Osteoporosis International

, Volume 25, Issue 2, pp 475–484 | Cite as

What determines health-related quality of life in hip fracture patients at the end of acute care?—a prospective observational study

  • B. Buecking
  • J. Struewer
  • A. Waldermann
  • K. Horstmann
  • N. Schubert
  • M. Balzer-Geldsetzer
  • R. Dodel
  • K. Bohl
  • S. Ruchholtz
  • C. Bliemel
Original Article



Hip fractures are associated with reduced health-related quality of life (HrQoL). We found pre-existing need of care or limited function, cognitive impairment, and depression to be independent factors associated with lower HrQoL during the postsurgical period. In contrast, joint replacement was associated with better HrQoL compared to internal fixation. Patients’ treatment should be focused on functional recovery and treatment of depression.


The aim of the study was to identify independent factors that were correlated with health-related quality of life (HrQoL) after hip fracture.


A total of 402 patients with a mean age of 81 years suffering from a hip fracture were included in this prospective, observational cohort study. HrQoL (determined by the EuroQol instrument) was measured at admission and at discharge from an acute care hospital. Independent factors correlated with HrQoL at discharge and changes from pre-fracture to discharge were determined using multivariate analyses. The influence of antidepressants was evaluated by an ANOVA with repeated measurements.


Need of care prior to fracture was the most important determinant of EQ-5D index at discharge (ß = −0.359, p = 0.003). Additionally, low Mini Mental Status Examination (MMSE) was associated with a lower EQ-5D index at discharge (MMSE 0–9: ß = −0.238, p <0.001; MMSE 10–19: ß = −0.294, p <0.001) and a greater decrease in EQ-5D during hospitalisation (MMSE 10–19: ß = 0.281, p <0.001), while joint replacement (compared to internal fixation) was associated with a higher EQ-5D index (ß = 0.188, p = 0.002) and a lower decrease in the index (ß = −0.216, p = 0.003). EQ VAS values at discharge were correlated with pre-fracture Barthel Index (ß = 0.253, p <0.001) and Geriatric Depression Scale scores (ß = −0.135, p = 0.026). Depressive patients on antidepressants demonstrated less of a decrease in the EQ-5D index compared to patients not receiving medication (F = 2.907, p = 0.090).


Acute care of hip fracture patients should be focused on functional recovery and treatment of depression. When the preferred surgical strategy is unclear, joint replacement should be considered.


Function Geriatric fracture Hip fracture Mobility Outcome Quality of life 


Conflicts of interest

Each author certifies that he or she and members, or a member of his/her immediate family, have no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose as a conflict of interest in connection with the content of the submitted article.


