Abstract
Aims
The aim of this study was to assess differences in the clinical profile and baseline characteristics between patients with femoral neck fracture (FNF) and trochanteric fracture (TF). The secondary aim was to explore potential differences in clinical outcomes and mortality.
Methods
A prospective hip fracture database (FAMMI) was used to obtain data for this observational cohort study. Patients with hip fracture surgery between January 2018 and February 2021 who were aged older than 70 years were prospectively included. Differences between patients with FNF and TF were evaluated by univariable logistic regression. A multivariable analysis was performed to analyze the relationship between type of fracture and mortality, adjusting for potential confounders.
Results
In total, 2,089 patients were analyzed, of whom 1,233 (59%) had FNF and 856 (41%) had TF. Patients with TF were older, more often female, had a higher rate of chronic obstructive pulmonary disease and dementia, and had a lower Katz Index of Independence in activities of daily living score. Patients with TF had a lower rate of clinical complications such as delirium, pneumonia, reoperation, or wound infections. No differences in 30-day and one-year mortality were observed, also after multivariable correction.
Conclusion
Based on this study, elderly patients with TF exhibit a comparatively inferior baseline status in comparison to patients with FNF. However, patients with TF have lower incidence of postoperative complications. No differences in 30-day and one-year mortality rates were observed between patients with the two types of proximal femoral fractures.
Cite this article: Bone Jt Open 2025;6(4):373–382.
Keywords: Trochanteric fracture, Femoral neck fracture, Epidemiology, Baseline characteristics, Proximal femoral fracture, trochanteric fractures, fractures: femoral neck, clinical outcomes, Proximal femoral fractures, Hip fractures, chronic obstructive pulmonary disease, cohort study, wound infections, reoperations, delirium
Introduction
Hip fractures and subsequent hip fracture surgeries are common in the elderly population.1 Proximal femoral fractures are classified into two main groups based on the anatomical location of the fracture: femoral neck fracture (FNF) and trochanteric fracture (TF) (Figure 1).2 Non- or marginally displaced (Garden type 1 and 2) FNF is commonly managed with sliding hip screw. Displaced FNF in the elderly population (Garden type 3 and 4) is generally treated with prosthesis, such as hemiarthroplasty (HA) or total hip arthroplasty (THA).3 THA is the option of choice for younger patients characterized by an active physical lifestyle and restricted medical history.4 For TF of the hip, osteosynthesis is the primary choice. This can be extramedullary implants (sliding hip screw) or intramedullary fixation (cephalomedullary nailing).3,5
Fig. 1.
Different types of a proximal femoral fracture. Left: trochanteric fracture. Right: femoral neck fracture.2
Different distribution rates of FNF and TF are described in the literature.6-10 The prevalence of FNF in all hip fractures is between 25% and 57%.6-11 Patients with TF are known to be older,7,10 have a more extensive medical history,10 and more often have chronic obstructive pulmonary disease (COPD) than patients with FNF.12 Patients with FNF are more often known to have cerebrovascular disease than patients with TF.10 Further, differences between these two types of fractures have not been extensively studied. It remains unclear whether patients with FNF and patients with TF can be considered equal regarding baseline characteristics, clinical outcomes, and mortality rates.
The aim of this study was to assess the clinical profile and possible differences in baseline characteristics between patients with FNF and patients with TF in an elderly population. The secondary aim of this study was to explore clinical outcomes and mortality rates in patients with FNF and TF.
Methods
Study design and patient selection
Data was collected from a multicentre database (FAMMI) of two level II trauma teaching hospitals in the Netherlands.13 Data for this database were obtained through careful and precise reviews of all patient records by the researchers of this study. All patients aged older than 70 years with proximal femoral fracture between January 2018 and February 2021 who underwent hip fracture surgery were prospectively included. This study aimed to identify distinctions between both fracture types within the elderly population, necessitating a minimum age threshold. Patients who had undergone THA were excluded, given their generally more favourable clinical status and prognosis when compared to the broader population of patients with FNF.4 In total, 2,089 patients were included in this study (Figure 2). Follow-up after surgery was at least one year.
Fig. 2.
Flowchart of included patients.
Baseline characteristics
Baseline characteristics and clinical outcomes were collected from patient charts. To estimate frailty, American Society of Anesthesiologists (ASA) grade,14 the Charlson Comorbidity Index,15 and the Nottingham Hip Fracture Score were used.16 Data on nutritional status were expressed in Short Nutritional Assessment Questionnaire for Residential Care score,17 BMI, and albumin. The Katz Index of Independence in activities of daily living (Katz-ADL)18 was used to determine the functional performance of a patient. Information about the living situation before the proximal femoral fracture was obtained.
