Long- Term Outcome of Hip Fracture in Elderly Rural Indian Population

Hip fractures are amongst the most commonly seen fractures in emergency departments worldwide, especially in elderly populations over 65 years old [1] and most commonly results from low-energy trauma like simple falls. As medicine evolves, the life expectancy is increasing, leading to an increase in osteoporosis, a harbinger of hip fractures. It is expected that the number of hip fractures would rise to double worldwide by the year 2050 [2]. If the world numbers are to be believed, the estimated incidence of hip fracture will rise from 1.66 million in 1990 to about 6.26 million by the year 2050 [3].


Orthopedics and Rheumatology Open Access Journal
As three-quarters of the world's population reside in Asian subcontinent, it is projected that Asian countries will contribute more towards hip fractures in coming years, resulting in enormous health related economic burden and significantly altering health related quality of life, especially in elderly population . In India the figures would be much more, because it's presently the world's 2nd largest populated country with wide diversity between urban and rural population .Problems of the hip fractures in elderly population, especially in rural population are [1] Associated with substantial morbidity and mortality [2]. Malunion of fracture is common despite good fixation devices available presently [3] implant failure, causing the implant to cut-out of head and resulting in implant penetration into hip joint causing intractable continuous pain [4].
Added financial burden to already low socioeconomic income rural family [5] associated co morbid medical conditions like diabetes, hypertension, malnutrition and osteoporosis etc. which are overlooked due to poor socioeconomic condition. The reasons for mortality related to hip fractures may be numerous, but reduced mobility and rehabilitation after sustaining a hip fracture may be one of the most important contributory factors, both in increasing the incidence of morbidity and in prolonging the subsequent recovery. Specifically, a patient's physical activity and ability to walk, both preoperatively and postoperatively, seems to correlate with survival time.
Consequently, medical costs will also be increased significantly and exponentially, imposing an intense burden on already disorganized and strained health system. There will be many hurdles to overcome in years to come as resources become scarce and the health demand increases. Published mortality rates have varied from 12% to 50% at one year after hip surgery [4][5][6][7][8][9][10] and as high as 30% at 2 years [11]. Surgical management of hip fracture in elderly are varied and the available common options include reduction and osteosynthesis, hemi arthroplasty, or total hip arthroplasty and depends on various factors like fracture geometry, physiological age of patient, available resources at hospitals and associated medical illnesses.
A hip fracture commonly includes all the fractures starting from the neck of the femur to the subtrochanteric region of proximal femur. For simplicity purposes, they are subdivided in three main categories depending on anatomical fracture location. Almost 90 -95%of hip fracture in elderly population comprises of neck and intertrochanteric fractures occurring in equal proportion, while the remaining 5 -10 % comprises of subtrochanteric fracture. Statistical data clearly indicate that one out of five women, aged 80 years or above, has sustained or will sustain a hip fracture [5].
Moreover, a fractured hip in elderly may lead to chronic disability, which might not recover and can also increase the incidence of fracture or age related complications leading to death. While rehabilitation interventions are meant to decrease the risks of falls for preventing hip fractures, post fracture rehabilitation care is important and crucial in recovery of the patient [12][13][14][15][16][17]. These rehabilitation interventions should be initiated as early as possible in post-operative phase and should be ideally continued till the individual has acquired maximum functional skills, physical activity and strength to be able to return within the community.
A detailed understanding of the newer treatment modalities, available resources at hospital and the appropriate medical management and rehabilitation strategies are necessary to minimize post fracture complications, morbidity and mortality. A combined approach of orthopedic surgeon along with physical therapist in early post-operative phase is usually the desired approach. The overall goal in the treatment of the geriatric hip fractures is to make an attempt to return the patient to the premorbid level of function [13][14][15][16].
The reasons for mortality after sustaining hip fractures may be numerous, but reduced mobility in elderly population may be one of the most important contributory factors, both in increasing the incidence of hip fractures themselves and in prolonging subsequent recovery [18]. Specifically, a patient's ambulatory status and physical activity both preoperatively and postoperatively, seems to correlate well with survival time [4].
The purpose of our study is to evaluate and determine the proportion of hip fractures in patients older than 65 years and those who experience long -term disability and morbidity due to hip fractures. A functional outcome evaluation following a hip fracture was carried out and results were compared with the pre injury activity level of the individuals.

Aim and Objectives
Aim of our study is to evaluate and determine the proportion of hip fractures in patients older than 65 years of age.
The objective was to evaluate the functional outcome following a hip fracture and to compare with the preinjury level activity of the individuals.

Materials and Methods
We included all the patients elder than 65 years with hip fractures as described attending trauma and orthopaedic department of our institute. A prospective study was carried out at our institute from January 2011 to May 2014. These patients were managed with non-operative means due to various reasons, fracture reduction and osteosynthesis, hemiarthroplasty and total hip arthroplasty, depending on fracture type, consent availability, socioeconomic status and willingness of patient and family, presentation days after injury and associated medical co morbid conditions. The data was analyzed was done with respect to age, gender, injury mechanism, fracture pattern related to stability of fracture, baseline preinjury functional status regarding ambulation and physical activity, timing of presentation to hospital, timing of surgery and medical complications.

