1 Introduction

A hip fracture is a prevalent and severe injury among the elderly, with an approximate 70 % mortality rate if left untreated.¹ The elevated mortality, especially within the initial three months, likely results from the interplay of trauma, extensive surgery in elderly individuals with concurrent health issues, and limited physiological resilience.^2,3

A hip fracture represents a considerable trauma, frequently coupled with potentially fatal complications. Osteoporosis, a common condition in the elderly, heightens the probability of sustaining hip fractures with advancing age. Seniors managing numerous coexisting health issues and taking polypharmacy regimens, compounded by challenges such as impaired vision and equilibrium deficits, face heightened vulnerability to falls, which are the predominant catalyst for hip fractures. Commonly, operative intervention for stabilization or arthroplasty is necessitated to manage a hip fracture, succeeded by a regimen of physiotherapeutic rehabilitation.

Significant predictors of postoperative mortality in hip fracture patients have included advanced age, male gender, clinical comorbidities, pre-fracture residence, cognitive impairment, and the timing of surgery.⁴

Patients have also been linked to heightened morbidity, a decrease in independence in performing Activities of Daily Living (ADLs), a substantial rate of institutionalization, and increased mortality.^4,5

Simultaneously, recent systematic reviews have highlighted the necessity for additional high-quality studies to more precisely delineate the mid-to-long-term outcomes and influencing factors for hip fracture patients.^6,7

Our investigation probed the ramifications of demographic variables and antecedent comorbid conditions on patient recuperation subsequent to surgery. Furthermore, we scrutinized the effect of age and preoperative comorbidities on patients' proficiency in executing activities of daily living following their operative interventions.

Additionally, our research endeavored to discern the determinants, whether consequential or negligible, that influence postoperative mortality rates. We explored a multitude of variables, encompassing patient age, the spectrum of preoperative health conditions, and the timeliness of receiving surgical intervention, to thoroughly evaluate their impact on surgical prognosis.

2 Materials and methods

A retrospective examination was conducted on a cohort of 52 patients who had been subject to hip stabilization surgery due to fractures. The ensemble of patients underwent diverse surgical interventions, such as hemiarthroplasty, dynamic hip screw fixation, and proximal femoral nail insertion. They were inpatients at Princess Esra Hospital in Hyderabad over the span from January 2020 to December 2021, with an explicit inclusion parameter of an age threshold of 60 years or greater. The average age of the individuals incorporated into our study was approximately 70.7 years, with a standard deviation of 9.8. Moreover, the ratio of females to males was approximately 0.793:1. ASA scale was used to assess comorbidities [Table 1].

The majority of the surgical interventions focused on remediating non-pathological hip fractures, performed either by the Department Head, 30 years in practice or by attendant surgeon 7 years and more in practice. Prior to surgery, all patients were subjected to a comprehensive preoperative assessment, we were able to diagnose the fracture with an X-ray, the patients did not require CT scan or MRI. The designated orthopedic surgeon dictated the approach to postoperative rehabilitation therapies and analgesia protocol catering to the different needs required by individual patients in accordance with the hospital protocols. Pre operation low dose heparin was used in all cases as a protocol beginning from the day of injury, post op low dose heparin was also given until the patient was mobilized. Patients benefited from vigilant monitoring throughout their hospitalization, with orthopedic surgeons at the helm, tracking their recuperation and managing any postoperative complications. In instances necessitating further expertise, consults were directed to specialized units including cardiology, gastroenterology, or nephrology.

The choice of surgical procedure was predominantly determined by the patient's age and the particular type of fracture they had, adhering to institutional protocols. We used surgical options such as compression screws, proximal femoral nails, and dynamic hip screws to treat intertrochanteric fractures. And femoral neck or subcapital fractures were typically treated with hemiarthroplasty, bipolar prosthesis and Moore's prosthesis, adhering to hospital protocols designed by surgeons based on several studies and experience. The majority of the patients got bipolar prosthesis only a few patients got Austin Moore's prosthesis when bipolar prosthesis wasn't available. Though the fractures are heterogenous i. e neck of femur fractures & intertrochanteric fractures, the study aims at hip fractures as an indicator of frailty. In that aspect the outcomes won't be much different in both these fractures. There was a strong focus on early mobilization, and patients underwent extensive physiotherapy during their hospital stay. Furthermore, upon discharge, patients were encouraged to continue with regular physiotherapy sessions and appropriate exercises, to gain muscle strength. As rehabilitation plays a major role in determining the ability of the patient to return to daily life activities post surgery.

