Characteristics of Elderly Hip Fracture Patients in Jordan: A Multicenter Epidemiological Study
Authors Dawod MS , Alisi MS , Saber YO, Abdel-Hay QA, Al-Aktam BM , Alfaouri Y, Alfraihat LB, Albadaineh AA, Abuqudiri AZ , Odeh RM , Altamimi AAR, Alrawashdeh MA, Alebbini MM, Abu-Dhaim OA , Al-Omari AA , Alaqrabawi I, Alswerki MN , Abuawad A, Al Nawaiseh MR, Hammad Y, Al-Ajlouni J
Received 4 May 2022
Accepted for publication 25 July 2022
Published 13 August 2022 Volume 2022:15 Pages 6591—6598
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Scott Fraser
Mohd Said Dawod,1 Mohammed S Alisi,2,3 Yaser O Saber,4 Qusai A Abdel-Hay,4 Basil M Al-Aktam,4 Yesar Alfaouri,4 Lama B Alfraihat,4 Ashraf A Albadaineh,4 Amr Z Abuqudiri,4 Rabea M Odeh,4 Anas AR Altamimi,5 Mutaz A Alrawashdeh,6 Mohanad M Alebbini,6 Omran A Abu-Dhaim,6 Ali A Al-Omari,6 Ihab Alaqrabawi,2 Mohammad N Alswerki,2 Abdelrahman Abuawad,2 Mohammad R Al Nawaiseh,2 Yazan Hammad,7 Jihad Al-Ajlouni2
1Department of Special Surgery, Division of Orthopaedics, School of Medicine, Mutah University, Al Karak, Jordan; 2Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan; 3Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine; 4Ministry of Health, Amman, Jordan; 5Department of General and Specialized Surgery, Faculty of Medicine, The Hashemite University, Zarqa, Jordan; 6Department of Special Surgery, Division of Orthopaedic Surgery, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan; 7Orthopedic Department, North Middlesex University Hospital, London, UK
Correspondence: Mohammed S Alisi, Division of Orthopaedics, Department of Special Surgery, School of Medicine, The University of Jordan, Queen Rania Al Abdullah St 266, Al Jubaiha, Amman, 11942, Jordan, Tel +962 790983284, Email [email protected]
Background: Elderly hip fractures represent a global health care burden. Several reports expected a massive increase in the incidence of hip fractures by the next few decades. Knowing the epidemiology of hip fractures is crucial for planning health care policies. The purpose of this study is to provide a nationwide epidemiological overview of hip fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare. .
Methods: We conducted a retrospective study at 2 university hospitals and 2 major governmental hospitals in Jordan. We reviewed the records for all patients (age > 55 years) who were diagnosed with hip fractures over a 3 years duration (2019– 2021). We documented the patient’s characteristics and the perioperative data (including preoperative, intraoperative, and postoperative details including the 1-year mortality).
Results: The total number of included patients was 1268; more than half (53.7%) were females. The mean age is 75 years (SD 9.7). The most common fracture type was trochanteric (66.2%). 7% of patients had a prior contralateral hip fracture. The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 hours for 56.7% of patients. Approximately, one-third of all patients (34.5%) received a blood transfusion. The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision for the same surgery are 2.4%, 10.7%, and 3% respectively. The 1-month, 6-month, and 12-month mortality rates are 4.5%, 9.1%, and 12.8% respectively.
Conclusion: The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals. The 1-year mortality rate of hip fractures in Jordan is 12.8%. Both findings are in the lower range of nearby Arab countries.
Keywords: hip fracture, elderly, epidemiology, incidence, mortality, Jordan
Hip fractures are among the most common fractures seen by orthopedic trauma teams. They represent a major public health issue in most countries. Life expectancy among the global population is increasing, and an increasing number of people are reaching older age. As a result, the health burden shifts toward diseases that manifest later in life. Osteoporosis is one of the most significant manifestations of the aging process. Hence, more osteoporotic hip fractures are expected to happen in more comorbid individuals.1 The global prevalence of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050.2
Several studies have been conducted over the last few decades; they discovered geographic variation in hip fracture incidence across continents and within regions. Hip fractures are most common in Sweden and North America, with rates nearly seven times lower in Southern European countries. The worldwide geographic variation of hip fracture incidence indicates that environmental and genetic factors may play a role in the etiology.3,4
Few studies discussed the epidemiology of elderly hip fractures within the region of the Middle East/ Arab populations.5–8 To the best of our knowledge, there is no previous nation-based study that discussed the epidemiology of elderly hip fracture in Jordan. There were only two single-center studies from Jordan that discussed hip fracture-related issues.9,10
Hip fractures can lead to significant morbidity and mortality in elderly patients. The 30-day and 1-year mortality can reach up to 10% and 30% respectively.11–13 Accordingly, knowing the details of perioperative care is paramount to exploring interventions that can lead to improving the outcomes and reducing the associated high mortality rate.