  1. 1.
    Cooper C, Campion G, Melton LJ (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2:285–289PubMedCrossRefGoogle Scholar
  2. 2.
    Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 332:767–773PubMedCrossRefGoogle Scholar
  3. 3.
    Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl DA, Cooper C, IOF Working Group on Epidemiology and Quality of Life (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23(9):2239–2256PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
  5. 5.
    Marks R (2010) Hip fracture epidemiological trends, outcomes, and risk factors, 1970–2009. Int J Gen Med 3:1–17PubMedCentralPubMedGoogle Scholar
  6. 6.
    Sernbo I, Johnell O (1993) Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int 3:148–153PubMedCrossRefGoogle Scholar
  7. 7.
    Becker C, Gebhard F, Fleischer S, Hack A, Kinzl L, Nikolaus T, Muche R (2003) Prediction of mortality, mobility and admission to long-term care after hip fractures. Unfallchirurg 106:32–38PubMedCrossRefGoogle Scholar
  8. 8.
    Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ (2002) Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc 50:1644–1650PubMedCrossRefGoogle Scholar
  9. 9.
    Boonen S, Autier P, Barette M, Vanderschueren D, Lips P, Haentjens P (2004) Functional outcome and quality of life following hip fracture in elderly women: a prospective controlled study. Osteoporos Int 15:87–94PubMedCrossRefGoogle Scholar
  10. 10.
    Hallberg I, Rosenqvist AM, Kartous L, Löfman O, Wahlström O, Toss G (2004) Health-related quality of life after osteoporotic fractures. Osteoporos Int 15:834–841PubMedCrossRefGoogle Scholar
  11. 11.
    Chiu MH, Hwang HF, Lee HD, Chien DK, Chen CY, Lin MR (2012) Effect of fracture type on health-related quality of life among older women in Taiwan. Arch Phys Med Rehabil 93:512–519PubMedCrossRefGoogle Scholar
  12. 12.
    Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA (2000) Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int 11:460–466PubMedCrossRefGoogle Scholar
  13. 13.
    Rohde G, Haugeberg G, Mengshoel AM, Moum T, Wahl AK (2010) Two-year changes in quality of life in elderly patients with low-energy hip fractures. A case–control study. BMC Musculoskelet Disord 11:226PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Ekström W, Miedel R, Ponzer S, Hedström M, Samnegård E, Tidermark J (2009) Quality of life after a stable trochanteric fracture–a prospective cohort study on 148 patients. J Orthop Trauma 23:39–44PubMedCrossRefGoogle Scholar
  15. 15.
    Ekström W, Németh G, Samnegård E, Dalen N, Tidermark J (2009) Quality of life after a subtrochanteric fracture: a prospective cohort study on 87 elderly patients. Injury 40:371–376PubMedCrossRefGoogle Scholar
  16. 16.
    Gjertsen JE, Vinje T, Lie SA, Engesaeter LB, Havelin LI, Furnes O, Fevang JM (2008) Patient satisfaction, pain, and quality of life 4 months after displaced femoral neck fractures: a comparison of 663 fractures treated with internal fixation and 906 with bipolar hemiarthroplasty reported to the Norwegian Hip Fracture Register. Acta Orthop 79:594–601PubMedCrossRefGoogle Scholar
  17. 17.
    Shyu YI, Chen ML, Chen MC, Wu CC, Su JY (2009) Postoperative pain and its impact on quality of life for hip-fractured older people over 12 months after hospital discharge. J Clin Nurs 18:755–764PubMedCrossRefGoogle Scholar
  18. 18.
    Iglesias CP, Manca A, Torgerson DJ (2009) The health-related quality of life and cost implications of falls in elderly women. Osteoporos Int 20:869–878PubMedCrossRefGoogle Scholar
  19. 19.
    Feng L, Scherer SC, Tan BY, Chan G, Fong NP, Ng TP (2010) Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in hip fracture rehabilitation. Int Psychogeriatr 22:246–253PubMedCrossRefGoogle Scholar
  20. 20.
    Hutchings L, Fox R, Chesser T (2011) Proximal femoral fractures in the elderly: how are we measuring outcome? Injury 42:1205–1213PubMedCrossRefGoogle Scholar
  21. 21.