We collected postoperative data by conducting surveys, after obtaining verbal consent from either the patients themselves or their caregivers. These surveys were carried out through telephone interviews, involving the patients or their family members. Information extracted from hospital records included patient particulars, such as their name, age, gender, existing comorbidities, the surgery date, and the type of hip fracture (intertrochanteric, femoral neck, or subtrochanteric), as well as details regarding the surgical procedure. This information was collected approximately one year after the surgery and included data on both pre- and post-operative medical complications, the development of comorbidities subsequent to the surgery, the extent of patient mobility, and the patients' postoperative vital status.

While collecting the data we used standardized scales like ASA [American Society of Anaesthesiologists] comorbidity scale, modified katz activity of daily living (ADL) scale, and Functional ambulation classification scale (FAC). They were used to classify the comorbidities, assess a person's ability to perform everyday tasks independently, and to assess post surgical ambulation.

The Functional Ambulation Category (FAC) scale is essential in assessing postoperative outcomes after hip stabilization surgery by categorizing patients based on their walking ability. It helps evaluate the success of surgery and rehabilitation in restoring patients' independence in walking and daily activities.

3 Calculations

We systematically compiled and evaluated all the data for analysis. Continuous data were expressed using metrics such as the mean, standard deviation of the mean, or median, and interquartile ranges were utilized when the data did not adhere to a “normal distribution. Categorical data were presented as frequencies and corresponding percentages.

We used the chi-square test to compute p-values and identify any significant associations within the data.

Furthermore, chi-square analyses were conducted to assess the relationship between comorbidities and different age groups.

However, our chi-square analysis of postoperative complications in different age groups revealed no significant association between age and the development of complications following surgery in our study population [Table 2].

We used the two sample independent t-tests. Here, two t-tests are mentioned: the t-test method used to explore the correlation between post-surgery ambulation and patient gender, and another t-test used to assess the ability to engage in daily activities (ADL) post-surgery for males and females.

T-Test for Post-Surgery Ambulation and Patient Gender:●The t-test is a statistical test used to determine if there is a significant difference between the means of two groups. In this case, the t-test was employed to assess whether there was a significant difference in post-surgery ambulation between male and female patients.●The t-test was appropriate in this scenario as it allowed for a comparison between two groups (male and female patients) to determine if there was a statistically significant difference in their post-surgery ambulation outcomes.

T-Test for Daily Activities (ADL) Post-Surgery:●Another t-test was conducted to evaluate the ability of males and females to engage in daily activities (ADL) following their surgeries.●The t-test was suitable for this analysis as it enabled a comparison of means between two groups (males and females) to determine if there was a statistically significant difference in their ability to perform daily activities after surgery.

To explore the correlation between post-surgery ambulation and patient gender, we used the t-test method. The resulting p-value did not demonstrate statistical significance, suggesting no association in our dataset [Table 3].

Both t-tests were appropriate for the respective analyses as they allowed for comparisons between groups and provided insights into the differences observed in post-surgery outcomes based on gender and daily activity performance. The significance of the results obtained from these t-tests was warranted as they helped in drawing conclusions about the impact of gender on post-surgery ambulation and daily activities in the study population.

When evaluating the ability to engage in daily activities post-surgery for males and females, a significant p-value was observed through the t-test. This confirmed our hypothesis that males displayed better performance in daily activities compared to females following their surgeries [Table 4].

4 Results and discussion

115 patients initially selected from the hospital's hip registry for the study were excluded if they were under 60 years of age, with approval from the institutional ethics committee. Subsequently, the study focused on 52 patients with hip fractures, after excluding individuals who were lost to follow-up despite attempts to contact them using the hospital's patient database. Among these patients, 23 experienced hip fractures in women, and 29 in men. The mode age was 60 years, while the mean and median age appeared to be around 70 years. The standard deviation and interquartile range being 0.437 and 14.5 respectively.

When comparing mortality rates between males and females, the chi-square statistic yielded a value of 1.3535, with a corresponding p-value of 0.244669, indicating a lack of statistical significance. Therefore, we concluded that gender did not significantly influence mortality rates in our dataset [Table 5].

Chi-square analyses were conducted to assess the relationship between comorbidities and different age groups. This analysis yielded a chi-square statistic of 9.0713 and a p-value of 0.01072, indicating a significant positive association between comorbidities and age [Table 6][Fig. 1].

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Fig. 1 Chi-square statistics and p-value.

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Regarding comorbidities and ambulatory status, after their respective surgical procedures, it was observed that 13 patients regained the ability to ambulate independently, 22 patients still required some form of walking support, and 1 patient remained unable to walk altogether [Fig. 2]. FAC was used to assess the post operative ambulation, the mean, median and mode of the FAC for this data are 3.47, 3 and 3 respectively. While the standard deviation and interquartile range are 1.29 and 2 [Table 7].

