Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE)

Transcription

1 Disability and Rehabilitation, 2005; 27(18-19): Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE) T. HEIKKINEN, J. PARTANEN, J. RISTINIEMI & P. JALOVAARA Department of Orthopaedic and Trauma Surgery, University of Oulu, Yliopisto, Finland Abstract Purpose: The aim of this paper is to introduce the extended data set inquiries of the Standardised Audit of Hip Fractures in Europe (SAHFE) and to report our experiences of its use. Method: The extended SAHFE data set was applied to 238 consecutive patients (mean age 78.4 (50 102) years, 52 males, 186 females) aged over 50 years with non-pathological fractures of the hip. The extended data set contains 95 questions concerning the patient s abilities prior fall and at follow-up, detailed background factors, concomitant diseases, additional details of the injury, treatment, fracture type and reduction and complications. Results: Thirty-nine percent of the fractures occurred at home and 38% in a hospital. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2) and half of the trochanteric fractures intertrochanteric two-part fractures (A11 A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 1448 to the postoperative 1688 and that from lateral projections from 1448 to 1718, respectively. Most of the patients (89%) had associated diseases, especially cardiovascular conditions. The patients functioning was significantly impaired at four months compared with the preoperative situation according to the ADL score. The need for social support and assistance had increased, respectively. A total of 63% of the surgeries were delayed for more than 24 hours. Low molecular weight heparin was given to every patient for thromboembolic prophylaxis and 92% received antibiotic prophylaxis. Urinary tract (21%) and chest infections (7%) were the most common complications. The deep infection rate was 2.5%. Conclusion: The extended SAHFE data set is useful and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner. Keywords: Hip fractures, aged, activities of daily living, antibiotic prophylaxis, postoperative complications, thromboembolism dementia, outcome, outcome measures Introduction The Standardised Audit of Hip Fractures in Europe (SAHFE) project supported by the European Union [1] developed a data set, which is based on the Swedish Multicenter Hip Fracture study data collection forms [2 10]. It was developed to promote Europe-wide comparisons of demographic features, surgical techniques and rehabilitation methods, determine the practicalities of collecting and disseminating this information on a Europewide basis, evaluate the effectiveness and differences of hip fracture care throughout Europe and to facilitate the dissemination of the best practice of hip fracture surgery and rehabilitation throughout Europe. The basic SAHFE data collection set includes three forms, which can be used to elicit basic information about the background factors, the type of fracture, the surgical method and the patient s places of living, functional capacity, reoperations and mortality [1]. It has been used in some reports recently [11,12]. There is also a more extensive set of inquiries, which render it possible to make a more comprehensive analysis of the factors associated with a hip fracture. In this paper, we report our experience of using the extended SAHFE data set in the Oulu University Hospital. Correspondence: Professor Pekka Jalovaara, Department of Orthopaedic and Trauma Surgery, University of Oulu, PO Box 5000, Oulun Yliopisto, Finland. Tel: Fax: pekka.jalovaara@oulu.fi ISSN print/issn online ª 2005 Taylor & Francis DOI: /