Perioperative factors, clinical outcomes, and mortality
Perioperative factors were time to surgery, duration of surgery, time of the week (week or weekend), time of day (day- or night-time), and skin closure. Complications were registered in the patient files during outpatient visits. These complications were transferred to the database at the end of the follow-up period. It was assumed that patients presented with a complication at the outpatient clinic of the hospital where they were operated. Reasons for failure of implant were defined as avascular necrosis, delayed or nonunion, and breakout of the implant. Statistics of mortality were obtained through verification of the citizen service number with the corresponding municipality.
Statistical analysis
Categorical variables were demonstrated as frequencies and percentages. Continuous variables were demonstrated as mean (SD) in case of an approximately normal distribution, or as median (IQR) otherwise. The tables show the number of missing per variable. Differences in population between patients with FNF and TF were evaluated by univariable logistic regression. An additional multivariable analysis was performed to analyze the relationship between fracture type and mortality, adjusting for potential confounders.19 Missing data in covariates were completed by multiple imputation with chained equations (m = 100 imputation datasets). Details of the multiple imputation procedure can be found in Supplementary Table i. Statistical analyses were performed using Stata v. 14.0 (StataCorp, USA). All statistical tests were two-sided with a significance level of p < 0.05.
Ethics
The study protocol was approved by the local ethics committee (L2017044, Toetsingscommissie Wetenschappelijk Onderzoek Rotterdam (TWOR), Rotterdam, Trial registration number NL8313). Because of the observational nature of the study (no change in standard practice of care) and the high percentage of cognitive dysfunction, the local ethics committee decided that patients’ consent to review their medical records was not required. Patient data were collected pseudonymized in the database used for the analyses. All the protocols were conducted in compliance with the Declaration of Helsinki.20 No external funding was used for this study. The STROBE guidelines were used to ensure the reporting of this study.21
Results
In total, 2,089 patients were analyzed, of whom 1,233 (59%) had FNF and 856 (41%) had TF. Of the 1,233 patients with FNF, 1,065 (86%) were treated with HA, 158 (13%) with sliding hip screw, and ten (1%) with cephalomedullary nailing. Of the 853 patients with TF, 850 (99%) were treated with cephalomedullary nail and three (1%) with sliding hip screw.
Baseline characteristics
Results of the univariable analysis of the baseline characteristics are presented in Table I. Compared to patients with FNF, patients with TF were older (84.5 years vs 83.6 years, odds ratio (OR) 1.02, 95% CI 1.01 to 1.03; p = 0.002), were less often male (26% vs 34%, OR 0.68, 95% CI 0.56 to 0.82; p < 0.001), more often had COPD (14% vs 11%, OR 1.33, 95% CI 1.02 to 1.73; p = 0.033), and dementia (29% vs 24%, OR 1.28, 95% CI 1.06 to 1.57; p = 0.012), had lower haemoglobin levels on admission (7.6 mmol/L vs 8.0 mmol/L, OR 0.69, 95% CI 0.63 to 0.76; p < 0.001), and had lower Katz-ADL scores (5 (1.5 to 6) vs 5 (2 to 6), OR 0.95, 95% CI 0.91 to 0.99; p = 0.006).
Table I.
Univariable analyses of risk and prognostic baseline factors.
