Background: The mortality rate of elderly patients who sustain a hip fracture is high compared to the general population. Identifying risk factors can help predict patients at risk of hip fracture to reduce the mortality rate. No studies have shown the mortality rate of patients with hip fractures in the western region of Saudi Arabia. Therefore, this study aimed to identify the risk factors associated with the mortality of patients with hip fractures admitted to the King Abdulaziz Hospital and compare the results with other studies. Methods: The mortality rate (within 1 yr or less) in 177 patients over the age of 60 yr who were admitted to the university hospital between July, 2007, and September, 2012, with hip fractures was retrospectively studied. The patients were assessed with regard to gender, age, type of hip fracture, and type of surgical intervention. Results: The overall mortality rate 1 yr after hip fracture was 12.43%, and the mean age was 77.77 yr old. The risk factors most associated with mortality were as follows: advanced age (71 to 80 and 81 to 90 yr old), male, peritrochanteric (extracapsular) fracture, and operative fixation with dynamic hip screw. Conclusions: The mortality rate of patients with hip fractures within 1 yr has a high-risk potential, especially for male patients over 71 yr of age with peritrochanteric (extracapsular) fractures. Surgical treatment with dynamic hip screw also was shown to be a risk factor between the different treatment options. Level of Evidence: Level IV.

2. Trauma
One-year mortality rate after hip fracture in the western
region of Saudi Arabia: A retrospective cohort study
Amro Al-Hebshi, MDa
, Adel Hegaze, MDa
, Hesham N. Mustafa, MDb
, Bayan Tash, MBBCha
,
Dana Sawan, MBBCha
and Khalid Al-Faris, MBBCha
a
Orthopedic Department, Faculty of Medicine, King Abdulaziz Hospital, Saudi Arabia
b
Anatomy Department, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
ABSTRACT
Background:
The mortality rate of elderly patients who sustain a hip fracture is
high compared to the general population. Identifying risk factors
can help predict patients at risk of hip fracture to reduce the
mortality rate. No studies have shown the mortality rate of
patients with hip fractures in the western region of Saudi Arabia.
Therefore, this study aimed to identify the risk factors associated
with the mortality of patients with hip fractures admitted to the
King Abdulaziz Hospital and compare the results with other
studies.
Methods:
The mortality rate (within 1 yr or less) in 177 patients over the
age of 60 yr who were admitted to the university hospital
between July, 2007, and September, 2012, with hip fractures was
retrospectively studied. The patients were assessed with regard
to gender, age, type of hip fracture, and type of surgical
intervention.
Results:
The overall mortality rate 1 yr after hip fracture was 12.43%, and
the mean age was 77.77 yr old. The risk factors most associated
with mortality were as follows: advanced age (71 to 80 and 81 to
90 yr old), male, peritrochanteric (extracapsular) fracture, and
operative fixation with dynamic hip screw.
Conclusions:
The mortality rate of patients with hip fractures within 1 yr has a
high-risk potential, especially for male patients over 71 yr of age
with peritrochanteric (extracapsular) fractures. Surgical treat-
ment with dynamic hip screw also was shown to be a risk factor
between the different treatment options.
Level of Evidence:
Level IV.
Key Words
hip fracture, one-year mortality, peritrochanteric, femoral
fracture.
INTRODUCTION
A
ccording to the World Health Organization’s estima-
tion, the population of those 65 yr and older is
estimated to reach about 1.5 billion by 2050,
representing 16% of the global population.1
Hip fracture is
a significant cause of mortality1
as the aging population
rapidly increases, and it is one of the most common clinical
diseases among elderly patients because they are more often
osteoporotic and are more likely to fall than younger people.2
Therefore, hip fractures will become more common as people
live longer. By the year 2050, there will be an estimated 6.3
million hip fractures worldwide.3
Hip fracture is a serious and life-changing event for an older
person. After an initial hip fracture, a person may not be able to
live independently.2
In addition, there is an association between
hip fracture and an increase in mortality. The 1-year mortality rate
after a hip fracture is estimated to be between 17% and 27%,3
although some studies have shown this rate to be between 14%
and 36%.4,5
Previous studies have discussed many factors that
could be related to the mortality of elderly patients after hip
fracture in different medical centers and countries.2,3,6
However,
knowledge about mortality rate after hip fractures in Saudi Arabia
is deficient; no previous studies have reported outcomes after hip
fracture in the western region of Saudi Arabia. Therefore, the
purpose of this study was to evaluate the risk factors for mortality
in elderly patients with hip fractures in this region during a 5-year
period and to compare the 1-year mortality rate of these patients
with those of different centers. The study also analyzed proposed
risk factors that might help with preventive measures. These risk
factors included age, gender, type of fracture, and treatment
modality.
