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Abstract

MJA 1997; 167: 412-415  

Introduction

The economic and social implications of hip fracture in the Australian community are enormous, with the overall cost approximating $420 million annually.⁶ Previous studies have shown an increased morbidity and mortality associated with hip fracture in elderly women, in whom outcomes are usually poor and partly related to age and medical conditions.^7-12 Until recently, there have been comparatively few data on hip fracture in elderly men.^12-19

Given the importance of hip fracture, we analysed the mortality and functional outcome of hip fracture in elderly men (aged 60 years and over) who presented to our hospital.  

Methods

We retrospectively audited the medical records of all men and women with hip fractures presenting to St George Hospital between 1 January and 31 December 1995. Men were eligible for the study if they were aged 60 years or over, and if their hip fracture was not the result of high impact injuries or local bone disease. The prognostic factors and outcomes following hip fracture of eligible men were compared with those of an equal number of age-matched women who presented with hip fractures during the same 12-month period. Ethical approval for this study was granted by the St George Hospital Ethics Committee.

From the hospital medical records, we recorded:

• Patient's age;
• Prognostic factors, such as pre-existing illness, osteoporotic risk factors^14,17-19 and type of fracture; and
• Outcome data, such as fracture-related complications, length of hospital stay, mortality, and level of function (as measured by the Barthel index of activities).²⁰

These data are routinely recorded by the orthopaedic intern or registrar, appropriate consultative services, occupational therapist, and/or aged care and rehabilitative services. The Barthel index consists of a questionnaire containing 10 questions pertaining to activities of daily living, such as mobility, bathing, dressing, and toilet use, and is scored out of a total of 20 points -- the lower the score, the worse the disability. Any additional data that were required were obtained by telephone interviews with the patients and/or their family members.

Subsequently, patients were followed up prospectively six and 12 months after hip fracture by telephone interview. We obtained data pertaining to whether they were living at home or in an institution, and then used the original 10 questions on the Barthel index questionnaire again to assess activities of daily living, self-care ability and mobility.  

Statistical analysis

Results

Forty-one men (80%) were contactable for assessment of outcomes at six and 12 months. We were unable to contact 10 men, either by a mailed questionnaire or through the telephone directory services. Their names had not been recorded in the death registry of the New South Wales Bureau of Births, Deaths and Marriages. They were considered lost to follow-up.

Box 1 (below) compares the clinical data of the men and women with hip fracture. The median age of the 51 eligible men was 80 years; four were aged less than 70 years. Their mean length of hospital stay was 13 days (range, 3-55 days). Sixteen men (32%) came from hostels or nursing homes before admission. Thirty men (58%) were classified radiologically as having trochanteric fractures and 21 (42%) as having cervical fractures; they did not differ with respect to clinical presentation or postfracture outcomes (data not shown).

Compared with women, men had a higher prevalence of excessive alcohol consumption (chi-squared = 13.95; P = 0.004) and current smoking (chi-squared = 14.96; P = 0.0004). Forty-eight men (95%) had at least one medical problem before admission; the mean number of medical problems per patient was three (range, 0-4). Forty-seven women (92%) had at least one medical problem, with a mean number of medical problems per patient of two (range, 0-4) (Box 2). Forty men (78%) had at least one risk factor for osteoporosis; the mean number of risk factors per patient was one (range, 0-3). Similarly, 36 women (72%) had at least one risk factor for osteoporosis (not including menopausal status), with a mean number per patient of one (range, 0-4) (Box 2). Ten men (20%) with hip fractures died: seven during hospital admission and another three during the first six months after fracture. More men than women with hip fractures died during their acute hospital admission, but this difference was not significant (P = 0.06). Fifteen men (30%) developed fracture-related complications, five of whom died in hospital. Those who had complications developed an average of two complications each (range, 0-4). This was similar for women; 16 (32%) developed fracture-related complications, three of whom died in hospital, and the average number of complications was one (range, 1-4). The occurrence of individual fracture-related complications did not differ significantly between men and women with hip fracture. Fracture-related complications were the single most important predictor of death in men (odds ratio [OR], 13.5; 95% CI, 1.74-132; P = 0.06). By contrast, the most important predictor in women was the prefracture Barthel index score. In men, age, smoking history, alcohol intake, pre-existing medical illness, prefracture Barthel index score, and length of hospital stay did not contribute significantly to the fracture-related mortality.

The Barthel index score (mean, 14.9 at baseline) deteriorated significantly by six months (mean, 13.4; P < 0.05) and 12 months (mean, 12.4; P < 0.05). The baseline Barthel score did not differ significantly between men and women. After fracture, an additional nine men required hostel or nursing home accommodation. This correlated significantly with both the patient's age and the per cent decline in the Barthel index score (r = 0.41; P = 0.0002).  