The purpose of this study is to provide a nationwide epidemiological overview of elderly hip fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare.
Materials and Methods
This study is a retrospective cohort study, conducted at the only 2 university hospitals and the 2 major governmental hospitals in Jordan.
After taking approval from the related research committees, we retrospectively reviewed the hospital records for all patients who were diagnosed with hip fractures over a 3 years duration (January 2019 - December 2021). The inclusion criteria include age > 55 years, diagnosis with hip fracture “femoral neck or trochanteric area”, and treatment by surgical procedure. The exclusion criteria include pathological fractures, motor vehicle accidents, and non-surgical treatment.
The collected data is categorized into patient characteristics, preoperative, intraoperative, and postoperative data. The patient’s characteristics include age at the time of injury, gender, smoking status, comorbidities, prior osteoporotic contralateral hip fracture, and medications (Aspirin, Clopidogrel, Warfarin). The preoperative details include the time of surgery after the hospital admission and hemoglobin (Hb) level. The intraoperative details include mode of anesthesia (general versus spinal), type of fracture (femoral neck or trochanteric), surgical procedure (dynamic hip screw (DHS), intramedullary nail (IMN), hemiarthroplasty, or total hip arthroplasty), cement and polarity status in arthroplasty cases (cemented versus cementless/ unipolar versus bipolar), and the operator (resident versus specialist). The postoperative details include blood transfusion, Hb level, thromboembolic events (deep vein thrombosis or pulmonary embolism), length of hospital stay, mortality (in-hospital, within 1, 3, 6, 12 months of surgery), readmission within 1 month of operation, and revision for the same surgery.
The data were entered using MS Excel and analyzed using PASW statistics 18 (IBM, USA) software. Descriptive analysis was done to identify frequencies (percentage), average/mean, and standard deviation.
The total number of included patients was 1268 distributed as 469, 373, and 426 patients over the years 2019, 2020, and 2021 respectively. More than half (53.7%) of the included patients were females.
The mean age for all included patients is 75 years (SD 9.7). More than half of patients (56.7%) are 75-year-old or older. Less than one-third of patients (28.1%) were smokers. The most common associated comorbidities were hypertension (65.7%), diabetes mellites (49.4%), cardiovascular disease (29.5%), cerebrovascular disease (18%), and chronic kidney disease (8.2%). More than half of the patients (58.6%) have 2 or more comorbidities. Eighty-eight patients (7%) had a prior contralateral hip fracture. Before the injury, 562 (44.3%) patients were taking aspirin; while 102 (8%) and 55 (4.3%) were taking clopidogrel and warfarin respectively. Table 1 demonstrates the details of patient’s characteristics.
Table 1 Demonstrates the Details of Patient’s Characteristics
The most common fracture type was trochanteric (66.2%) followed by femoral neck (33.8%). The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 hours for 56.7% of patients. Table 2 illustrates the details of fracture types, surgical procedures, mode of anesthesia, and the operator.
Table 2 Illustrates the Details of Fracture Types, Surgical Procedures, Mode of Anesthesia, and the Operator for All Patients
The mean preoperative hemoglobin level was 12 g/dl (SD 1.87), while the mean postoperative hemoglobin level was 10.47 g/dl (SD 1.66). Approximately, one-third of all patients (34.5%) received a blood transfusion. The mean postoperative hemoglobin level for those who received blood was 9.55 g/dl (SD 1.58). The postoperative hemoglobin level was more than 8 g/dl in 84.4% of patients who received blood.
The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision for the same surgery are 2.4%, 10.7%, and 3% respectively. Of note, only 28% of patients who were readmitted within 1 month of surgery were readmitted due to surgery-related issues such as (wound complications, metal failure, dislocation, and periprosthetic infection). The rest were readmitted due to medical-related complications. Table 3 demonstrates the details of postoperative outcomes for all patients.
Table 3 Demonstrates the Postoperative Outcomes and Mortality for All Patients
The overall mortality rate within 1 year of surgery is 12.8%. Table 3 demonstrates the details of mortality rates (in-hospital and within 1, 3, 6, 12 months of surgery).