2 1108 T. Heikkinen et al. Patients and methods The extended SAHFE data set was applied to 242 consecutive hip fracture patients aged over 50 years between September and August in the Oulu University Hospital. Four of these fractures were caused by a malignant secondary bone tumour, and these were excluded from the analysis. The mean age of the remaining 238 patients was 78.4 (range ) years. Twenty-two percent were males (mean age 74, years) and 78% females (mean age 80, years). The type of fracture was undisplaced intracapsular in 20 patients, displaced intracapsular in 125, basicervical in five, trochanteric two-fragment in 40, trochanteric multifragment in 44 and subtrochanteric in four patients. The method of treatment was screw osteosynthesis in 32 cases, hemiarthroplasty in 102 cases, Gamma nail in 82 cases, sliding hip screw (SHS) in eight and Girdlestone in two cases. The general condition of four patients was so poor that they could not be operated on. The data set contains inquiries about the patient s abilities and other background factors immediately prior to the fall (see Table I). The patient s mental condition is evaluated by the abbreviated mental test (Short Portable Mental Status Questionnaire, SPMSQ) [13], which comprises of ten simple questions (with one point for each correct answer, a maximum score of ten points). A few questions evaluate the patient s psychological state. Concomitant diseases, smoking, oral steroid consumption, a few laboratory parameters, height, weight, body mass index (BMI) and age for menarche and menopause are also recorded. The activities of daily living (ADL) are evaluated by ten questions consisting of four basic ADL questions and six independent ADL questions (Table II). For each question, the patient can get 1 (best score) to 5 points (worst score), the best possible total score being 10. The patient s need and received social support and assistance, falls before and after the fracture and fear of falls are also included. The inquiry on prefracture state, especially the items on mental and psychological status, should be administered to the patient on admission to the acute orthopaedic ward, preferably prior to surgery. Inquiry can be recorded in again at follow-up, to monitor any changes in the patient s abilities. The detailed questions of the injury and the treatment include the time and place of the injury and possible other coexistent fractures, the delay before operation and the reasons for this delay, the grade and type of the surgeon and the anaesthetist, thromboembolic prophylaxis and details of the operation (Table III). Table I. Additional background data. Abbreviated mental test score (SPMSQ) 205 (n of rec.) Lucid (10-8 pts) % Mild cognitive impairment (7-6 pts) 22 11% Moderate cognitive impairment (5-3 pts) 20 10% Severe cognitive impairment (2-0 pts) 47 23% Psychological state (n of rec.) 146 Enjoys the things used to 82 56% Feels lonely 56 38% Finds hard to make contact to people 47 32% Feels that there is nobody to be close to 23 16% Feels burden to people 33 23% Enjoys a good book, radio or TV program % Concomitant diseases (n of rec.) 232 Cardiovascular disease % Previous stroke 40 17% Respiratory disease 43 19% Renal disease 41 18% Diabetes mellitus 55 24% Rheumatoid disease 23 10% Parkinson s disease 19 8% Malignant disease 36 16% Paget s disease 2 1% Risk factors for osteoporosis (n of rec.) 232 Smoking 32 14% On oral steroids 25 11% Blood hemoglobin (n of rec.) 231 Mean (g/l) (SD) 124 (17) Serum kreatinine (n of rec.) 231 Mean (mmol/l) (SD) 89.6 (38) Serum albumen (n of rec.) 221 Mean (g/l) (SD) 33.0 (6.3) Body mass index BMI (n of rec.) 210 Mean (SD) 24.0 (4.5) Age of menarche (n of rec.) 123 Mean (years) (SD) 15 (2) Age of menopause (n of rec.) 125 Mean (years) (SD) 50 (5) The additional details of the type of fracture and reduction includes an AO classification [14] of all fractures, Garden [15] and the Pauwels [16] grades of intracapsular fractures, the Jensen and Michaelsen classification [17] of trochanteric fractures, the preand postoperative Garden alignment index [15], the Singh grade [18] and the bone mineral density (Dexa) value (Table IV). Detailed questions on complications includes the occurrence of pressure sores [19], chest infection, cardiac failure, deep vein thrombosis, pulmonary embolism, wound infection and haematoma, urine retention and infection, acute renal failure, gastrointestinal haemorrhage, myocardial infarction and cerebrovascular accident (Table V). The data on inquiries concerning prefracture status, operation and complications were recorded by a research nurse simultaneously with the basic SAHFE inquiry. An orthopaedic surgeon (JP) reviewed all pre- and postoperative roentgenograms and evaluated the types, grades and indexes. Four