Discussion

Although our study has the major limitation of small sample size, it is the first Australian study to show a significant decline in physical functioning in men after hip fracture. A decline in physical functioning has been noted in both men and women after hip fracture, with many survivors requiring institutionalisation. Almost one-third (32%) of our men originated from institutionalised care, and an additional 18% were subsequently discharged to institutionalised care. Age and percent decline in Barthel index score were the most important criteria leading to their institutionalisation. While the use of the Barthel index may potentially identify individuals who will need long term institutionalisation, this is only a gross assessment of activities of daily living. Thirty per cent of the men in our study returned home to their previous level of function as measured by the Barthel index, but anecdotally many reported a decline in more subtle activities not measured by this index. In a study by Marotolli et al., 29% of all hip fracture patients were institutionalised at six months postfracture.¹³ Another study reported that 79% of the patients surviving at one year were residing in nursing homes or intermediate care facilities, while those who returned home had significant functional decline, with almost 60% limping or requiring a cane or walker.¹⁵

Reported rates of mortality and morbidity in men with hip fracture vary from 13%-44%,^{1,4,5,9,10,11,16,22} with the likelihood of a man dying after hip fracture increased by 83% and the likelihood of subsequent hospital admission after hip fracture increased by 231%.⁵ In our study, 20% of men with hip fractures died, either during the initial hospital admission or within the first six months after fracture. Although not statistically significant, we found that, compared with women, twice as many men with hip fractures died during the acute hospital admission (P = 0.06). These data are consistent with those of many other studies which have shown higher postfracture mortality rates in men.^1,10,22 For example, Holt et al. recorded 17% mortality in men compared with 11.5% in women,²² while Jacobsen et al. reported mortality rates per 1000 person-months postfracture of 33.7 in white men compared with 17.2 in white women.¹⁰ In our study, death occurred predominantly within the first two months postfracture, and fracture-related complications was the strongest predictor of death. In a longitudinal study of ageing, Wolinsky and colleagues found a one-year postfracture mortality among 7527 members of approximately 24%, with the greatest risk of dying in the first six months after hip fracture (hazard-risk ratio, 57.4; 95% CI, 43.7-75.3); survival rates estimated at six months postfracture returned to a trend similar to that of control subjects.⁵

Despite the limitations of small sample size and a lack of control subjects who had not had hip fracture, this study shows men who present with hip fracture are usually elderly and fragile and have numerous risk factors for osteoporosis, pre-existing medical illnesses and fracture-related complications. In men, this results in higher postfracture mortality compared with age-matched women, as well as in significant functional decline. This study highlights the need to identify men with osteoporosis in the community, and the need to find effective strategies for preventing hip fracture.  

References

1. Cummings SE, Kelsey JL, Nevitt MC, O'Dowd KJ. Epidemiology of osteoporosis and osteoporotic hip fractures. Epidemiol Rev 1985; 7: 178-208.
2. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z J Surg 1993; 63: 352-355.
3. Jones G, Nguyen T, Sambrook PN, et al. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporosis Int 1994; 4: 277-282.
4. Cumming RG, Klineberg RJ. Case-control study of risk factors for hip fractures in the elderly. Am J Epidemiol 1994; 139: 493-503.
5. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization and functional status: a prospective study. Am J Public Health 1997; 87: 398-403.
6. Wark JD. Osteoporosis: the emerging epidemic. Med J Aust 1996; 164: 327-328.
7. Aitken JM. Relevance of osteoporosis in women with fracture of the femoral neck. BMJ 1984; 288: 597-601.
8. Pettiti DB, Sidney S. Hip fracture in women. Clin Orthop 1989; 246: 150-155.
9. Myers AM, Robinson EG, Van Natta ML, et al. Hip fractures among the elderly: factors associated with in-hospital mortality. Am J Epidemiol 1991; 134: 1128-1137.
10. Jacobsen SJ, Goldberg J, Miles TP, et al. Race and sex differences in mortality following fracture of the hip. Am J Public Health 1992; 82: 1147-1150.
11. Cooper C, Atkinson EJ, Jacobsen SJ, et al. Population-based study of survival after osteoporotic fractures. Am J Epidemiol 1993; 137: 1001-1005.
12. Marotolli RA, Berkman LF, Cooney LM. Decline in physical function following hip fracture. J Am Geriatr Soc 1992; 40: 861-866.
13. Marotolli RA, Berkman LF, Leo-Summers L, Cooney LM. Predictors of mortality and institutionalisation after hip fracture: The New Haven EPESE Cohort. Am J Public Health 1994; 84: 1807-1812.
14. Seeman E. Osteoporosis in men: epidemiology, pathophysiology and treatment possibilities. Am J Med 1993; 95 (Suppl 5A): 23S-28S.
15. Poor G, Atkinson EJ, Lewallen DJ, et al. Age-related hip fractures in men: clinical spectrum and short-term outcomes. Osteoporosis Int 1995; 5: 419-426.
16. Poor G, Atkinson EJ, O'Fallon WM, Melton LJ. Determinants of reduced survival following hip fractures in men. Clin Orthop 1995; 319: 260-265.
17. Ringe JD. Hip fractures in men. Osteoporosis Int 1996; 6 (Suppl 3): 48-51.
18. Looker AC, Mussolino ME, Madans JH, Orwoll ES. Risk factors for hip fractures in white men: The NHANES I Epidemiologic Follow up Study [abstract]. J Bone Miner Res 1996; 11: 233.
19. Smerdely P, Thornley S, Sekel R, Diamond T. Subclinical vitamin D deficiency is the major biochemical risk factor associated with hip fracture in elderly men [abstract]. J Bone Miner Res 1996; 11: 233.
20. Mahoney F, Barthel D. The Barthel index. Maryland State Med J 1965; 14: 61-65.
21. StatCalc (Epi Info) [computer program]. Version 6.046. Geneva: WHO, 1997.
22. Holt EM, Evans RA, Hindley CJ, Metcalfe JW. 1000 femoral neck fractures: the effect of pre-injury mobility and surgical experience on outcome. Injury 1994; 25: 91-95.