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