3 Extended data set inquiries of the SAHFE 1109 Table II. Patients abilities of daily living (ADL) prior to fall and at four months follow-up. Prefacture Four months p-value ADL-score (10 50 pts) (n of rec.) * Mean (SD) 27.5 (13.9) 32.3 (13.4) Dressing (n of rec.) { Able to dress completely without help % 84 43% Needs some help with buttons or zippers 17 7% 9 5% Needs assistance with shoes and stockings 10 4% 24 12% Needs assistance with up to 3 items 20 9% 29 15% Needs to be dressed by others 43 18% 48 25% Bathing or showering (n of rec.) { Able to bath or shower % 51 26% Needs some help in washing a single part of the body, such as 25 11% 30 15% back or feet, or needs a bystander Needs assistance in getting in and out of the bathtub 8 3% 9 5% Needs assistance in washing one or several parts of the body 30 13% 39 20% Always needs to be bathed by others 69 30% 65 34% Eating (n of rec.) { Able to cut food and eat without help % % Needs help from others to cut hard food 1 0% 13 7% Needs assistance in handling food, e.g. buttering bread 7 3% 14 7% Needs a lot of help to eat 9 4% 15 8% Has to be completely fed by others 9 4% 11 6% Toileting (n of rec.) { Able to get to the toilet, get on and off, manage clothing, etc % % Needs assistance in getting to and from toilet 5 2% 4 2% Needs assistance in getting on and off the toilet and adjusting 5 2% 17 9% clothing Needs assistance in cleaning organs of excretion 11 5% 23 12% Wears pads or uses a catheter or bedpan at all times 38 16% 41 21% Shopping (n of rec.) { Able to do all shopping without assistance 64 27% 20 10% Needs assistance in getting to or returning from shops, can only 43 18% 51 27% shop independently for small purchases or is able to shop but gets someone else to do it Needs assistance with selecting shopping, is unsure what he/she 15 6% 5 3% needs to buy or must always be accompanied due to physical, psychological or visual impairment Needs help with two or more tasks associated with grocery 10 4% 10 5% shopping Completely unable to shop % % Household chores (n of rec.) { Able to manage housekeeping alone or with only occasional 59 25% 22 11% assistance Able to perform all home maintenance tasks but needs some 12 5% 14 7% assistance with, e.g., lifting or is able to do housework but has someone else to do it Able to perform only light daily tasks 46 20% 35 18% Needs assistance with light household duties 14 6% 11 6% Unable to do housework % % Laundry (n of rec.) { Able to do laundry 73 31% 38 20% Needs assistance in doing or hanging up laundry or is able to do 17 7% 19 10% it but somebody else does it or would be able to do laundry if there were a machine at home Able to wash delicates and personals by hand or needs some 8 3% 5 3% assistance in loading or unloading the machine Needs a lot of help to do laundry 22 9% 13 7% Unable to do laundry % % Preparation of meals (n of rec.) { Able to prepare meals 84 36% 48 25% Able to prepare meals but someone else does it 13 6% 10 5% Able to prepare a small meal or sandwich if supplied with ingredients 16 7% 14 7% (continued)

4 1110 T. Heikkinen et al. Table II. (continued) Prefacture Four months p-value Able only to reheat meals 19 8% 22 11% Must have all meals prepared % 99 51% Banking/finances (n of rec.) { Able to manage all financial matters 70 30% 24 12% Needs assistance in going to bank or does billing and banking 38 16% 41 21% by mail or cannot go to bank but is able to perform all other financial tasks or is able to do it but someone else does it Able to manage day-to-day purchases, but needs assistance 3 1% 1 1% with banking and major purchases Needs to be taken to the bank and requires someone to handle 21 9% 25 13% the transactions and all other financial needs Unable to handle financial matters % % Use of transportation (n of rec.) { Able