference population with the age of 75+ [20].

Fig. 3. EQ-5D index scores. MeanEQ-5D index scores with SD over time of fourteen included studies [27,28,30,36,37,48,50,55,57,65,66,69,71,72]. The size of the circle around the mean score is related to the number of patients included in the study. Studies which compared more than one patient group were aggregated to form one group with a mean EQ-5D index score for each individual study. The vertical line presents EQ-5D index scores of a Swedish reference population with the age of 75+ [22].

complication rate [45,65]. There were no differences found in HRQOL and HS scores between the U-HA and B-HA treatment group, apart from a higher HS score at 4 years postoperative for the B-HA group in the study of Inngul et al. [67]. In conclusion, THA and

HA are probably the best treatment options for displaced FNF’s regarding the HS scores. There are indications suggesting that THA should be the preferred method of treatment in active elderly patient with a long life expectancy. However, there was only one

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RCT with a follow-up study which investigated the differences in HS outcomes between these two treatment groups [37,47]. More RCT’s are warranted with adequate measurements of HRQOL using questionnaires regarding on a combination of objective functioning in the three health dimensions of HRQOL and more subjective perceptions of health. In conclusion, a hip fracture has a major impact on HRQOL and HS on both physical and psychosocial dimensions, and the recovery of HS to the pre-fracture levels is lengthy, if that level is ever reached. Optimizing nutrition intake and physical (home) rehabilitation programmes could be recommended after surgery, however few studies have examined its effectiveness. In addition, screening for patients with difficulties in the psychosocial dimensions by HRQOL questionnaires or licensed nurses is advisable to provide them the possibility for psychological counselling during the hospital-stay and afterwards, if necessary. Besides HS questionnaires as EQ-5D and SF-36, adequate measurements like the WHOQOL-Bref or ICECAP-O would be recommended in future studies regarding hip fracture surgery and postoperative treatment options in order to improve the quality of care for patients faces with the hip fracture epidemic. Author contributions CP, EV, TG, CR, BO and JV contributed to conception and design of this study; Study selection and data extraction of the finally included studies was done by CP. CP and EV independently assessed the methodological quality of each included study. CP, EV, CR, TG, BO and JV contributed to preparation of the manuscript. The final version of the article was approved by all the authors. CP takes responsibility for the integrity of the work as a whole. Conflict of interests The authors have no conflicts of interest to disclose. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2016.04. 018. References [1] Bergstrom U, Jonsson H, Gustafson Y, Pettersson U, Stenlund H, Svensson O. The hip fracture incidence curve is shifting to the right. Acta Orthop 2009;80(5):520–4. [2] Cooper C, Campion G, Melton 3rd LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992;2(6):285–9. [3] Schurch MA, Rizzoli R, Mermillod B, Vasey H, Michel JP, Bonjour JP. A prospective study on socioeconomic aspects of fracture of the proximal femur. J Bone Miner Res 1996;11(12):1935–42. [4] Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int 2004;15(11):897–902. [5] Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ 1993;307(6914):1248–50. [6] Vestergaard P, Rejnmark L, Mosekilde L. Increased mortality in patients with a hip fracture-effect of pre-morbid conditions and post-fracture complications. Osteoporos Int 2007;18(12):1583–93. [7] Valizadeh M, Mazloomzadeh S, Golmohammadi S, Larijani B. Mortality after low trauma hip fracture: a prospective cohort study. BMC Musculoskelet Disord 2012;13 ((Valizadeh M., [email protected]) Metabolic Disease Research Center, Zanjan University of Medical Sciences, Zanjan, Iran). [8] Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a populationbased study. J Am Geriatr Soc 2002;50(10):1644–50. [9] Gill TM, Feinstein AR. A critical appraisal of the quality of quality-of-life measurements. JAMA 1994;272(8):619–26. [10] Den Oudsten BL, Van Heck GL, De Vries J. Quality of life and related concepts in Parkinson’s disease: a systematic review. Mov Disord 2007;22(11):1528–37. [11] Group W. Development of the WHOQOL: rationale and current status. Int J Mental Health 1994;23(3):24–56.

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