| Variable | All patients (2,089) | FNF (1,233) | TF (856) | OR (95% CI) | p-value |
|---|---|---|---|---|---|
| Mean age, yrs (SD) | 84.0 (6.8) | 83.6 (6.6) | 84.5 (7.2) | 1.02 (1.01 to 1.03) | 0.002 |
| Male sex, n (%) | 636/2,089 (30) | 416/1,233 (34) | 220/856 (26) | 0.68 (0.56 to 0.82) | < 0.001 |
| ASA grade, n (%) | |||||
| I (ref.) | 11/2,089 (1) | 7/1,233 (1) | 4/856 (1) | - | - |
| II | 517/2,089 (24) | 320/1,233 (26) | 197/856 (23) | 1.08 (0.31 to 3.73) | 0.906 |
| III | 1,399/2,089 (67) | 815/1,233 (66) | 584/856 (68) | 1.25 (0.37 to 4.30) | 0.719 |
| IV | 162/2,089 (8) | 91/1,233 (7) | 71/856 (8) | 1.37 (0.38 to 4.85) | 0.630 |
| Mean CCI (SD) | 5.2 (1.5) | 5.2 (1.6) | 5.2 (1.4) | 1.02 (0.96 to 1.08) | 0.455 |
| Mean NHFS (SD) | 4.9 (1.3) | 4.9 (1.3) | 5.0 (1.3) | 1.06 (0.99 to 1.13) | 0.104 |
| Missing, n (%) | 4 (1) | 3 (1) | 1 (1) | - | - |
| Medical history, n (%) | |||||
| Atrial fibrillation | 415/2,089 (20) | 257/1,233 (21) | 158/856 (18) | 0.86 (0.69 to 1.07) | 0.179 |
| Cardiac valve disease | 184/2,089 (9) | 107/1,233 (9) | 77/856 (9) | 1.04 (0.77 to 1.41) | 0.801 |
| Cerebrovascular accident/TIA | 461/2,089 (22) | 288/1,233 (23) | 173/856 (20) | 0.83 (0.67 to 1.03) | 0.088 |
| COPD | 259/2,089 (12) | 137/1,233 (11) | 122/856 (14) | 1.33 (1.02 to 1.73) | 0.033 |
| Congestive heart failure | 150/2,089 (7) | 89/1,233 (7) | 61/856 (7) | 0.99 (0.70 to 1.38) | 0.936 |
| Dementia | 547/2,089 (26) | 298/1,233 (24) | 249/856 (29) | 1.29 (1.06 to 1.57) | 0.012 |
| Diabetes mellitus | 395/2,089 (19) | 220/1,233 (18) | 175/856 (20) | 1.18 (0.95 to 1.48) | 0.136 |
| Malignancy in < 20 years | 344/2,089 (16) | 211/1,233 (17) | 133/856 (16) | 0.89 (0.70 to 1.13) | 0.340 |
| Myocardial infarction | 201/2,089 (10) | 119/1,233 (10) | 82/856 (10) | 0.99 (0.74 to 1.33) | 0.956 |
| Parkinson’s disease | 108/2,089 (5) | 73/1,233 (6) | 35/856 (4) | 0.68 (0.45 to 1.02) | 0.064 |
| Previous hip fracture surgery | 223/2,089 (11) | 126/1,233 (10) | 97/856 (11) | 1.12 (0.85 to 1.49) | 0.418 |
| Anticoagulation use, n (%) | |||||
| No anticoagulation use (ref.) | 897/2,089 (43) | 528/1,233 (43) | 369/856 (43) | - | - |
| PAI | 655/2,089 (31) | 387/1,233 (31) | 268/856 (31) | 0.99 (0.81 to 1.22) | 0.930 |
| VKA/DOAC | 475/2,089 (23) | 280/1,233 (23) | 195/856 (23) | 1.00 (0.79 to 1.25) | 0.976 |
| Combination | 62/2,089 (3) | 38/1,233 (3) | 24/856 (3) | 0.90 (0.53 to 1.53) | 0.707 |
| Immunosuppression | 82/2,089 (4) | 54/1,233 (4) | 28/856 (3) | 0.74 (0.46 to 1.18) | 0.201 |
| Polypharmacy (> 4 medications) | 1,286/2,089 (62) | 747/1,233 (61) | 539/856 (63) | 1.11 (0.92 to 1.32) | 0.271 |
| Median albumin on admission, g/L (IQR) | 38 (34 to 40) | 38 (34 to 40) | 38 (34 to 40) | 1.00 (0.99 to 1.03) | 0.506 |
| Missing, n (%) | 504 (24) | 346 (28) | 158 (18) | - | - |
| Median GFR on admission, ml/min/1.73m2 (IQR) | 65 (48 to 79) | 66 (48 to 80) | 64 (48 to 79) | 1.00 (0.99 to 1.00) | 0.273 |
| Missing, n (%) | 4 (1) | 3 (1) | 1 (1) | - | - |
| Median Hb on admission, mmol/L (IQR) | 7.8 (7.1 to 8.5) | 8.0 (7.3 to 8.6) | 7.6 (6.9 to 8.3) | 0.69 (0.63 to 0.76) | < 0.001 |
| Missing, n (%) | 1 (1) | 1 (1) | 0 (0) | - | - |
| Residential status, n (%) | |||||
| Home (ref.) | 1,370/2,089 (66) | 819/1,233 (66) | 551/856 (64) | - | - |
| Semi-independent nursing home | 194/2,089 (9) | 111/1,233 (9) | 83/856 (10) | 1.11 (0.82 to 1.51) | 0.496 |
