Elsevier

Injury

Volume 40, Issue 4, April 2009, Pages 371-376
Injury

Quality of life after a subtrochanteric fracture: A prospective cohort study on 87 elderly patients

https://doi.org/10.1016/j.injury.2008.09.010Get rights and content

Abstract

Background

The subtrochanteric fracture constitutes approximately 5–10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures.

Objective

To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.

Setting

Four university hospitals.

Design

A prospective cohort study with a 2-year follow-up.

Patients and methods

Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5Dindex score).

Results

The EQ-5Dindex score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months.

Conclusions

A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs).

Introduction

The subtrochanteric fracture is one of the less frequent types of fracture in the proximal femur and constitutes approximately 5–10% of all hip fractures.8 This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. Although not based on scientific evidence proven in randomised controlled trials (RCTs), there has been a gradual change in the operative techniques used to stabilise these fractures, from the extramedullary devices such as the blade plate, the compression hip screw and dynamic condylar screw to the current widespread use of cephalomedullary nails. The rationale for this shift is probably the theoretical advantages of the cephalomedullary nails owing to the improved biomechanics with a shorter lever arm leading to a more stable fracture construct and the percutaneous insertion technique which may result in less soft tissue trauma and thereby potentially facilitate fracture healing and reduce bleeding and the incidence of infection. Recent prospective studies including elderly patients with subtrochanteric fractures treated with cepahlomedullary nails also confirm comparatively good results with reoperation rates below 10%.20, 24

Previous studies have focused on evaluating different surgical methods and implants with the primary aim of reducing the fracture complication and reoperation rates. In contrast to the field of research on patients with the more common femoral neck fractures1, 2, 3, 30, 31, 32 and trochanteric fractures,20 few studies have evaluated the health-related quality of life (HRQoL) of patients with subtrochanteric fractures. In a recent RCT, Miedel et al.,20 reported a substantial negative influence on the quality of life after the treatment of an unstable trochanteric or subtrochanteric fracture in 217 patients. However, the HRQoL for the subgroup of 28 patients with subtrochanteric fractures was not reported separately.

The aim of this study was to report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.

Section snippets

Patients and methods

We included 87 consecutive patients with an acute subtrochanteric fracture of the femur26 treated with a cephalomedullary nail at any of the four university hospitals in Stockholm during the period from 1 January to 31 December 2003 in a prospective cohort study with a 2-year follow-up. The inclusion criteria were absence of severe cognitive dysfunction and independent walking capability with or without walking aids before the fracture. Patients with pathological fractures were not included.

Results

Baseline data for all patients included (n = 87) are displayed in Table 1. The mean age was 83 years and 75% of the patients were females. The vast majority, 94%, came from independent living conditions and 94% were assessed as ADL A or B, i.e. they were independent in all six functions of ADL or in all but one. According to the inclusion criteria there were no patients with severe cognitive dysfunction (SPMSQ < 3) and all patients were independent walkers with or without walking aids before the

Discussion

The results of our study confirmed an acceptable reoperation rate after subtrochanteric fractures in elderly patients treated with a cephalomedullary nail. Although the patients experienced a limited amount of pain at the hip there were obvious consequences for walking ability and ADL function reflected in a significant deterioration in both short and long-term HRQoL.

The rate of revision surgery, 8%, was of the same magnitude as reported in the two major studies on elderly patients treated with

Conflict of interest statement

All authors state that there are no conflicts of interest.

Acknowledgements

Special thanks are due to the Stockholm Hip Fracture Group for running the study during the course of years: i.e. Paul Ackerman, Amer Al-Ani, Richard Blomfeldt, Tommy Cederholm, Margareta Hedström, Paula Kelly-Pettersson, Kristina Källbom, Gustaf Neander, Åsa Norling, Sari Ponzer, Bodil Samuelsson, Maria Sääf, Anita Söderqvist and K.-G. Thorngren.

Funding: The study was supported by the Stockholm County Council Research Fund for clinical studies (EXPO 1999).

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