Data on the functional outcomes of hip fracture patients in Sri Lanka are limited. As this information is required for the design of long-term care plans, we assessed the physical activities (activities of daily living [ADL]) and quality of life (QoL) of hip fracture survivors in Sri Lanka.
A group of 180 consecutive patients with incident hip fractures admitted to a tertiary care center in Southern Sri Lanka were followed up for 12 months. The Sinhala versions of the Barthel Index, 36-Item Short-Form Survey, and Mini-Mental State Examination were used to assess ADL, QoL, and mental status, respectively.
Of the 180 patients (149 women), 107 underwent surgery. An initial sharp decline and partial recovery of ADL and QoL were observed among patients with hip fractures. Furthermore, patients who underwent surgical treatment showed faster recovery of ADL and QoL than did patients who were managed conservatively. Similarly, patients who did not have complications during the hospital stay showed faster recovery of ADL and QoL than did patients with one or more complications.
Hip fractures profoundly affected both ADL and QoL, and recovery remained incomplete at 12 months post fracture. Patients who underwent surgery had a faster recovery than did patients who did not undergo surgery; similarly, patients without complications also had a faster recovery than did those with complications.
Hip fracture is considered the most ominous clinical outcome of osteoporosis because of the high mortality, morbidity, and healthcare costs.
In addition to excess mortality, hip fractures are also associated with high healthcare costs, which vary among countries. A Canadian study in 2013 estimated a mean attributable cost in the first year after fracture of Can$36,929 among women and Can$39,479 among men, translating to Can$282 million in directly attributable healthcare costs in Ontario and Can$1.1 billion in Canada annually.
Aside from the economic implications, impairment of physical function and quality of life (QoL) frequently occurs among hip fracture survivors. Nearly 40%–50% of hip fracture survivors have limitations in at least one activity of daily living (ADL) 12 months after a fracture.
Asia, with the expanding elderly population, will become the epicenter of hip fractures. On the basis of epidemiological data from four Asian countries—Singapore, Malaysia, Thailand, and Hong Kong—Lau et al.
This 12-month follow-up study assessed the physical dependence and QoL of patients admitted with incident hip fractures to a tertiary care center in Southern Sri Lanka. After an extensive search of the major electronic databases, we were unable to identify previous studies examining the QoL of hip fracture survivors in Sri Lanka.
This prospective cohort study did not include a parallel control group. Follow-up data from a hip fracture registry maintained since September 2017 were used for this analysis. One hundred eighty patients with incident fragility hip fractures (FHFs) admitted consecutively to a tertiary care center (Teaching Hospital, Karapitiya, Galle) in the southern province of Sri Lanka were followed up for 12 months. Written informed consent was obtained from all patients or their immediate family members before recruitment. This study included only those patients with new hip fractures resulting from a simple fall (from a standing height or less) and excluded patients with high-energy (non-fragility) fractures and readmissions for the same fracture. The study was approved by the Ethics Review Committee of the Faculty of Medicine, University of Ruhuna, Sri Lanka (No. 19.12.2016: 3.3).
In this study, we applied the validated Sinhala version of the 36-Item Short-Form Survey (SF 36)
On the basis of the information on comorbidities gathered from patients during the interview and collected from case notes, we calculated the age-adjusted Charlson Comorbidity Index (ACCI) by weighting comorbid conditions and adding additional points for each decade over 40 years of age.
Data are presented as mean±standard deviation, median (interquartile range), or number (percentage). We applied the chi-square and independent t-test for categorical and numerical data, respectively, and used analysis of variance (ANOVA) to compare two groups. Statistical significance was set at p<0.05.
The study cohort included 180 consecutive patients (149 women) with incident hip fractures admitted during the study period to the Teaching Hospital, Karapitiya, Galle, Sri Lanka. All fractures occurred following minor falls from a standing height or less.
