Proximal femoral fractures : Functional outcome, quality of life and mortality

Detta är en avhandling från Stockholm : Karolinska Institutet, Department of Molecular Medicine and Surgery

Sammanfattning: A hip fracture in the elderly is one of the most devastating consequences of osteoporosis and has a high rate of complications, including death and a serious threat to the patient s future mobility, social functioning, quality of life and autonomy. The aim of this thesis was to gain a better knowledge of the functional outcome after treatment with an intramedullary (proximal femoral nail;PFN) or an extramedullary (Medoff sliding plate; MSP) fixation device in patients with unstable trochanteric and subtrochanteric fractures. The purpose was also to report on the long-term outcome for the health-related quality of life in patients with stable trochanteric fractures treated with a sliding hip screw and patients with subtrochanteric fractures treated with a cephalomedullary nail. A further intention was to identify factors associated with mortality in hip fracture patients and to create a predictive model to assess the mortality risk. In Study I patients with a trochanteric or subtrochanteric fracture were assessed with regard to walking ability, rising from a chair, the curb test and abductor strength. The ability to walk 15 metres at 6 weeks was significantly better in the PFN group with no difference in other functional parameters. The major complication rate, 8% in the PFN group and 4% in the MSP group, did not differ statistically but reoperations were more frequent in the PFN group. Studies II and III evaluated the patients with regard to function, HRQoL and mortality. Among patients with a stable trochanteric fracture, 55% had regained their prefracture walking ability, 66% had regained their prefracture level of ADL function and almost their prefracture HRQoL level 2 years after surgery. Among patients with a subtrochanteric fracture, 46% had regained their prefracture walking ability and 48% their prefracture level of ADL function but showed a substantial and persistent deterioration in their HRQoL at 2 years. Study IV focused on predictors of mortality among patients with hip fractures. 1944 patients were assessed with regard to gender, age, type of hip fracture, smoking habits, comorbidities, the ASA classification and cognitive function according to the SPMSQ. A predictive model was created based on factors that were significantly associated with death and were all readily accessible upon admission. The mortality rate was 4% during the acute hospitalisation period, 16% at 4 months, and 38% at 24 months. High ASA scores, low SPMSQ scores, advanced age and male gender were the most prominent factors associated with mortality. The analyses showed that the combination of ASA and SPMSQ could effectively identify patients at risk for increased mortality. In conclusion, the PFN contributed to a better walking ability in the early rehabilitation period but also caused more reoperations than the MSP. There was an obvious deterioration in the HRQoL in the early rehabilitation phase after both stable trochanteric and subtrochanteric fractures. However, in patients with subtrochanteric fractures this deterioration persisted over time. A combined use of ASA and SPMSQ and a predictive model, also including age and gender, can be used to identify patients with an increased risk of mortality.

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