Osteoporotic hip fractures are very common among elderly population. The annual incidence in the Middle East Arab region is ranging from 60 to 150 per 100,000 individuals.5–8 It is estimated that the number of hip fractures is projected to double and even quadruple in Middle East countries, according to the Middle East and Africa International Osteoporosis Foundation’s audit.14 Knowing the present and projected epidemiology of this major healthcare issue is paramount for healthcare policymakers. Unfortunately, there is no national database to know the true hip fracture incidence in Jordan. This study provides a rough estimate of the epidemiology of hip fractures in Jordan.
In Jordan, hip fracture care is provided by 4 main categories: the governmental, university, military, and private hospitals. This study included patients from the only 2 university hospitals and the 2 major governmental hospitals. According to the national report of population estimates for the end of 2021 provided by The Population Statistics Division in Jordan, the approximate number of people aged above 55 years is 885,000.15 Given that this study included patients from nearly 50% of hip fracture care-providing institutions, we can expect that the annual incidence of hip fractures (in individuals aged 55 years and more) in 2021 is approximately 96 cases per 100,000 individuals.
Our study showed that 7% of included patients had a prior contralateral hip fracture. Saad et al16 reported a rate of 20% previous contralateral hip fracture in a single-center study from Lebanon. This ratio may indirectly reflect that the incidence of hip fracture in Jordan is at the lower limit of the Middle East Arab countries. A further large long-term national-based study is recommended to identify the accurate incidence of hip fractures in Jordan.
Barake et al17 reported that the mean age for hip fracture patients from Arab countries is 74.2 years with more than 50% of patients being female. Our results were consistent with these trends; as the mean age for our population was 75 years and 53.7% were females.
Regarding the most prevalent type of osteoporotic hip fracture, there is a disparity between Arab countries. The largest study from Lebanon reported dominancy of femoral neck fractures (74%),18 while in Saudi Arabia the trochanteric fractures are in favor (47% trochanteric Vs 43% femoral neck).5,19 In our study, the trochanteric fractures are double the femoral neck fractures. Several previous reports emphasized that trochanteric fractures are present in older people compared with femoral neck fractures; thus, associated with higher mortality rates.20,21 Additionally, more than half of patients included in this study were aged ≥ 75 years and had 2 or more comorbid diseases. We believe that clinicians in Jordan should know that most of their patients are at higher risk of mortality.
The length of hospital stay for hip fracture care is different across the world. Lawrence et al22 and Piscitelli et al23 reported an average of 23 and 15 days in the UK and Italy respectively. Our findings showed a lower average hospital stay of 7.44 days. Indeed, this is close to the finding reported by Saad et al from Lebanon.16 We expect that the great social support provided by the family may have a role in reducing the days of hospitalization for elderly people in Arab countries. In western countries, elderly patients may wait a considerable time to get formal social support or to have a place in a nursing home facility. Additionally, in western countries, the transfer of hip fracture patients to geriatric care after the surgical intervention may play a role in lengthening the hospital stay. This service is not available in Jordan, thus, explaining the notable difference in average hospital stay between Jordan and western countries.
Internationally, the 1-year mortality rate of hip fracture patients may reach up to 33%.12,24 Recent studies documented the 1-year mortality rate of hip fractures in the nearby Arab countries (such as Saudi Arabia and Lebanon); it is ranging from 10 to 25%.16,17,19,25,26 Our findings showed a 12.8% 1-year mortality rate, which is at the lower limit of the rates of nearby Arab countries.
Blood transfusion for elderly hip fracture patients is associated with higher costs and transfusion-related complications. The American Academy of Orthopaedic Surgeons recommends a blood transfusion threshold of no higher than 8 g/dL in asymptomatic patients with hip fractures postoperatively.27 In our study, nearly one-third of all patients (34.5%) received a blood transfusion. The postoperative hemoglobin level was more than 8 g/dl in 84.4% of patients who received blood. Unfortunately, we did not find a well-documentation for those patients if they were symptomatic or without symptoms before blood transfusion.
Previous Studies About Hip Fractures in Jordan
To the best of our knowledge, we identified two studies about hip fractures in Jordan. The first study discussed the practice of management of elderly hip fracture in a single center within one year compared to the guidelines recommended by the American Academy of Orthopaedic Surgeons.9 Their findings were close to our findings regarding average age, female gender and trochanteric type predominance, medical comorbidities, and the average length of hospital stay. The second study focused on the relationship between red cell distribution width and 6-months mortality of hip fractures. It was also from single center but included patients over 3.5 years duration.10 They reported a 12.8% mortality rate within 6 months of surgery. Our study is a multicenter study from 4 major hospitals covering about 50% of hip fracture care in Jordan. This study is the first study from Jordan reporting the incidence and mortality over a 1-year duration.
Based on the findings of this study, here we provide recommendations that may help clinicians and healthcare policymakers to improve the delivered care for hip fracture patients.