to travel independently on public transportation or drive 60 26% 20 10% a car. Arranges his/her own travel by taxi but does not use bus or 36 15% 35 18% train Must always be accompanied due to physical, psychological or 18 8% 17 9% visual impairment Travels in taxi or car only with assistance 46 20% 40 21% Unable to travel 73 31% 80 42% *Wilcoxon Signed Ranks test. {Marginal homogeneity test. Table III. Patients need and received social support and assistance prior to fall and at four months follow-up. Prefracture Four months p-value Social support and assistance (n of rec.) { Needs no assistance in normal ADL 54 23% 19 10% Needs some assistance in a few aspects of the more strenuous ADL 34 15% 33 17% Needs assistance in preparing meals and housework 44 19% 26 14% Needs assistance in washing and dressing 62 27% 47 25% Needs assistance in toileting and feeding 39 17% 64 34% Social support and assistance provided by (n of rec.) { No assistance necessary 42 18% 10 5% Spouse 14 6% 24 13% Other relatives 33 14% 21 11% Spouse and other relatives 10 4% 8 4% Paid help either private or from the state % 87 46% Spouse and paid help 4 2% 5 3% Paid help and relatives 16 7% 33 17% Spouse, relatives and paid help 1 0% 3 2% Social support economically provided by (n of rec.) { Privately paid for 68 29% 58 30% Provided by the state % % None received 45 19% 23 12% Hours of social support received (No of rec.) * Number of patients 97 41% 88 45% Mean (hours/week) (SD) 15.0 (30.0) 24.2 (41.9) Number of falls (n of rec.) No 82 37% % Up to three falls 89 40% 47 25% More than three falls 50 23% 9 5% Fear of fall (n of rec.) { No % 59 33% Yes % % *Wilcoxon Signed Ranks test. {Marginal homogeneity test. {Mc Nemar test. Preoperative column: During last one year before the hip fracture. Four months column: During first 4 months after the operation.

5 Table IV. Details of the injury and the operation. Extended data set inquiries of the SAHFE 1111 Place of fall (n of rec.) 234 At own home 91 39% Inside but not at own home or hospital 13 6% Outside 41 18% Hospital 88 38% No fall or other trauma 1 0% Other coexistent fractures (n of rec.) 234 No % Upper limb fracture 10 4% Other upper and lower limb fractures 1 0% Other fracture not of limbs 1 0% Delay to operation (n of rec.) 234 No delay (operation within 24 hours after fracture) 86 37% Over 24 hours delay* % Prior to admission to orthopaedic ward 21% To establish/confirm the diagnosis 1% Diagnosis confirmed by later review 2% Diagnosis confirmed by repeat x-rays 1% Diagnosis confirmed by bone scan Diagnosis confirmed by CT scan Other method of confirming diagnosis Administrative delay 1% Lack of hospital bed on orthopaedic ward Lack of available theatre space 51% No surgeon available 2% No anaesthetist available Other administrative delay 2% The fracture was initially treated conservatively Operation delayed as patient was medically unfit 3% Electrolyte imbalance Diabetes mellitus to stabilise 1% Treatment of chest condition 2% Rehydration Transfusion for anaemia Treatment of congestive cardiac failure 2% Cardiac arrhythmia 1% Gastrointestinal bleed 1% To assess medical state 7% Other 5% Grade of surgeon (n of rec.) 230 Qualified/specialist 50 22% Staff grade surgeon/associate specialist 4 2% A trainee surgeon on a training scheme % Other trainee surgeon but not on a trainee scheme 60 26% Locum or temporary surgeon 1 0% Other 1 0% Type of surgeon (n of rec.) 230 Orthopedist/orthopedic 52 23% General surgeon % Other 60 26% Grade of anesthetic (n of rec.) 225 Qualified/specialist 74 33% Staff grade surgeon/associate specialist 44 20% A trainee anaesthetist 59 26% An anaesthetic technician Locum or temporary anaesthetist 48 21% Type of anesthetic (n of rec.) 229 General 2 1% Spinal or epidural % Local blocks and infiltration Cement used on fixation (n of arthroplasties) 109 Yes 4 4% Growth factor used (n of rec.) 234 Yes 1 0% (continued)

