Quality of Life and Disability in Patients with Femoral Neck Fractures After Surgical Management

 

 

Study Design and Participants: This study employed a cross-sectional design and included participants who underwent surgical treatment for femoral neck fractures at King Fahad Hospital Hofuf between 2018-2023. The study was approved by the local ethics committee (Ethical approval number: No. 42-EP-2023). Patients who are under 18 years old, who had incomplete data, non-Arabic speakers, and patients who refused participating were excluded from the study.

 Data collection: Participants were selected using convenience sampling technique. All participants provided informed consent before proceeding to complete the survey. Data were collected through a direct interview-based questionnaire by trained medical students. The questionnaire contained four sections. The first section included personal data such as age, gender, weight, height, and comorbidities. The second section included Oxford Hip Score. The third section included Short Form Health Survey-36. The fourth section included EuroQol Five-Dimensional Questionnaire.

 Descriptive Statistics: Descriptive statistics were used to summarize the demographic and clinical characteristics of the participants. Frequencies and percentages were calculated for categorical variables such as sex, post-operative complications, diabetes, complications status, and pre-existing health conditions. Mean, standard deviation (SD), median, and interquartile range (IQR) were calculated for continuous variables including age, weight, height, BMI, and number of days of hospitalization.

 

Scoring Systems: Several scoring systems were utilized to assess post-operative health outcomes:

●       Oxford Hip Score (OHS): The Oxford Hip Score is a questionnaire designed to evaluate hip-specific symptoms and functional limitations. It is scored on a scale from 0 to 48, with higher scores reflecting better hip function and less pain.

●       SF-36 (Short Form Health Survey-36): SF-36 measures eight domains of health, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health perception. Scores range from 0 to 100, with higher scores indicating better health-related quality of life.

●       EQ-5D-5L (EuroQol Five-Dimensional Questionnaire): EQ-5D-5L assesses health-related quality of life across five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has five response levels ranging from "no problems" to "extreme problems." EQ-5D-5L index scores ranging from 0 to 1 were calculated based on established value sets.

●       Charlson Comorbidity Index (CCI): CCI was used to assess the burden of comorbidities. Scores range from 0 to 37, with higher scores indicating a greater comorbidity burden.

 Inferential Statistics: Due to the non-normal distribution of data, small sample size and relatively ordinal nature of variables, inferential analyses were conducted using non-parametric tests. The Mann-Whitney U test was used to compare continuous variables among groups. Spearman rank correlation coefficients were calculated to examine the relationships between continuous variables such as the scores for the scales. Statistical significance was set at p < 0.05. Statistical analyses were performed using IBM SPSS version 27.0.1.

 

 

 

 

 

 

 

 

 

 

 

 

Hip fractures impact over 4.5 million people worldwide each year, and by 2040, that number is expected to rise to 21 million people who live with a disability. (12) Intracapsular fractures of the femoral neck account for about half of all hip fractures and are thought to be the most prevalent traumatic injury linked with aging. (13) FNFs have become a serious health issue in recent years, having a significant effect on both society and the health care system. In addition to its long-term impacts on the independence, functional status, and quality of life (QoL) of patients. (14)

 Patient Demographics, Hospitalization Details, and Post-Operative Complications

In this cohort study, a representative sample of the population of Saudi Arabia composed of 27 participants sustained FNF. Of the whole population of the study, 51.9% (n = 14) were males, while females comprised 48.1% (n = 13) with almost equal distribution of both genders. Previous research indicates that hip fractures were more frequent in women than in men. In both sexes, the incidence increased with age. However, more men than women patients less than 60 years old sustained a fracture caused by high-energy trauma or stress fractures which also determined that older females and younger males exhibited the highest prevalence. (15) According to Crépon, 2006, Productivity increases with age until the age of 40  at which point it stabilizes corresponding with the mean age of our participants which is 45.67 years [SD]: 20.03 years. (16) This emphasizes how important it is to receive enough care and rehabilitation in order to decrease the financial strain, permanent physical limitations and low functional status brought on by these injuries. Based on the data collected from the current study, FNF affecting the right hip are commonly seen, consisting of 63.0% of cases. On another hand, FNF affecting both hips are relatively uncommon, consisting only 3.7%. Even though the majority of participants were hospitalized for more than 7 days, 85.2% experienced no complications following the surgical procedure.