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Fig. 2 Ambulatory status of the patients.

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3 individuals faced challenges in carrying out their daily tasks, leading them to feel disheartened and eventually cease their efforts, while 27 managed to do so without any assistance. Additionally, 6 patients successfully performed daily activities with assistance. The patient's ability to perform daily activities were assessed by modified Katz activity of daily living (ADL) scale. The mean, median and mode of modified Katz activity of daily living (ADL) of this data is 3.02, 4 and 4 respectively. The standard deviation and interquartile range are 1.31 and 0.5 [Table 8].

The patients exhibited varying comorbidities, with some having single comorbidities and others experiencing multiple conditions. While assessing the comorbidities according to the ASA comorbidity scale, most of the patients were grade 2, which indicates mild systemic disease that does not limit their daily activities. A few of them were grade 1, indicating that the patient has no comorbidities and is considered healthy. A few were grade 3 ASA, in which the patient has severe systemic disease with significant functional limitations. The mean ASA for this data is 1.61, its mode being 2, median of 2, it's standard deviation 0.59 and interquartile range of 1. The most prevalent comorbidities were cardiovascular disease (41 %) and diabetes mellitus (30 %), while cerebrovascular and hepatic diseases were less common. Approximately 30 % of the patients experienced postoperative complications, including conditions such as urinary tract infections, sepsis, bed sores, urinary incontinence, and hyperglycemia.

In terms of mortality and its relation to age and gender, out of the patient group described above, 16 individuals had passed away. Although the mortality rate appeared slightly higher among women compared to men, there was no statistically significant difference between male and female patients regarding mortality. The mortality rates within different age groups were as follows: for the 60–70 age group, it was 24 %, for the 71–80 age group, it was also 24 %, and for the 81–90 age group, it significantly increased to 62 %.The most common cause of death was cardiac arrest, followed by infection (leading to sepsis), and renal failure [Fig. 3].

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Fig. 3 Cause of death

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5 Conclusion

In our analysis of 52 patients who underwent surgical treatment for hip fractures, we identified a significant relationship between mortality and several key factors, including advanced age, gender, pre-existing medical conditions, and post-operative complications. The assessment of mortality rates was based on patient survival one year following the surgical procedure, revealing a notable 30.7 % mortality rate in this cohort. The study aims to determine 1 year mortality & morbidity in hip fractures. Patients with immediate post operative mortality were not included in the study as seen in embolism events post reaming. So that data was not calculated. The primary aim of our investigation was to identify important factors associated with mortality in the elderly population undergoing hip surgery, with the goal of developing strategies to reduce mortality. It is important to note that hip fractures among the elderly are serious injuries, carrying a higher risk of mortality compared to the general population, and there has been an increasing incidence of hip fractures in recent decades.

In contrast to prior studies, our findings did not substantiate male gender as a significant risk factor for elevated mortality. Interestingly, our data indicated a minor, albeit statistically insignificant, increase in mortality among women within this study. Multiple studies have explored the association between gender and mortality. For example, an investigation by Endo et al.,⁸ encompassing 983 hip fracture patients, of which 206 were men, identified a higher risk of postoperative complications and nearly double the one-year mortality rate for men in comparison to women. Similarly, }a study examining patients managed within a hip fracture clinical pathway⁹ revealed a 12-month mortality rate of 35 % for men, as opposed to 22 % for women. The precise reasons underpinning this gender-based mortality difference remain uncertain and necessitate further exploration. Some conjecture that men may exhibit less robust health at the time of the fracture, rendering them more susceptible to postoperative mortality, particularly from infections such as pneumonia and influenza.

Furthermore, our investigation unveiled a pronounced correlation between patients' ambulatory status and their mortality rate. Bedridden patients were observed to experience a significant surge in mortality compared to those who utilized walking aids or could ambulate independently. Notably, our findings underscored the substantial predictive value of the cumulative ambulation score in estimating postoperative mortality, emphasizing the significant influence of postoperative ambulation on survival.

It is imperative to emphasize the importance of addressing modifiable comorbidities to curtail complications. Early preventive interventions administered by an orthogeriatric team hold promise in reducing both morbidities and associated mortality, although further in-depth studies are warranted.^10–13 Additionally, our research underscored the significant role of physical therapy and post-operative follow-up in improving patient recovery and reducing the occurrence of postoperative complications, as reported by attending surgeons. Enhanced social support for individuals after surgery may also accelerate their recovery. In Indian culture, strong family support for elderly patients is customary, often involving the hiring of domestic help specifically for patient care. As a result, these patients may demonstrate reduced motivation to regain mobility following surgery.