Financial Disclosure: The authors report no conflicts of
interest.
Correspondence to Hesham N. Mustafa, MD, Anatomy Department,
Faculty of Medicine, King Abdulaziz University, P.O. Box 80205, Jeddah
21589, Saudi Arabia
Tel: +966 126 400000; fax: +966 126 400000;
e-mail: hesham977@hotmail.com.
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S P E C I A L F O C U S
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3. TABLE 1. Mortality and complication data
#
Time to
surgery/day Age
Length of
stay/day Readmission
Home
care Dementia Anesthesia
Blood
loss/ml
Surgical
time/min Surgeon Cause of death Comorbidity ASA Treatment
1 6 84 10 2 0 0 General 100 62 C Liver carcinoma Diabetes
High blood urea
anemia
Liver carcinoma
III E DHS
2 4 87 8 0 0 0 General 400 127 C Cardiac (sudden
death)
Anemia II E Total Hip
3 6 74 12 1 0 0 General 100 65 C Head trauma High renal function
High blood glucose
III E DHS
4 4 99 15 0 0 0 General 100 90 C Cardiac renal
dysfunction
Diabetic
Renal failure
IV E DHS
5 1 87 24 0 0 0 General 200 101 C Cardiac arrest Anemia II E Bipolar
6 13 81 27 0 0 0 Neuroaxial
(Epidural)
300 158 C Renal failure Renal impairment III E Bipolar
7 8 70 20 0 1 0 General 250 120 C Cardiac arrest Ischemic heart
Diabetic
Hypertensive
IV E DHS
8 4 95 15 0 0 0 General 500 100 C Cardiac arrest Diabetic
Impairment liver
function
III E DHS
9 5 81 15 0 0 0 Neuroaxial
(Spinal)
300 95 C Cardiac arrest Renal impairment III E DHS
10 5 89 15 0 0 0 Neuroaxial
(Epidural)
100 82 C Cardiac arrest Anemia I E Bipolar
11 1 60 20 3 0 0 Neuroaxial
(Spinal)
300 76 C Renal failure Diabetic
Hypertension
Renal impairment
Tuberculosis
lymphadenopathy
II E DHS
12 5 66 30 2 0 1 General 400 116 C Renal and Liver
failure
Hepatocellular
carcinoma
Renal Hepatic
failure
II E Bipolar
13 2 76 25 0 0 0 Neuroaxial
(Spinal)
600 153 C Wound infection Diabetic III E DHS
14 2 77 20 3 0 0 General 100 65 C Wound infection
(Septacemia)
Renal failure III E Bipolar
15 4 99 12 1 0 0 General 100 68 C Liver failure Anemia
Electrolyte imbalance
Liver impairment
II E DHS
16 10 90 48 0 0 0 General 100 87 C Megaloblastic
anemia
Anemia IV E DHS
17 3 68 57 3 0 0 General 300 108 C Malignant otitis
media
Diabetic
Hypertension
Ischemic heart
III E Bipolar
18 1 90 12 2 0 0 Local 10 20 C Cardiac arrest Diabetic
Hypertension
Renal failure
Bradycardia
III E Traction
19 5 86 12 1 0 0 Neuroaxial
(Epidural)
350 139 C Respiratory failure Chronic obstructive
airway disease
II E Bipolar
20 6 72 11 0 0 0 Neuroaxial
(Spinal)
300 105 C Pulmonary
embolism
Anemia
Uremia
III E DHS
21 1 73 20 1 0 0 Local 10 20 C Cardiac arrest Renal failure
Ischemic heart
II E Traction
22 0 83 0 0 0 0 / 0 0 C Cardiac arrest Diabetic
Renal failure
/ No
procedure
ASA, American Society of Anesthesiologists; C, consultant; DHS, dynamic hip screw; E, for emergency; I, No organic disease; II, Mild systemic disease; III, Severe systemic disease {not incapacitating}; IV, Severe disease
{constant threat to life}.