- Although the incidence of hip fractures in Jordan is lower than the incidence in some nearby Arab countries, it is still a common problem. Approximately, 10,000 cases will present annually to the hospitals in Jordan.
- Osteoporotic hip fracture is a disease, and the first step in the treatment of a disease is prevention. Healthcare policymakers should stress more on prevention projects such as community education, guidelines for bone density tests, methods for prevention of falls at home, and medical therapy for osteoporosis.
- Majority of osteoporotic hip fractures patients in Jordan are older than 75 years and have at least two medical comorbidities. Hospitals should have a special treatment protocol for management of those high-risk patients. We recommend involvement of geriatric specialists in the treatment pathway.
- Blood transfusion for elderly hip fracture patients is associated with higher costs and complications. We advise following international blood transfusion guidelines or implementing a national protocol to minimize the transfusion rate and its adverse effects.
- Orthopedic surgeons are advised to be aware and updated about all measures that could help in reducing the mortality rate and complications of hip fracture patients. These measures include, but are not limited to, medical optimization preoperatively, surgical intervention within 48 hours, thromboembolic prophylaxis, adequate analgesia, early mobilization, medical therapy for osteoporosis, patient education about falls prevention at home, and regular follow-up by bone density scan.
Unanswered Questions and Future Research
This study provides a valuable set of data about the characteristics and outcomes of patients with hip fractures. Future research based on this study should be conducted to analyze the risk factors that are significantly associated with in-hospital, short-term, and long-term mortality. Additionally, several comparative studies can be implied to explore the difference between practice in university hospitals and governmental hospitals. This will help improve the outcomes of perioperative care for high-risk patients.
Limitations of this study include the descriptive nature and lack of comparison between the included groups. Nonetheless, it provides new information about the situation of elderly hip fractures in Jordan. The authors confirm that more than one comparative study will be conducted based on the available data. Moreover, this study did not include patients from the military hospitals which approximately provide one-third of hip fracture care in Jordan. We recommend implementation of a similar study in this indispensable healthcare-providing sector.
The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals; this is at the lower range of incidence in the Middle East Arab region. They are more common in females with a mean age of 75 years. Trochanteric fractures are the most common fracture type. The average time from admission to surgery was 2.96 days. The 1-year mortality rate (12.8%) is at the lower limit of the range of nearby Arab countries.
The authors certify that this research was approved by the institutional review boards of Jordan University Hospital, King Abdullah University Hospital, and Jordanian Ministry of Health. This study complies with the Declaration of Helsinki. As our study is a retrospective one that does not include patient identifying features, the institutional review boards documented that informed consent is not required from the participants.
There is no funding to report.
The authors declare that they have no conflicts of interest in relation to this work.
1. Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P. Epidemiology of Hip fractures: systematic literature review of German data and an overview of the international literature. Epidemiologie von Hüftfrakturen: systematisches Literaturreview deutscher Daten und ein Überblick über die internationale Literatur. Z Gerontol Geriatr. 2019;52(1):10–16. doi:10.1007/s00391-018-1382-z
2. Veronese N, Maggi S. Epidemiology and social costs of Hip fracture. Injury. 2018;49(8):1458–1460. doi:10.1016/j.injury.2018.04.015
3. Kanis JA, Odén A, McCloskey EV, et al. A systematic review of Hip fracture incidence and probability of fracture worldwide. Osteoporos Int. 2012;23(9):2239–2256. doi:10.1007/s00198-012-1964-3
4. Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of Hip fracture: worldwide geographic variation. Indian J Orthop. 2011;45(1):15–22. doi:10.4103/0019-5413.73656
5. Saleh YAL, Sulimani RA, Alomary S, et al. Incidence of Hip fracture in Saudi Arabia and the development of a FRAX model. Arch Osteoporos. 2022;17(1):56. doi:10.1007/s11657-022-01085-x