An initial sharp decline and partial recovery in ADL were observed among patients with hip fractures (
In the correlation analysis, age and ACCI were found to be inversely related to the two domains of QoL, whereas BI measured at five time points showed positive correlations (
Analysis of the trends of BI and SF-36 values over time showed a steady increase in all indices in the group of patients who underwent surgery. In contrast, no major improvement in QoL indices was observed, as ADL decreased slightly over time (
This analysis revealed a sharp decline in ADL and QoL after a hip fracture and a gradual but partial recovery over the next 12 months. The ADL score of patients with FHF at 12 months did not reach the pre-fracture level, and nearly 60% still had a limitation of at least one ADL function at 12 months post fracture.
We observed that age and comorbidity negatively impacted QoL at 12 months post hip fracture, whereas ADL, both pre- and post-fracture ADL, and MMSE score at discharge showed positive influences on QoL. Patients managed surgically showed steady improvements in both ADL and QoL over the next 12 months compared with patients who were managed non-surgically. Similarly, patients without complications during hospital stay showed greater recovery of ADL and QoL than did patients with complications.
Physical dependence and poor QoL after hip fracture are common observations, and the findings of the current study are consistent with those reported previously. Analyzing a large cohort of 10,325 patients, Gjertsen et al.
In this study, age and comorbidity negatively affected the QoL of patients with hip fractures, whereas cognition and function (represented by MMSE) and independence in ADL positively affected the QoL of patients with hip fractures. Furthermore, patients treated surgically and those without complications had better outcomes. Amarilla-Donoso et al.
The positive association between ADL and QoL suggests the need for caregivers to focus on interventions that enhance the physical independence of patients with hip fractures. Unlike age and comorbidities, ADL is a modifiable determinant of QoL. Thus, attempts must be made to improve the QoL of these patients by improving their ADL. However, this concept needs to be tested in an interventional study before implementation.
Our observations reconfirm the debilitating nature of hip fractures. Although a gradual improvement in both ADL and QoL is observed during the first year, patients did not reach pre-fracture ADL, and their QoL remained lower. Furthermore, nearly 58% of patients were not fully physically active at 12-month post-fracture. Poor QoL and ADL make patients with hip fractures a burden for their families and caregivers.
Only 59% of patients in our study group had undergone surgery. The reasons for non-surgical management included advanced age, higher comorbidity, and lack of consent for the procedure. The ADL and QoL at each follow-up were greater among patients who had undergone surgery than among those who were managed conservatively. Compared with non-surgical management, surgery, particularly when performed early, showed advantages related to mortality, ADL, and QoL in hip fracture patients.
In the current study, all patients were followed up for 12 months post-fracture, except for 33 patients who died during the 12-month follow-up. This can be considered a strength of this study. The study, however, was limited to one area of the country; thus, studies of similar nature from other parts of the country are needed before generalization of the results. Another limitation was that we did not assess other measurements of physical function such as gait speed or chair rise in this study.
In conclusion, hip fractures led to a rapid decline in ADL and QoL immediately after the event, with a gradual but partial recovery during the first 12 months post-fracture. We observed significant differences in the ADL and QoL between surgically and conservatively treated patients and between those who did and did not have complications. On the basis of these findings, we urge relevant authorities to take steps to increase the rate of surgical treatment for patients with hip fractures. To achieve this, the barriers and limitations of surgical treatment should be assessed and the necessary steps be taken to address them. Furthermore, steps should also be taken to avoid post-fracture complications. Most complications can be avoided by adhering to proper nursing practices, venous thromboembolism prophylaxis, and early mobilization.
The researchers claim no conflicts of interest.
This study was supported by the Faculty Research Grant in 2017 from Faculty of Medicine, University of Ruhuna, Matara, Sri Lanka, and the University Grants Commission, Colombo, Sri Lanka (No. UGC/VC/DRIC/PG2017(1)/RUH/01).
Conceptualization, TA, SL, JL, GA; Data curation, TA; Formal analysis, TA, SL; Funding acquisition, TA, SL; Investigation, TA; Methodology, TA, SL, JL, GA; Project administration, TA, SL, JL, GA; Supervision, SL, JL, GA; Writing-original draft, TA, SL; Writing-review & editing, TA, SL.