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4. MATERIALS AND METHODS
Ethical Review and Study Design
This retrospective cohort study was conducted at the King
Abdulaziz University Hospital, Jeddah, Saudi Arabia. The
study was performed in accordance with the Code of Ethics
of the World Medical Association (Declaration of Helsinki)
for experiments involving humans, and the privacy rights of
the human subjects were respected. Patients signed informed
consent for the procedures. The study was approved by the
Unit of Biomedical Ethics Research Committee in Faculty of
Medicine, King Abdulaziz University (approval no. 590-17).
Data Collection
Patients with hip fractures who were admitted to the hospital
for management from July, 2007 to September, 2012 were
identified, and their medical records were retrospectively
reviewed. The factors investigated were age, gender, type of
fracture, and type of management. The data were collected
on a routine basis, and the analysis was carried out
retrospectively. The patients were followed-up for 1 yr after
surgery or until death.
Statistical Analysis
Continuous variables were compared using the Wilcoxon
rank sum test or Student’s independent t test, as appropriate.
Categorical variables were compared using the chi-square
test. A P value 0.05 was considered to show statistical
significance. All statistical analyses were conducted using
SPSS 24 (IBM Corp, Armonk, NY, USA).
RESULTS
One hundred and seventy-seven patients with hip fractures were
admitted during the period of study, and 22 (12.43%) of these
patients died within 1 yr (14 patients died in the hospital;
Table 1). The mean age of the patients was 77.77±10.24 (range,
60 to 99) years. The mean age of male patients was 76.69±8.68
(range, 60 to 90) years, and the mean age of female patients was
79±12.56 (range, 65 to 99) years. Male patients had a higher
incidence of hip fractures (13 patients [59.1%]; 95% CI, 8.000;
P≤0.05) than female patients (nine patients [40.9%]; 95% CI,
1.333; P≤0.05).
Mortality was higher for patients between 81 to 90 yr old
(31.82%) and for male patients (22.73%; Figure 1). The fracture
sides of patients who died were equal (11 patients for each side
[50%]). Of the patients who died, 13 had pertrochantric
(extracapsular) fractures (59.1%) and nine had femoral neck
(intracapsular) fractures (40.9%; Table 2). Pertrochantric fractures
were higher in patients ranging in age from 71 to 80 and 91 to
100 yr and were equal in patients ages 60 to 70 and 81 to 90 yr
(Table 2; Figure 2). Regarding operative management, a dynamic
hip screw (DHS) was used in the majority of patients who died
(50%), and the majority of patients receiving this intervention
were women (Table 3; Figure 3). In the deceased group,
nonoperative management was used in two patients (skeletal
traction; 9.1%), and no procedure was used with one patient
(4.5%; Tables 3 and 4A, B).
DISCUSSION
Many studies have reported an increase in the mortality rate of
patients with hip fractures compared to controls,7
but the risk
factors are still unrecognized in many countries. Multiple factors
have been speculated as risk factors for mortality after hip
fracture, such as age, gender, comorbidities, types of fracture,
types of operations, and timing of surgery.8
In this study, the age,
gender, type of fracture, and types of operation were evaluated.
To the authors’ knowledge, this was the first study to review the
FIGURE 1. Mortality percentage regarding age and gender.
TABLE 2. Findings of femoral neck and petrochanteric fractures
Fracture type Femoral neck Petrochanteric Total Age group Femoral neck Petrochanteric
Frequency 9 13 22 60-70 3 3
% 40.9 59.1 100 71-80 2 4
Valid percent 40.9 59.1 100 81-90 4 4
Cumulative percent 40.9 59.1 91-100 0 2
Total 9 13
FIGURE 2. Findings of femoral neck and pertrochanteric fracture.