6 1112 T. Heikkinen et al. Table IV. (Continued) Surgical approach for arthroplasty (n of rec.) 109 Anterior Anterolateral 4 4% Lateral with osteotomy 2 2% Posterior % Thromboembolic prophylaxis used (n of rec.) 234 Graduated stockings below knee Graduated stockings above knee Foot pump Pneumatic calf compression Conventional heparin Low molecular weight-heparin % Warfarin Dextran Aspirin No prophylaxis used Commencement of thromboembolic prophylaxis (n of rec.) 229 Before surgery 14 6% Within 6 hours of admission but before surgery % Within 12 hours of admission but before surgery 32 14% Within 24 hours of admission but before surgery 2 1% 4 24 hours after admission but before surgery 3 1% After surgery 1 0% Within 6 hours after surgery Within 12 hours after surgery 1 0% Within 24 hours after surgery 1 0% More than 24 hours after surgery Duration of thromboembolic prophylaxis (n of rec.) 224 Mean (days) (SD) 7 (3.4) Antibiotic prophylaxis (n of rec.) 229 Yes % Blood transfused prior to operation (n of rec.) 238 Number of patients 17 7% Mean volume (ml) (SD) 494 (182) Length of surgery (n of rec.) 226 Mean (min) (SD) 54 (31) Time from surgery to mobilisation (n of rec.) 178 Mean (days) (SD) 2 (1.2) Operative blood loss (n of rec.) 220 Mean (ml) (SD) 243 (219) Blood transfused in 5 days from the surgery (n of rec.) 234 Number of patients % Mean volume (ml) (SD) 820 (470) Blood hemoglobin immediately after surgery (n of rec.) 119 Mean (g/l) (SD) 100 (14) Blood hemoglobin day after the surgery (n of rec.) 210 Mean (g/l) (SD) 102 (14) *One patient can have several reasons for delay. months after the fracture patients filled in follow-up forms including similar questions on patients abilities as on admission (Table II). If patients were unable to fill the forms, they were filled in by the study nurse interview by talking to the patients themselves or their relatives or the staff of the relevant institution over the telephone. Data organization was done using the SAHFE computer program and the statistical analyses were performed by a statistician using the SPSS statistical software (SPSS, SPSS Inc., 1998, Standard Version for Windows). A marginal homogeneity test was performed for multicategorical variables, McNemar test for binomial variables and Wilcoxon signedranks test for continuous variables, to assess the statistical significances of the functional outcomes between the baseline and the four-month follow-up. Results The majority (89%) of the patients had one or more associated diseases, especially cardiovascular conditions (Table I). Diabetes mellitus, respiratory diseases, previous stroke and renal diseases were

7 Extended data set inquiries of the SAHFE 1113 Table V. Details of the fracture and reduction. AO-classification (for trochanteric 81 fractures (n of rec.) A % A % A13 3 4% A % A % A23 3 4% A31 4 5% A32 2 3% A33 3 4% Jensen & Michaelsen classification 82 (n of rec.) % % % 4 5 6% 5 1 1% Garden grade (n of rec.) % 2 6 5% % % Pauwels grade (n of rec.) % % % Preop Garden alignment index 127 AP* (n of rec.) Mean angle (min-max) 1428 ( ) Preop Garden alignment index 83 LAT{ (n of rec.) Mean angle (min-max) 1448 ( ) Postop Garden alignment index 25 AP* (n of rec.) Mean angle (min-max) 1688 ( ) Postop Garden alignment index 19 LAT{ (n of rec.) Mean angle (min-max) 1718 ( ) *Anterio-posterior radiograph, {Lateral radiograph. also relatively common. Fourteen percent of the patients were smokers and 11% were on oral steroids. The mean blood haemoglobin, serum creatinine and serum albumine values were within the reference values. The cognitive function screening test (SPMSQ) showed that 57% of the patients were cognitively lucid at admission (Table I). This test was not administered at four months. Weight status of 58% of the patients was normal (BMI ), 24% were over weight (BMI ) and 9% were obese (BMI 30.0 and above). The patients functions were significantly impaired at four months compared with the preoperative situation; the mean ADL score dropped from (Table II). The need for social support and assistance had increased respectively; at fracture 18% managed without any support and at follow-up 4% (Table III). The increased amount of social support and assistance was mainly provided by the patients