 Patients undergoing surgery for a FNF frequently exhibit comorbidities that increase their risk of complications(17). It turns out that our sample had relatively considerable postoperative problems (14.8%) indicating that the surgical management of complex FNF at our medical center meets the high standards of care in addition to providing the most suitable postoperative interventions for all affected aspects by working as multidisciplinary team (MDT) which consists of professionals and practitioners from across different sectors to work together around the needs of people, their families, and their communities to ensure achieving the holistic approach. A retrospective cohort study discovered that patients treated in the MDT model had significantly shorter times to surgery. The MDT model had fewer complications overall (16.5% vs. 31.3%; P = 0.039), with significantly lower risks of delirium, postoperative infection, bleeding, cardiac complication, hypoxia, and thromboembolism(18).This underlines the need for following MDT approach to provide sufficient treatment and rehabilitation to reduce the long- term impairment and financial burden caused by these injuries.

 Significant consequences of FNF including increased morbidity, decreased quality of life which may vary from patient to other based on various factors(15). As mentioned above only 14.8% experienced postoperative complications in the sample which is realistically matched with EQ-5D-5L data in this study that assessed health related quality of life that represented 9.93 mean (SD 5.56) supporting findings indicating that having complications has a high impact on quality of life. In 47 of the 65 patients (72%), the fracture was healing, while 18 patients (28%) experienced a fracture healing complication, according to Tidermark (2003). In regard to the EQ-5D in their study, all patients' quality of life was significantly reduced after their hip fracture than it was before. The mean quality of life (EQ-5D index score) at 4 months and 17 months (p<0.05 and p<0.005) was higher for individuals with healing fractures than for those with fracture healing complications at each follow-up evaluation. (19)

 Frequency and Intensity of Hip Joint Pain and Functional Impact Over the Past Four Weeks

Our study's assessment of pain severity and functional limitations reflects the complex impact of FNF on daily living. The postoperative pain experiences among patients were varied. Notably, 29.6% of participants reported no pain in the past four weeks, while a similar proportion experienced very mild (25.9%) and severe pain (25.9%). A systematic review and meta-analysis by Shen et al. (2023), which analyzed pain outcomes in FNF patients treated with bipolar versus unipolar hemiarthroplasty, demonstrated that patients treated with bipolar hemiarthroplasty experienced significantly less postoperative pain compared to those who underwent unipolar hemiarthroplasty. (20) This suggests that the type of prosthesis used in surgical management can significantly influence pain outcomes.

 Our findings also demonstrated the functional limitations experienced by patients, with 44.4% reporting no difficulty with personal hygiene, but 14.8% finding it impossible to complete this task. Additionally, 40.7% of patients struggled with getting in and out of cars, and 33.3% could walk for more than 30 minutes before severe pain occurred, whereas 25.9% experienced severe pain immediately upon walking. These functional limitations show the significant impact of postoperative pain on daily activities and quality of life. In contrast, the study by Shen et al. found that patients who underwent bipolar hemiarthroplasty not only reported lower pain levels but also demonstrated better functional outcomes. The lower erosion rates associated with bipolar prostheses likely contribute to this enhanced functional capacity, reducing the long-term impact of the surgery on daily activities. These findings support the notion that bipolar hemiarthroplasty may offer advantages over unipolar options, particularly in reducing pain and improving function postoperatively. (20) However, it is important to note that our study was unable to determine the reasons behind the varying degrees of postoperative pain and functional impact in our patients. This limitation is primarily due to the fact that the type of surgical management was not specified in our sample. Without this information, it is challenging to draw conclusions about the factors contributing to these outcomes in our patient population.

 In this study, the OHS demonstrated a moderate mean value of 29.96 (SD: 16.42), with a median of 27.00 and an IQR of 15.00 to 40.00. Our findings suggest that, on average, patients had moderate hip function postoperatively. The analysis of postoperative complications did not reveal significant differences in OHS among patients, regardless of whether they experienced complications, with a p-value of 0.147. A recent study by Shapira et al. (2023) examined the outcomes of total hip arthroplasty (THA) in patients with hip fractures compared to those with arthritis. The study found that the mean OHS in the hip fracture group [43.7 points (range, 10.0 to 48.0)] was lower than that typically reported for arthritis patients [43.6 points (range, 10.0 to 48.0)]. (21) it is evident that our study's mean OHS (29.96) falls within the range typically observed in hip fracture patients but may be considered lower than the outcomes reported for arthritis patients undergoing THA reflecting the greater challenge in achieving optimal functional outcomes in this population.