Results
A total of 1165 elderly patients, belonging to rural geographical region were included in the study with the mean age was 69.32±5.8. Out of 1165 patients, the male patients were 468(40.17%) and female patients were 697 (59.82%). A total of 663 (56.90 %) subjects of these elderly populations were independent ambulatory at pre -injury period324 (27.81%) patients were ambulatory with some mild restrictions like the help of walking stick. 102 (8.75 %) elderly individuals were ambulatory with major restrictions in walking with a clear use of crutches or walker. 76 (6.52%) of this population was non -ambulatory or were dependent on family members for ambulation or practically non-ambulatory (Table 1). Complications related to fracture and modality of treatment was observed in operative and non -operative group of patients. Out of total 1165 patients, the recovery was uneventful in 897 (76.99%) patients without any complications. 24 (2.06%) patients had developed surgical site infection (SSI). In 79 (6.78%) patients there were medical complications like electrolyte imbalance and CNS related manifestations like postoperative delirium etc. In 65 (5.57%) patients there were recumbence related complications (development of sacral pressure sores). Intertrochanteric fractures were seen in 671 patients (57.59%), intracapsular femoral neck fractures in 431 patients (36.99%) and 63 (5.40%) patients had sustained subtrochanteric fracture. We noted that the fracture configuration was not related to activity at the time of fall, or to the location of the fall. Treatment was individualized in each patient and modality of treatment depended on fracture location, days after presentation, socioeconomic status of patient and family. Nearly all intertrochanteric fractures were treated by open reduction and internal fixation (ORIF) with dynamic hip screw and plate fixation or proximal femoral nailing where as Intracapsular fracture were treated with hemiarthroplasty or total hip arthroplasty according to the state of joint and socioeconomic status of patient and family ( Figure 1). Preoperatively, 92.5% patients were ambulatory, either independently or with some form of restrictions, and 88% of the survivors at 1 year remained ambulatory. The risk of dying or being non-ambulatory 1 year postoperatively was increased in patients who were nonambulatory preoperatively and belonged mostly from ASA grade IV (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.3-1.6; P < .0001), by increasing age of >75 years (HR, 1.8; 95% CI, 1.2-2.6; P < .007).

Discussion
Hip fractures are one of the leading causes of morbidity and mortality in the geriatric age group population. Many studies have been led to evaluate the factors playing a role in the falls and subsequent fractures in elderly patients [19][20][21]. Current study was designed to evaluate and determine the proportion of hip fracture in patients older than 65 years and to evaluate the long-term consequences after sustaining hip fracture in elderly patients.
The mean age incidence in various studies were as in Bolhofner et al. [22] 79 years, Sahlstrand [23] 75 years, Baumgaertner et al. [24] 77 years, Kanojia et al. [25] 56.79 Orthopedics and Rheumatology Open Access Journal years, Sedighi [26] 76.7 years. For our study age incidence was 69.32±5.8 years as we have included only those patients who were more than 65 years of age.
Most common cause of mode of injury is stumbling and tripping which usually occurs indoors at a level ground [27][28][29][30]. In our study population, the most common cause of sustaining fracture was fall while working in the field as majority of our patient were laborer or farmer. Due to the deprived socio economic and deprived family support to the patients' presentation to the hospital is usually late. Average time of presentation to the hospital was 9 days and ranged from 0 to 23 days after injury. Delay in presentation in our study is explained by the lack of family emotional support for elderly patients, lack of transport infrastructure in rural area of India and socioeconomics in rural population in India. In intracapsular fractures of neck of femur, most of the elderly patients were managed with hemiarthroplasty or total hip replacement for early ambulation of these populations.
Whereas Wongwai and co-scientists [31], however, showed that delayed reduction and fixation of these fractures also brings good results, so the timing of surgery is a matter of debate. We preferred to perform hemiarthroplasty in patients of intracapsular fractures who were physiologically less active, presented late after injury and in older patients for need of early mobilization and early ambulation, and subsequently to avoid second surgery, in case the osteosynthesis related surgery, which has a high failure rate in geriatric age group. We performed reduction and internal fixation for patients who were physiologically active, Intertrochanteric and subtrochanteric fractures, presented early after injury along with some familial emotional support, so that in an event of failure of first surgery, subsequent surgery is not a problem. We observed that there was a direct correlation between presentation time after patients and familial emotional support and socioeconomic background. Major cause for this divergence may be a better optimization protocol for patients with co-morbidity and require added time for medical clearance prior to surgery.
The correlation between ASA grade and post-operative mortality has already been established and confirmed by other authors and in our data [32][33][34]. However we observed that the patient who were not ambulatory or minimally ambulatory before sustaining trauma showed higher percentage of morbidity and mortality. Study conducted at Scottish National Health Service [35] found 21% mortality within 120 days. Similar work from New Zealand [36] used age-matched population data to attribute 15.6% of the cohort mortality at one year to the fractured hip process. In our study 16 patients died within 3 months of fracture treatment and remaining 1 patient died within one year after injury and its treatment. However the age group of study population at Scottish National Health service and New Zealand were approximately 12.2 year older than our study group population [35,36].

Conclusion
Elderly patients with proximal femoral fracture usually recover and do well after surgery. The rate of recovery and the deterioration in patients' status is maximal within three months after injury / surgery. Rate of complications and mortality increases as the severity of grade of ASA grade increases. The rate of complications is directly proportional to presentation after injury and preinjury activity level. However, preinjury ambulatory status has direct impact on the ambulatory outcome after treatment of the proximal femoral fracture.
If the elderly patient survives without any major complications within first three months period after injury or surgery, then there is a good likelihood of recovery of the patient, and return to preinjury level is expected. However, Long term follow up is generally required to look for implant related problems, late infections. Prevention of falls in elderly population is would result in major reduction in injury burden and morbidity as well as reduced impact on socioeconomic status on already burdened rural household.