relatives. Thirty-nine percent of the fractures occurred at home and 38% in a hospital (Table IV). Significantly more fractures occurred during daytime than at night (see Figure 1). Other coexistent fractures were rather rare: Only ten patients (4%) had an upper limb fracture, one ( 5 1%) had another lower and upper limb fracture and one ( 5 1%) had a non-limb fracture (see Table IV). Two thirds of the operations were delayed for more than 24 hours (see Table IV). The most common reason for delay was the lack of theatre space (51%). Half of the operations were performed by trainee surgeons on a training scheme. Only two patients (1%) underwent surgery under general anaesthesia while the rest were performed in spinal or epidural anaesthesia. Low molecular weight heparin was used in every case for thromboembolic prophylaxis (Table IV). The prophylaxis was in 75% of cases commenced within six hours of the admission before the surgery. Antibiotic prophylaxis was used in 92% of cases. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2). The cervical fractures were distributed almost equally into the three Pauwels grades. Half of the trochanteric fractures were intertrochanteric two-part fractures (A11 A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 1448 to the postoperative 1688 and that from lateral projections from 1448 to 1718, respectively. The most common complications were urinary tract (21%) and chest infections (7%) (see Table VI). Thirty patients (13%) had pressure sores. The total number of pressure sores was 41, thus some patients had more than one. There were six deep wound infections, the deep infection rate being 2.5%. Most of the complications occurred after discharge from the primary hospital because of the short primary hospitalization time. Discussion The questionnaires excluding follow-up inquiry were filled in by the research nurse. The completion took an average of hours. Very often, the patient was not able to answer all the questions because of memory failure or dementia. In these cases, the nurse contacted the patients relatives or the staff of the relevant institution to get the lacking information. Despite that, some data still remained missing. The abbreviated mental test and the questions concerning psychological status were applied either prior to surgery or afterwards, when the patient s medical condition had stabilized. The mental test

8 1114 T. Heikkinen et al. Figure 1. The occurrence of hip fractures as a function of the time of the day. Number of patients = 219. Table VI. Complications (n of rec. 238) Pressure sore on buttock Non blanching erythema of intact skin 7 Partial thickness skin loss 9 Extensive destruction involving damage to muscle, bone or tendon 1 Pressure sore on heel Non blanching erythema of intact skin 10 Partial thickness skin loss 1 Full thickness skin loss and extension into subcutaneous fat but not through underlying facia 2 Pressure sore on other area Non blanching erythema of intact skin 4 Partial thickness skin loss 7 Chest infection 16 Cardiac failure 0 Deep vein thrombosis 3 Pulmonary embolism 3 Superficial wound infection 0 Deep wound infection 6 Wound hematoma 3 Urine retention 10 Urine infection 49 Acute renal failure 1 Gastrointestinal hemorrhage 1 Myocardial infarction 5 Cerebrovascular accident 1 Other 27 n was not administered to the patients at four months, because the patients themselves filled in the fourmonth forms and the test requires an examiner. The answers to the questions on ADL function and social support and assistance were in most cases obtained from the patient themselves, but quite often also from the patients family members or the staff of the patients service blocks, old people s homes, etc. Health status, laboratory values (blood haemoglobin, serum creatinine and albumin) and information on