 EQ-5D-5L Health Dimensions for Post-Operative Complications

Our study evaluated the post-operative health-related quality of life (HRQoL) using the EQ-5D-5L. The results indicated a broad spectrum of outcomes across the different dimensions of the EQ-5D-5L. Specifically, 44.4% of participants (n=12) reported no problems with mobility, while 14.8% (n=4) faced severe difficulties, and 7.4% (n=2) were unable to walk at all. Regarding personal care, 63.0% (n=17) had no issues with washing or dressing, although 14.8% (n=4) experienced significant challenges. A majority of participants (55.6%, n=15) were able to engage in their usual activities without difficulty, but 11.1% (n=3) were completely unable to perform these tasks. Pain and discomfort were absent in 40.7% (n=11) of the participants, though 11.1% (n=3) reported severe pain. A study by Slobogean et al. (2018), which examined factors associated with HRQoL, hip function, and health utility following the operative management of FNFs, demonstrated a significant proportion of patients reported diminished HRQoL, with notable impairments in mobility, self-care, and usual activities, particularly in older patients or those with greater comorbidities. (1) The study's findings are consistent with our results, where a substantial subset of our participants faced severe mobility challenges and significant pain, which negatively affected their overall quality of life.

 In our study, the psychological impact of the hip fracture was relatively low, with 48.1% (n=13) of participants reporting no anxiety or depression, while the remaining participants experienced varying levels of these symptoms. Conversely, Slobogean et al.'s study emphasized the psychological impact of hip fractures, noting that anxiety and depression were common among patients postoperatively. (1) While our study found that nearly half of the participants did not experience anxiety or depression, the remaining half reported varying degrees of psychological distress, corroborating the findings of Slobogean et al. on the mental health challenges faced by patients recovering from hip fractures. This suggests that while surgical intervention can improve HRQoL in many patients, a substantial proportion continues to experience significant impairments in various dimensions of life. Tailored rehabilitation programs that address both physical and psychological needs are crucial for optimizing recovery and enhancing overall HRQoL in this patient population.

 Comparison of Health Outcomes and Patient Characteristics by Post-Operative Complications

By using the SF-36 survey, our results compared patients with and without complications. The median score for physical functioning was significantly different in the group without complications (85.00; IQR: 50.00-95.00) compared to the group with complications (17.50; IQR: 0.00-60.00) (p = 0.034). Additionally, there was a statistically significant difference in the emotional well-being of the patients, with the median score for those without issues being 64.00 (IQR: 44.00-84.00) and for those with complications being 28.00 (IQR: 18.00-50.00) (p = 0.034). Other SF-36 dimensions, such as energy/fatigue, social functioning, pain, role constraints caused by emotional issues, role limits due to physical health, and general health, are not considerably different between the two groups. SF-36 survey results lead to clear cut evidence about how hip fractures reduced patients overall function.  In line with Randell et al investigation, the SF-36 quality of life alterations for 32 individuals who have had hip fractures have been evaluated. In comparison to before the fracture, there was a noticeable decline in quality of life after three months in the areas of social functioning, energy, and physical functioning. Following a displaced FNFs in elderly people, alterations in the complex domains of physical, psychological, and social functioning appear to be captured by the EQ-5D and the SF-36. (22)

 LIMITATIONS

Our study has several notable limitations that must be considered when interpreting the findings. Firstly, the study's relatively small sample size limits the power of our analysis and may affect the reliability of the results. This small sample size is partially due to the study's focus on patients who underwent surgical management of femoral neck fractures at a single location, Al-Ahsa, Saudi Arabia, without specifying the type of surgical interventions. The lack of differentiation between surgical techniques limits the ability to draw specific conclusions regarding the efficacy of different surgical approaches.

 Additionally, the majority of patients with FNFs are elderly, and the length and complexity of the assessment tools used in our study may have deterred some from participating. This hesitancy likely contributed to our smaller sample size, further impacting the study's generalizability. As a result, caution should be exercised when extending our conclusions to broader populations, especially in different geographic or demographic settings.

 Given these limitations, we recommend that future research should aim to include a larger and more diverse population, with a particular focus on comparing the outcomes of different types of surgical interventions versus non-surgical management of FNFs. This would provide a more comprehensive understanding of the optimal treatment strategies for this common and significant injury, thereby improving patient care and outcomes.

FNF represents a significant public health challenge, particularly in aging populations, with profound implications for patients' QoL and functional independence. This study highlights the multifaceted impact of FNF on physical, emotional, and social well-being, even after surgical intervention. Despite advancements in surgical techniques and postoperative care, many patients continue to experience persistent pain, limited mobility, and reduced ability to perform daily activities, showing the need for a more comprehensive and patient-centered approach to management.

 The findings emphasize the importance of addressing not only the physical consequences of FNF but also the psychological and social dimensions of recovery. The significant burden of comorbidities and postoperative complications further complicates recovery, necessitating tailored rehabilitation programs and multidisciplinary care models.

 Ultimately, improving outcomes for patients with FNF requires a holistic approach that prioritizes both physical recovery and emotional well-being. By addressing the complex interplay of factors that influence recovery, healthcare systems can reduce the burden of FNF, enhance patient satisfaction, and improve overall QoL for those affected by this debilitating injury.