6. Abdulla N, Alsaed OS, Lutf A, et al. Epidemiology of Hip fracture in Qatar and development of a country specific FRAX model. Arch Osteoporos. 2022;17(1):49. doi:10.1007/s11657-022-01083-z
7. Maalouf G, Bachour F, Hlais S, et al. Epidemiology of Hip fractures in Lebanon: a nationwide survey. Orthop Traumatol Surg Res. 2013;99(6):675–680. doi:10.1016/j.otsr.2013.04.009
8. Azizieh FY. Incidence of Hip fracture in Kuwait: a national registry-based study. Arch Osteoporos. 2015;10:40. doi:10.1007/s11657-015-0248-x
9. Alisi MS, Al-Ajlouni J, Hammad Y, et al. Management of Hip fractures among elderly patients at Jordan University Hospital: a cross-sectional study. Curr Orthop Pract. 2020;31(3):231–239. doi:10.1097/BCO.0000000000000862
10. Hamdan M, Haddad BI, Jabaiti M, et al. Does red cell distribution width predict hip fracture mortality among the arab population? A single-center retrospective cohort study. Int J Gen Med. 2021;14:10195–10202. doi:10.2147/IJGM.S343538
11. Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric Hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord. 2018;19(1):369. doi:10.1186/s12891-018-2276-3
12. Guzon-Illescas O, Perez Fernandez E, Crespí Villarias N, et al. Mortality after osteoporotic Hip fracture: incidence, trends, and associated factors. J Orthop Surg Res. 2019;14(1):203. doi:10.1186/s13018-019-1226-6
13. Giannoulis D, Calori GM, Giannoudis PV. Thirty-day mortality after Hip fractures: has anything changed? Eur J Orthop Surg Traumatol. 2016;26(4):365–370. doi:10.1007/s00590-016-1744-4
14. El-Hajj Fuleihan G, Adib A, Nauroy L. The Middle East & Africa regional audit: epidemiology, costs & burden of osteoporosis in 2011 [Internet]. Nyon, Switzerland: International Osteoporosis Foundation (IOF); 2011 [
15. The national report of population estimates for the end of 2021, The Population Statistics Division in Jordan; 2022. Available from: http://dosweb.dos.gov.jo/population/population-2/.
16. Saad R, Beydoun M, Fuleihan GE. Management of hip fractures at an academic center: challenges and opportunities. J Clin Densitom. 2020;23(4):524–533.
17. Barake M, El Eid R, Ajjour S, et al. Osteoporotic Hip and vertebral fractures in the Arab region: a systematic review. Osteoporos Int. 2021;32:1499–1515. doi:10.1007/s00198-021-05937-z
18. Saad RK, Harb H, Bou-Orm IR, Ammar W, El-Hajj Fuleihan G. Secular trends of hip fractures in Lebanon, 2006 to 2017: implications for clinical practice and public health policy in the Middle East Region. J Bone Miner Res. 2020;35(1):71–80. doi:10.1002/jbmr.3870
19. Al Saleh Y, El Seid ME, Ruhaiyem ME, et al. Characteristics and outcomes of osteoporotic Hip fractures: treatment gaps in a tertiary care center in Riyadh, Saudi Arabia. Aging Clin Exp Res. 2020;32(9):1689–1695. doi:10.1007/s40520-019-01377-2
20. Frisch NB, Wessell N, Charters M, et al. Hip fracture mortality: differences between intertrochanteric and femoral neck fractures. J Surg Orthop Adv. 2018;27(1):64–71.
21. Cui Z, Feng H, Meng X, et al. Age-specific 1-year mortality rates after Hip fracture based on the populations in mainland China between the years 2000 and 2018: a systematic analysis. Arch Osteoporos. 2019;14(1):55. doi:10.1007/s11657-019-0604-3
22. Lawrence TM, White CT, Wenn R, Moran CG. The current hospital costs of treating Hip fractures. Injury. 2005;36(1):88–92. doi:10.1016/j.injury.2004.06.015
23. Piscitelli P, Iolascon G, Gimigliano F, et al. Incidence and costs of Hip fractures compared to acute myocardial infarction in the Italian population: a 4-year survey. Osteoporos Int. 2007;18(2):211–219. doi:10.1007/s00198-006-0224-9
24. Sheehan KJ, Sobolev B, Chudyk A, Stephens T, Guy P. Patient and system factors of mortality after Hip fracture: a scoping review. BMC Musculoskelet Disord. 2016;17:166.
25. Al-Hibshi A, Hegaze A, Mustafa H, Tash B, Sawan D, Al-Faris K. Al-Faris K one-year mortality rate after Hip fracture in the western region of Saudi Arabia: a retrospective cohort study. Curr Orthop Pract. 2020;31(2):115–119. doi:10.1097/BCO.0000000000000841
26. Al-Mohrej OA, Alshaalan FN, Aldakhil SS, Rahman WA. One-year mortality rates following fracture of the femoral neck treated with hip arthroplasty in an aging Saudi population: a trauma center experience. Geriatr Orthop Surg Rehabil. 2020;11:2151459320922473. doi:10.1177/2151459320922473
27. American Academy of Orthopaedic Surgeons, Management of hip fractures in the elderly. Evidence-based clinical practice guideline [AAOS Website]; 2014. Available from: https://www.aaos.org/uploadedFiles/hip-fractures-elderly-clinical-practice-guideline-4-24-19%20-2.pdf.
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