9 Extended data set inquiries of the SAHFE 1115 the surgery were easily obtained from patient records, and only a few data were missing concerning these. The dates of menarche and menopause could not be found in the patient files. Most of the females were unable to reliably remember these data, and a considerable number of dates are therefore missing. Details of the injury were reliably obtained from the patients in most cases. An orthopaedic surgeon completed the inquiries concerning different fracture classifications. Their simultaneous use is only indicated in special studies focusing on very detailed problems. There were some problems in availability of the roentgenograms for classification because they were reserved by the treatment staff. Detailed information on complications provides notable added value to the results. It is likely, however, that some complications are missing because this form was only filled in case of complication, not routinely for all patients. In such mode of action underreporting is very likely. Despite its minor limitations, the extended SAHFE data set is a useful tool and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner. The data presented here may serve as control material for future studies. Acknowledgements We thank Mrs Eila Haapakoski for her persistence and honest work with the data collection and Mr Mikko Simonaho for help with the statistical analysis. References 1. Parker MJ, Currie CT, Thorngren KG. Standardised Audit of Hip Fractures in Europe. Hip International 1998;8: Berglund-Rödén M, Swierstra B, Wingstrand H, Thorngren KG. Prospective comparison of hip fracture treatment 856 cases followed for 4 months in The Netherlands and Sweden. Acta Orthop Scand 1994;65: Cserháti P, Fekete K, Berglund-Rödén, Wingstrand H, Thorngren KG. Hip fractures in Hungary and Sweden differences in treatment and rehabilitation. Int Orthop 2002;26: Heikkinen T, Parker M, Jalovaara P: Hip fractures in Finland and Great Britain a comparison of patient characteristics and outcomes. Int Orthop 2001;25: Heikkinen T, Wingstrand H, Partanen J, Thorngren KG, Jalovaara P. Hemiarthroplasty or osteosynthesis in cervical hip fractures: matched-pair analysis in 892 patients. Arch Orthop Trauma Surg 2002;122: Jalovaara P, Berglund-Rödén M, Wingstrand H, Thorngren KG: Treatment of hip fracture in Finland and Sweden: Prospective comparison of 788 cases in three hospitals. Acta Orthop Scand 1992;63: Kitamura S, Hasegava Y, Suzuki Sasaki R, Iwata H, Wingstrand H, Thorngren KG. Functional outcome after hip fracture in Japan. Clin Orthop Rel Res 1998;348: Partanen J, Jalovaara P. Functional comparison between uncemented Austin-Moore hemiarthroplasty and osteosynthesis with three screws in displaced femoral neck fractures a matched-pair study of 168 patients. Int Orthop 2004;28: Partanen J, Saarenpää I, Heikkinen T, Wingstrand H, Thorngren KG, Jalovaara P. Functional outcome after displaced femoral neck fractures treated with osteosynthesis or hemiarthroplasty a matched-pair study of 714 patients. Acta Orthop Scand 2002;73: Thorngren KG, Berglund-Rödén M, Wingstrand H. The Swedish multicentre hip fracture study: Influence of age. Acta Orthop Scand 1994;65(Suppl. 260): Scheerlinck T, Opdeweegh L, Vaes P, Opdecam P. Hip fracture treatment: Outcome and socio-economic aspects. A one-year survey in a Belgian University Hospital. Acta Orthop Belgica 2003;69: Rosell PA, Parker MJ. Functional outcome after hip fracture. A 1-year prospective outcome study of 275 patients. Injury 2003;34: Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1981;1: Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag, Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br 1961;43: Pauwels F. Der Schenkelholsbruch, em mechanisches Problem Grundlagen des Heilungsvorganes Prognose und causale Therapie. Stuttgart, Beilageheft zur Zeitedchrift fur Orthopaedische Chirurgie. Ferdinand Enke, Stuttgart Germany Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthop Scand 1975;46: Singh M, Nagrath AR, Maini MS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am 1970;52: Effective Health Care Bulletin. NHS centre for reviews and dissemination. University of York. Prevention and treatment of pressure sores. October; Vol. 2: no 1. Edinburgh: Churchill Livingstone, 1995.

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