    Coast J, Peters TJ, Richards SH, Gunnell DJ (1998) Use of the EuroQoL among elderly acute care patients. Qual Life Res 7:1–10PubMedCrossRefGoogle Scholar
  22. 22.
    Brazier JE, Walters SJ, Nicholl JP, Kohler B (1996) Using the SF-36 and Euroqol on an elderly population. Qual Life Res 5:195–204PubMedCrossRefGoogle Scholar
  23. 23.
    Hagino H, Nakamura T, Fujiwara S, Oeki M, Okano T, Teshima R (2009) Sequential change in quality of life for patients with incident clinical fractures: a prospective study. Osteoporos Int 20:695–702PubMedCrossRefGoogle Scholar
  24. 24.
    Borgström F, Zethraeus N, Johnell O, Lidgren L, Ponzer S, Svensson O, Abdon P, Ornstein E, Lunsjö K, Thorngren KG, Sernbo I, Rehnberg C, Jönsson B (2006) Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 17:637–650PubMedCrossRefGoogle Scholar
  25. 25.
    ICD-10 Version:2010. International Statistical Classification of Diseases and Related Health Problems 10th Revision. Available at: http://apps.who.int/classifications/apps/icd/icd10online/. Accessed 2 May 2012
  26. 26.
    Baker SP, O’Neill B, Haddon W, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196Google Scholar
  27. 27.
    Anesthesiologists ASo ASA physical status classification system(2010) http://www.asahq.org/clinical/physicalstatus.htm. Accessed 2 May 2012
  28. 28.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383PubMedCrossRefGoogle Scholar
  29. 29.
    EQ-5-D;A standardised instrument for use as a measure of health outcome;User Giude; 2009;http://www.euroqol.org/fileadmin/user_upload/Documenten/PDF/User_Guide_v2_March_2009.pdf. Accessed 2 May 2012
  30. 30.
    Greiner W, Claes C, Busschbach JJ, von der Schulenburg JM (2005) Validating the EQ-5D with time trade off for the German population. Eur J Health Econ 6:124–130PubMedCrossRefGoogle Scholar
  31. 31.
    Lübke N, Meinck M, Von Renteln-Kruse W (2004) The Barthel Index in geriatrics. A context analysis for the Hamburg Classification Manual. Z Gerontol Geriatr 37:316–326PubMedCrossRefGoogle Scholar
  32. 32.
    Sheikh JI, Yesavage JA (1986) Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. In: Brink TL (ed) Clinical gerontology: a guide to assessment and intervention. Haworth, New York, pp 165–173Google Scholar
  33. 33.
    Almeida OP, Almeida SA (1999) Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry 14:858–865PubMedCrossRefGoogle Scholar
  34. 34.
    Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198PubMedCrossRefGoogle Scholar
  35. 35.
    Arbeitsgemeinschaft Wissenschaftlich Medizinischer Fachgesellschaften (AWMF) (2009) S3-guideline „dementia“, long version. http://www.awmf.de. Accessed 10 July 2012
  36. 36.
    Trzepacz PT, Baker RW, Greenhouse J (1988) A symptom rating scale for delirium. Psychiatry Res 23:89–97PubMedCrossRefGoogle Scholar
  37. 37.
    Bond MR, Pilowsky I (1966) Subjective assessment of pain and its relationship to the administration of analgesics in patients with advanced cancer. J Psychosom Res 10:203–208PubMedCrossRefGoogle Scholar
  38. 38.
    König HH, Heider D, Lehnert T, Riedel-Heller SG, Angermeyer MC, Matschinger H, Vilagut G, Bruffaerts R, Haro JM, de Girolamo G, de Graaf R, Kovess V, Alonso J, ESEMeD/MHEDEA 2000 investigators (2010) Health status of the advanced elderly in six European countries: results from a representative survey using EQ-5D and SF-12. Health Qual Life Outcomes 8:143PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Rohde G, Haugeberg G, Mengshoel AM, Moum T, Wahl AK (2008) Is global quality of life reduced before fracture in patients with low-energy wrist or hip fracture? A comparison with matched controls. Health Qual Life Outcomes 6:90PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Tidermark J, Zethraeus N, Svensson O, Törnkvist H, Ponzer S (2002) Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma 16:34–38PubMedCrossRefGoogle Scholar
  41. 41.