Sociodemographic and clinical characteristics of patients with surgically and conservatively managed fragility hip fractures
Characteristic | FHF patient management (n=180) |
|
---|---|---|
Surgical (n=107) | Conservative (n=73) | |
Sex, female | 90 (84.1) | 59 (80.8) |
Age (y) | 73.6±8.0 | 82.0±8.5 |
History of previous fragility fracture | 8 (7.5) | 6 (8.2) |
Family history of fragility fracture | 9 (8.4) | 7 (9.6) |
Smoking | 7 (6.5) | 7 (9.6) |
Alcohol consumption | 9 (8.4) | 10 (13.7) |
Use of glucocorticoids | 32 (29.9) | 19 (26.0) |
Comorbid conditions | ||
Vascular diseases | 39 (36.4) | 32 (43.8) |
Dementia | 2 (1.9) | 10 (13.7) |
COPD/bronchial asthma | 23 (21.5) | 22 (30.1) |
Rheumatic diseases | 3 (2.8) | 3 (4.1) |
Peptic ulcer disease | 14 (13.1) | 4 (5.5) |
Liver disease | 5 (4.7) | 5 (6.8) |
Diabetes mellitus | 15 (14.0) | 21 (28.8) |
Renal diseases | 0 (0) | 4 (5.5) |
Hypertension | 34 (31.8) | 35 (47.9) |
Hyperlipidemia | 10 (9.3) | 3 (4.1) |
Values are presented as number of patients (%) or mean±standard deviation.
COPD, chronic obstructive pulmonary disease.
Comparisons of complications between surgically and conservatively managed patients with fragility hip fractures
Complications | FHF patient management (n=180) |
p-value |
|
---|---|---|---|
Surgical (n=107) | Conservative (n=73) | ||
Pressure ulcer | 3 (2.8) | 11 (15.1) | 0.003 |
Wound infection | 1 (0.9) | 8 (11.0) | 0.002 |
Urinary tract infection | 7 (6.5) | 12 (16.4) | 0.034 |
Acute renal failure | 1 (0.9) | 2 (2.7) | 0.353 |
Cardiac complication | 1 (0.9) | 4 (5.5) | 0.068 |
Pneumonia | 2 (1.9) | 8 (11.0) | 0.009 |
Myocardial infarction | 2 (1.9) | 2 (2.7) | 0.697 |
Cerebrovascular accident | 2 (1.9) | 3 (4.1) | 0.369 |
Pulmonary embolism | 0 (0) | 3 (4.1) | 0.034 |
Deep venous thrombosis | 0 (0) | 3 (4.1) | 0.034 |
Gastrointestinal bleeding | 3 (2.8) | 0 (0) | 0.149 |
Number of complication(s) | |||
0 | 91 (85.0) | 36 (49.3) | < 0.001 |
1 | 12 (11.2) | 21 (28.8) | < 0.001 |
2+ | 4 (3.7) | 16 (21.9) | < 0.001 |
Values are presented as number of patients (%).
Chi-square test.
Changes in the physical dependence of patients with hip fractures during 12 months post-fracture
Time of assessment | Barthel index | Physically dependent subjects |
---|---|---|
Before fracture (n=180) | 100 (95–100) | 10 (5.6) |
At discharge (n=175) | 30 (20–45) | 175 (100) |
At 3 months (n=172) | 40 (15–60) | 172 (100) |
At 6 months (n=159) | 55 (20–80) | 152 (95.6) |
At 12 months (n=147) | 85(30–90) | 87 (59.2) |
Values are presented as median (interquartile range) or number of patients (%).
Barthel index <90.