It is interesting to note that our data suggested a faster recovery among men following surgery compared to women, despite the lack of significant studies supporting this observation.

The fact that men were able to recover quickly by carrying out daily tasks independently highlights their capability and self-reliance in this particular society. This accelerated recovery could be linked to their significant role within the family unit, where they are often relied upon for support and assistance.

Additionally, the need for independence and the desire to fulfill their responsibilities may have motivated men to push themselves to recover swiftly.

Our study did not take into account additional risk factors like smoking and alcohol consumption, as our primary focus was on other variables. It is worth noting that alcohol consumption is nil to minimal in the area, and smoking prevalence is also low, this might be due to religious reasons. However, these factors could have potentially influenced morbidity and mortality rates though not significantly.

The significance of comorbidities in influencing mortality following a fracture has been postulated, with several studies indicating a connection between the severity of comorbidities and the risk of mortality.^14,15 Notably, research based on Medicare data in the USA revealed a substantial reduction in mortality risk during the early post-fracture period (within the first 6 months), which disappeared entirely in the later post-fracture follow-up period, once adjustments were made for comorbidities.¹⁶ The severity of these comorbidities also has a notable impact, as some deaths might be attributed to these underlying health conditions. In our study, we observed an increasing trend in comorbidities with advancing age.

Surgery is almost universally recommended for geriatric hip fractures to mitigate the morbidity and mortality associated with prolonged immobilization.¹⁷ Given the correlation between mortality rates, age, and preoperative/postoperative complications, there is a clear imperative to perform surgery as early as possible. Educating elderly patients about the risks associated with delaying surgical treatment is crucial, as there is often reluctance among them to opt for surgery, with a preference for non-surgical fixation procedures. A prevailing perception in the regional population is that their elderly individuals lack the capacity to withstand the rigors of surgery.¹⁸ The 30.7 % mortality rate observed may be attributed to the increased vulnerability of the elderly to various stressors, resulting in diminished physiological reserves and dysregulation of multiple organ systems. Prolonging postoperative hospital stays for patients with multiple comorbidities may potentially lead to a decrease in mortality rates. Additionally, increased physiotherapy, early ambulation, and continued follow-up for older and frail patients can aid in the early recognition of complications, potentially lowering mortality rates.

Rehabilitation plays a crucial role in the recovery process for patients who have undergone hip fracture surgery. Following surgical intervention, patients often require extensive physiotherapeutic rehabilitation to regain strength, mobility, and independence in performing daily activities. Rehabilitation programs typically focus on improving gait, balance, and muscle strength, which are essential for enhancing mobility and reducing the risk of falls in the future. Certain individuals may not cooperate for the exercises, despite being explained its significance.

Additionally, rehabilitation helps in restoring the patient's confidence and quality of life by enabling them to resume their daily activities. Moreover, family involvement and social support play a vital role in the rehabilitation process, as having a strong support system can positively impact the patient's motivation, adherence to the rehabilitation program, and overall recovery outcomes. The multidisciplinary approach involving physiotherapists, occupational therapists, and healthcare professionals ensures that the rehabilitation program is tailored to meet the individual needs of each patient, promoting a successful recovery and minimizing the risk of postoperative complications. Taking a step further and promoting rehabilitation in mass media campaigns can help in public education and increased patient follow ups.

A crucial limitation of our study is its retrospective design, with a significant number of patients lost to follow-up. Inclusion of these individuals would have provided a more comprehensive understanding of mortality and ambulatory status postoperatively.

Despite the study's reliance on a relatively small patient cohort and the limitation of missing data during the follow-up period, it offers valuable insights into mortality trends one year after hip fracture surgery within the Indian population. In conclusion, without effective primary prevention measures, the burden of geriatric hip fractures on the public healthcare system will continue to rise. Enhanced public education and collaborative efforts from orthogeriatric and physiotherapeutic teams can substantially contribute to reducing this issue.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics approval

Granted by the institution, in accordance with IRB, a summarized copy is provided.

Consent to participate

The participant has consented to the submission of the case report to the journal.

Consent for publication

Verbal informed consent was obtained prior to the interview.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Sadia Sarwath: Investigation, Data collection, Formal analysis, Writing – original draft, Project administration. Fouzia Nikhath: Data curation, Writing – review & editing. Mohammed Siddique Mohiuddin: Supervision, Project administration. Adeeba Sana: Data collection, Visualization.