Elsevier

Injury

Volume 44, Issue 6, June 2013, Pages 769-775
Injury

Health related quality of life, reoperation rate and function in patients with diabetes mellitus and hip fracture—A 2 year follow-up study

https://doi.org/10.1016/j.injury.2012.10.003Get rights and content

Abstract

Introduction

Diabetes mellitus confers an increased risk of hip fractures. There is a limited knowledge of how the outcome after a hip fracture in patients with diabetes affect Health Related Quality of Life (HRQoL). The primary aim of this study was to evaluate HRQoL. Secondary aims were reoperation rate, complications and functions in patients with diabetes followed for 2 years after a hip fracture.

Materials and methods

Out of 2133 patients diabetes was present in 234 patients (11%). Main outcome measurements were HRQoL evaluated with EuroQoL 5-Dindex score, reoperation rate, surgical and medical complications, function as walking ability, daily activities, living condition and pain.

Results

Preoperatively, patients with diabetes mellitus had more pain (p = 0.044), co-morbidities, reduced health status (p = 0.001) and more often used a walking frame (p = 0.014) than patients without diabetes, whereas Katz ADL index, cognition and body mass index did not differ. There was no difference in fracture type, surgical method or reoperation between the two groups or between patients with insulin treated or oral treated diabetes. The EQ-5Dindex score decreased from 0.64 at admission to 0.45 at 4 months, 0.49 at 12 months and 0.51 at 24 months with similar results for patients with and without diabetes. During the first postoperative year there was not more medical complications among patients with diabetes, however cardiac (p = 0.023) and renal failure (p = 0.032) were more frequent in patients with diabetes at 24 months. Patients with diabetes more often had severe hip pain at 4 months (p = 0.031). At 12 months more diabetic patients were living independently (p = 0.034). There was no difference in walking ability, ADL and living condition between the groups at 24 months.

Conclusion

The findings of this study indicate that patients with diabetes mellitus had more pain, co-morbidities, reduced health status preoperatively than patients without diabetes. Hip fracture patients with diabetes mellitus have more hip pain at 4 months. Cardiac and renal failure was more frequent in patients with diabetes at 24 months but otherwise we found a comparable re-operation rate, function and deterioration of Health Related Quality of Life as patients without diabetes within 2 years after a hip fracture.

Introduction

Old adults with diabetes mellitus sustain an increased risk of hip fracture.1, 2 Up to one-third of seniors above 65 years of age could be affected by diabetes.3 The increased relative risk for a hip fracture in patients with Type 1 and Type 2 diabetes is reported to be within 1.7–12.3, and 1.7, respectively.4 The risk of falling is two- to three fold increased in patients with insulin treated diabetes compared to those without diabetes.5 Other possible problems contributing to the increased fracture risk in diabetes are impaired vision, reduced balance, peripheral neuropathy, hypoglycemic events, impaired bone quality and thiazolidinedione therapy.6, 7, 1 Previous studies evaluating complications and morbidity after a hip fracture have shown that patients with diabetes manage functionally, in aspects of ambulatory ability and Activity Of Daily Living status, as well as patients without diabetes during hospitalisation and later during the postoperative period.8, 9 Other studies indicate that patients with diabetes have an increased mortality risk during the post-operative hospital stay.9, 10 A recent study reported that hip fracture patients with diabetes are at increased risk for post-operative cardiac complications, pressure ulcers and a longer hospital stay, whereas their functional recovery was similar to patients without diabetes after 1 year.11

There are several reports on deteriorated quality of life after hip fracture.12, 13, 14, 15 To our knowledge, evaluation of Health Related Quality of Life (HRQoL) after a hip fracture in the diabetic population has not yet been performed. Thus, the aim of this study was to evaluate the HRQoL, medical and functional outcome in patients with diabetes followed for 2 years after a hip fracture.

Section snippets

Materials and methods

We included 2133 patients in a prospective study with a 2-year follow-up. Two-hundred and thirty-four (N = 234, 11%) were diagnosed to have diabetes mellitus. Patients with pathological fractures were excluded. The assessment at baseline, data collection and follow-up were performed by research nurses. The study was conducted in conformity with the Helsinki Declaration and was approved by the local Ethics Committee.

The primary assessment included function i.e., walking ability and Activities of

Statistical methods

The statistical software used was SPSS 18.0 for Windows. The Pearson Chi-Square test was used for comparison between groups. Continuous variables were compared with Student t-test. Fischer's exact test was used when sample size was less than 10. The tests were two-sided and the results were considered significant at p < 0.05. Logistic regression analysis was performed with severe pain as the dependent variable and age, gender, ASA classification, surgical method, type of diabetes and fracture, as

Results

Baseline data for all included patients are displayed in Table 1. Among the patients with diabetes 74/234 (32%) had insulin/insulin and oral treatment and 160/234 (68%) of the patients had oral treatment. The mean age was 82 years (SD 8.5) for patients with diabetes and 81 (SD 10.8) for non-diabetic patients. No differences were found in pre-operative living conditions, Activity of Daily Living, Body Mass Index or cognitive function between the groups (Table 1). A lower number of patients with

Surgical outcome

The mean waiting time from fracture to surgery was 1.2 days (SD 0.95, range 0–7days) without any difference between the groups. In patients with diabetes 78% were operated within 0–1 day compared to 76% in the non-diabetes group. There was no difference in distribution of fracture types or surgical method (Table 2, Table 3). At 24 months, 246 patients (11.5%) had a secondary surgery.

Twenty-four patients (10%) among the diabetic population had a re-operation, 7 (10%) patients with

Functional outcome and Health Related Quality of Life

Function and pain for all patients available at each follow-up are displayed in Table 3. At 4 months, 46% of the patients with diabetes reported no pain in the hip vs. 49% in the non-diabetic group (n.s.). Severe pain affected patients with diabetes almost twice as often, i.e. 12% vs. 7% (OR 1.7, p = 0.031) at 4 months. None of the variables tested in the multivariate analyses, i.e. age, gender, type of fracture, type of diabetes, surgical method and ASA were related to the development of severe

Discussion

Patients with diabetes had a marked decline in Health Related Quality of Life after hip fracture but this was not different from patients without diabetes. No increase of medical complications was seen among the diabetic population within the first postoperative year but cardiac and renal failure was more frequent at 24 months in patients with diabetes mellitus. The re-operation rate among patients with diabetes and their functional recovery was similar to that of patients without diabetes even

Conclusion

Patients with diabetes have a marked decline in Health Related Quality of Life after hip fracture but not different from non-diabetic patients. No increase of medical complications was seen among the diabetics within the first postoperative year but cardiac and renal failure became more frequent during the second post-operative year. The re-operation rate among patients with diabetes and their functional recovery was similar to that of the non-diabetes even though more diabetic patients had

Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References (30)

  • S. Volpato et al.

    Risk factors for falls in older disabled women with diabetes: the women's health and aging study

    Journals of Gerontology Series A: Biological Sciences and Medical Sciences

    (2005)
  • T.H. Keegan et al.

    Foot problems as risk factors of fractures

    American Journal of Epidemiology

    (2002)
  • C. Wallace et al.

    Incidence of falls, risk factors for falls, and fall-related fractures in individuals with diabetes and a prior foot ulcer

    Diabetes Care

    (2002)
  • A. Hjortrup et al.

    Morbidity after femoral neck fracture not increased in diabetics

    Acta Orthopaedica Scandinavica

    (1985)
  • A. Dubey et al.

    The effects of diabetes on outcome after hip fracture

    Bulletin/Hospital for Joint Diseases

    (2000)
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