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5. morbidity and mortality of patients with hip fracture in the
western region of Saudi Arabia.9,10
Studies concerning the 1-year mortality rate after hip fracture
have shown different rates, with some ranging from 8.4% to
36%11,12
and others ranging from 6.22% to 23.45%.13
In the
current work, the mortality rate was about 12.43%, which was
within the ranges shown by other studies. A higher mortality rate
was identified for male patients; this agreed with other studies
that showed a higher mortality rate of men compared to
women.12–14
No clear reason has been shown behind the higher
mortality rate of male patients, but some studies have considered
male gender as a risk factor for postoperative complications.15
Additionally, a higher mortality rate was found for men between
the ages of 71 to 80 and 81 to 90 yr14
and for women between 60
and 70 yr old.16
Surgical management is advised for hip fractures to
decrease the period of immobilization and reduce the
mortality rate. A higher mortality rate was shown for
pertrochantric (extracapsular) fracture (59.1%), and most of
these fractures were managed by DHS (50%). This interven-
tion requires prolonged postoperative immobilization,
whereas arthroplasty offers early mobilization.15,16
In our study 50% of mortality occurred in patients who had
surgical treatment using DHS, although in other studies this was
significantly associated with the survival group.15–18
The liter-
ature, however, does not indicate a difference between the types
of implant.17,18
In our study there were factors other than time
causing these mortalities in DHS osteosynthesis. The mean blood
loss was 250 mL/l, the mean time of operation was 92.8 min,
mean time of postoperative hospital stay was 18.45 days, the
American Society of Anesthesiologist (ASA) classification was III E
in 54.5% of patients, the mean age was 81.45 yr, and the days
from admission until operation was 5 days. The most prevalent
comorbidities were diabetes mellitus, hypertension, and renal
function impairment.
This study has a number of limitations, including its
retrospective nature, short-term follow-up, a limited number
of patients, no comparisons with other groups receiving
other types of revisions, and measurement bias, as the
outcome assessors were not masked to the study. Based on
our limitations, we recommend future prospective studies
with longer follow-up and larger numbers of patients as well as
comparative studies between the technique used in this study
and other groups receiving other types of revisions.
CONCLUSIONS
Hip fracture is considered a major cause of mortality in elderly
patients. The mortality rate of elderly patients who sustained hip
fractures in a hospital in the western region of Saudi Arabia was
shown to be higher in men over 71 yr of age with pertrochantric
fractures treated by DHS. In the future, more collective studies
should be implemented for all regions of Saudi Arabia.
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TABLE 3. Comparison of different management
modalities
Frequency Percent
Valid
percent
Cumulative
percent
Hemiarthroplasty 7 31.8 31.8 31.8
Total hip arthroplasty 1 4.5 4.5 36.4
Dynamic hip screw 11 50.0 50.0 86.4
Traction 2 9.1 9.1 95.5
No procedure 1 4.5 4.5 100.0
Total 22 100.0 100.0
FIGURE 3. Comparison of different management modalities.
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N Mean ± Std. deviation
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Age 22 81.23 ± 10.62
Days in hospital before surgery 22 4.36 ± 3.14
Days in hospital after surgery 22 19.45 ± 12.76
Readmission 22 0.86 ± 1.13
Blood loss (ml) 22 223.63 ± 165.46
Time in surgery (min) 22 88.95 ± 41.06
Valid N (listwise) 22
B. Descriptive statistics for deceased patients treated with dynamic
hip screw
Age 11 81.8182 ± 12.82
Days in hospital before surgery 11 5.0909 ± 2.55
Days in hospital after surgery 11 18.4545 ± 10.80
Readmission 11 0.6364 ± 1.03
Blood loss (ml) 11 250.0000 ± 174.64
Time in surgery (min) 11 92.8182 ± 26.89
Valid N (listwise) 11
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