    Miedel R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J (2011) Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail. J Orthop Trauma 25:208–213PubMedCrossRefGoogle Scholar
  42. 42.
    Silverman S, Viswanathan HN, Yang YC, Wang A, Boonen S, Ragi-Eis S, Fardellone P, Gilchrist N, Lips P, Nevitt M, Palacios Gil-Antuñano S, Pavelka K, Revicki D, Simon J, Macarios D, Siris ES (2012) Impact of clinical fractures on health-related quality of life is dependent on time of assessment since fracture: results from the FREEDOM trial. Osteoporos Int 23:1361–1369PubMedCrossRefGoogle Scholar
  43. 43.
    Frihagen F, Nordsletten L, Madsen JE (2007) Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ 335:1251–1254PubMedCrossRefGoogle Scholar
  44. 44.
    Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J (2005) Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am 87:1680–1688PubMedCrossRefGoogle Scholar
  45. 45.
    Holt G, Smith R, Duncan K, Hutchison JD, Gregori A (2008) Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg Br 90:480–483PubMedCrossRefGoogle Scholar
  46. 46.
    Network GR Acute care Hip Fracture Clinical Pathway October 2011 http://www.gtarehabnetwork.ca/clinical-care-guidelines-hip-fracture Accessed 25 Dec 2011.
  47. 47.
    (SIGN) SIGN Management of hip fracture in older people—a national clinical guideline http://www.sign.ac.uk/pdf/sign111.pdf Accessed 25 Dec 2011.
  48. 48.
    Leitlinie Schenkelhalsfraktur, Deutsche Gesellschaft für Unfallchirurgie, 2008, http://www.awmf.org/uploads/tx_szleitlinien/012-001_S2e_Schenkelhalsfraktur_leitlinientext_05-2008_05-2013.pdf Accessed 14 Jun 2011.
  49. 49.
    Heinonen M, Karppi P, Huusko T, Kautiainen H, Sulkava R (2004) Post-operative degree of mobilization at two weeks predicts one-year mortality after hip fracture. Aging Clin Exp Res 16:476–480PubMedCrossRefGoogle Scholar
  50. 50.
    Papaioannou A, Kennedy CC, Ioannidis G, Sawka A, Hopman WM, Pickard L, Brown JP, Josse RG, Kaiser S, Anastassiades T, Goltzman D, Papadimitropoulos M, Tenenhouse A, Prior JC, Olszynski WP, Adachi JD, Group CS (2009) The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study. Osteoporos Int 20:703–714PubMedCrossRefGoogle Scholar
  51. 51.
    AQUA – Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen. Bundesauswertung zum Erfassungsjahr 2011. 17/1 - Hüftgelenksnahe Femurfraktur. Qualitätsindikatoren. www.aqua-institut.de. Accessed 31 May 2012
  52. 52.
    Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesæter LB (2011) Clinical outcome after undisplaced femoral neck fractures. Acta Orthop 82:268–274PubMedCrossRefGoogle Scholar
  53. 53.
    Wilkins CH, Mathews J, Sheline YI (2009) Late life depression with cognitive impairment: evaluation and treatment. Clin Interv Aging 4:51–57PubMedCentralPubMedGoogle Scholar
  54. 54.
    Yiannopoulou KG, Anastasiou IP, Ganetsos TK, Efthimiopoulos P, Papageorgiou SG (2012) Prevalence of dementia in elderly patients with hip fracture. Hip Int 22:209–213PubMedCrossRefGoogle Scholar
  55. 55.
    Tidermark J, Bergström G, Svensson O, Törnkvist H, Ponzer S (2003) Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 12:1069–1079PubMedCrossRefGoogle Scholar
  56. 56.
    Bryant D, Norman G, Stratford P, Marx RG, Walter SD, Guyatt G (2006) Patients undergoing knee surgery provided accurate ratings of preoperative quality of life and function 2 weeks after surgery. J Clin Epidemiol 59:984–993PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  • B. Buecking
    • 1
  • J. Struewer
    • 2
  • A. Waldermann
    • 1
  • K. Horstmann
    • 3
  • N. Schubert
    • 1
  • M. Balzer-Geldsetzer
    • 3
  • R. Dodel
    • 3
  • K. Bohl
    • 3
  • S. Ruchholtz
    • 1
  • C. Bliemel
    • 1
  1. 1.Department of Trauma, Hand and Reconstructive SurgeryUniversity of Giessen and Marburg GmbHMarburgGermany
  2. 2.Department of Orthopedics and RheumatologyUniversity of Giessen and Marburg GmbHMarburgGermany
  3. 3.Department of NeurologyUniversity of Giessen and Marburg GmbHMarburgGermany

Personalised recommendations