Changes in SF-36 total scores and physical and psychological domains
Measure | At discharge (n=175) | At 3 months (n=172) | At 6 months (n=159) | At 12 months (n=147) |
---|---|---|---|---|
Physical health | 9.6 (6.7–11.7) | 19.3 (10.2–22.7) | 33.8 (13.1–45.6) | 44.6 (16.5–56.7) |
Psychological health | 13.3 (11.7–15.0) | 28.3 (15.4–31.7) | 44.6 (15.4–58.8) | 60.8 (14.2–73.0) |
Total SF-36 score | 11.0 (7.9–12.8) | 22.0 (11.1–25.7) | 34.0 (10.7–49.9) | 40.0 (8.1–60.4) |
Values are presented as median (interquartile range).
SF-36, 36-item Short-Form Health Survey questionnaire.
Correlations of two domains of the SF-36 at 12 months with selected variables
Variable | SF-36 at 12 months |
p-value |
|
---|---|---|---|
Physical health domain | Psychological health domain | ||
Age | -0.53 | -0.48 | <0.001 |
ACCI | -0.42 | -0.38 | <0.001 |
BI before fracture | 0.33 | 0.35 | <0.001 |
BI at discharge | 0.61 | 0.59 | <0.001 |
BI at 3 months | 0.86 | 0.85 | <0.001 |
BI at 6 months | 0.89 | 0.89 | <0.001 |
BI at 12 months | 0.90 | 0.90 | <0.001 |
MMSE at discharge | 0.42 | 0.38 | <0.001 |
SF-36, 36-item Short-Form Health Survey questionnaire; ACCI, age-adjusted Charlson Comorbidity Index; BI, Barthel Index; MMSE, Mini-Mental State Examination.
Pearson correlation.
Trends in BI and SF-36 scores during follow-up according to the type of treatment and the presence or absence of complications
At discharge | At 3 months | At 6 months | At 12 months | p-value |
||
---|---|---|---|---|---|---|
Within-group | Intergroup | |||||
Surgical | (n=106) | (n=105) | (n=103) | (n=101) | ||
SF-36 physical | 11.3±2.9 | 24.7±8.8 | 41.6±9.9 | 51.7±10.8 | <0.001 | <0.001 |
SF-36 psychological | 14.1±2.5 | 33.8±9.9 | 54.9±14.0 | 66.8±14.4 | <0.001 | <0.001 |
Conservative | (n=69) | (n=67) | (n=56) | (n=46) | ||
SF-36 physical | 5.9±2.5 | 9.8±4.0 | 11.1±6.6 | 11.5±6.2 | <0.001 | |
SF-36 psychological | 10.8±3.4 | 12.7±3.9 | 12.2±5.7 | 12.5±7.8 | <0.001 | |
BI | ||||||
Surgical BI | 37.7±10.4 | 56.0±14.7 | 68.7±15.5 | 85.8±12.0 | <0.001 | <0.001 |
Conservative BI | 24.1±9.7 | 17.0±7.5 | 16.3±7.6 | 16.6±10.0 | <0.001 | |
No complications | (n=122) | (n=121) | (n=117) | (n=116) | ||
SF-36 physical | 9.9±3.8 | 21.0±10.6 | 34.5±15.7 | 42.4±20.3 | <0.001 | >0.001 |
SF-36 psychological | 13.3±2.9 | 28.7±12.9 | 44.5±22.6 | 54.1±26.6 | <0.001 | >0.001 |
BI | 33.3±13.1 | 45.2±23.6 | 53.1±30.0 | 63.8±37.2 | <0.001 | <0.001 |
With complications | (n=53) | (n=51) | (n=42) | (n=31) | ||
SF-36 physical | 7.5±3.4 | 13.7±7.4 | 20.6±16.5 | 26.5±19.0 | <0.001 | |
SF-36 psychological | 11.6±3.6 | 18.4±10.7 | 26.7±23.0 | 33.6±28.7 | <0.001 | |
BI | 26.5±11.7 | 24.2±16.8 | 23.7±22.5 | 25.0±31.0 | <0.001 |
Values are presented as mean±standard deviation.
BI, Barthel Index; SF-36, 36-item Short-Form Health Survey questionnaire.
Analysis of variance (ANOVA).