| Nursing home and psychiatric ward | 525/2,089 (25) | 303/1,233 (25) | 222/856 (26) | 1.09 (0.89 to 1.34) | 0.413 |
| Walking aids, n (%) | |||||
| None (ref.) | 1,023/1,950 (52) | 629/1,157 (54) | 394/793 (50) | - | - |
| Rollator | 864/1,950 (44) | 493/1,157 (43) | 371/793 (47) | 1.20 (1.00 to 1.44) | 0.051 |
| Wheelchair/mobility scooter/ no functional mobility | 63/1,950 (3) | 35/1,157 (3) | 28/793 (4) | 1.28 (0.76 to 2.13) | 0.350 |
| Mean BMI, kg/m2 (SD) | 24.1 (4.3) | 24.0 (4.0) | 24.3 (4.7) | 1.02 (0.99 to 1.04) | 0.186 |
| Missing | 568 (27) | 294 (24) | 274 (32) | - | - |
| Median Katz-ADL (IQR) | 5 (2 to 6) | 5 (2 to 6) | 5 (1.5 to 6) | 0.95 (0.91 to 0.99) | 0.006 |
| SNAQ, n (%) | |||||
| 0 (ref) | 1,264/1,893 (67) | 762/1,122 (68) | 502/771 (65) | - | - |
| 1 to 2 | 304/1,893 (16) | 174/1,122 (16) | 130/771 (17) | 1.13 (0.88 to 1.46) | 0.331 |
| ≥ 3 | 325/1,893 (17) | 186/1,122 (17) | 139/771 (18) | 1.13 (0.89 to 1.45) | 0.317 |
ASA, American Society of Anesthesiologists; CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease; DOAC, direct oral anticoagulants; FNF, femoral neck fracture; GFR, glomerular filtration rate; Hb, haemoglobin; Katz-ADL, Katz Index of Independence in Activities of Daily Living; NHFS, Nottingham Hip Fracture Score; OR, odds ratio; PAI, platelet aggregation inhibitor; SNAQ, Short Nutritional Assessment Questionnaire; TF, trochanteric fracture; TIA, transient ischaemic attack; VKA, Vitamin K antagonist.
Perioperative factors, clinical outcomes, and mortality
Results of the univariable analysis of clinical outcomes, adverse events, and mortality are presented in Table II. Patients with TF were less often admitted at other medical departments than the geriatric trauma department (6% vs 12%, OR 0.57, 95% CI 0.41 to 0.80; p = 0.001), had less time to surgery (18 hrs vs 20 hrs, OR 0.99, 95% CI 0.98 to 0.99), p < 0.001), had shorter surgery time (39 mins vs 57 mins, OR 0.95, 95% CI 0.94 to 0.95; p < 0.001), had more haemoglobin loss (1.6 mmol/l vs 1.2 mmol/l, OR 1.57, 95% CI 1.41 to 1.74; p < 0.001). Patients with TF had fewer complications (such as delirium (16% vs 21%, OR 0.72, 95% CI 0.57 to 0.90; p = 0.005), pneumonia (8% vs 12%, OR 0.65, 95% CI 0.48 to 0.88; p = 0.005), reoperation (3% vs 5%, OR 0.57, 95% CI 0.36 to 0.91; p = 0.018), wound infection (1% vs 2%, OR 0.19, 95% CI 0.07 to 0.56; p = 0.002). Moreover, patients with TF were ready for discharge earlier (four days (3 to 5) vs four days (3 to 6), OR 0.92, 95% CI 0.89 to 0.95; p < 0.001) and had shorter time to discharge (six days (4 to 9) vs seven days (4 to 10), OR 0.97, 95% CI 0.95 to 0.98; p < 0.001).
Table II.
Univariable analysis of risk and prognostic perioperative and clinical factors.
| Variable | All patients (2,089) | FNF (1,233) | TF (856) | OR (95% CI) | p-value |
|---|---|---|---|---|---|
| Admission ward, n (%) | |||||
| Trauma/orthopaedic surgery (ref.) | 829/2,089 (40) | 494/1,233 (40) | 335/856 (39) | - | - |
| Geriatric trauma unit | 1,063/2,089 (51) | 597/1,233 (48) | 466/856 (54) | 1.15 (0.96 to 1.38) | 0.134 |
| Other | 197/2,089 (9) | 142/1,233 (12) | 55/856 (6) | 0.57 (0.41 to 0.80) | 0.001 |
| Median time to surgery, hrs (IQR) | 19 (13 to 26) | 20 (14 to 30) | 18 (11 to 24) | 0.99 (0.98 to 0.99) | < 0.001 |
| Missing, n (%) | 4 (1) | 1 (1) | 3 (1) | ||
| Time of the week, n (%) | - | - | - | - | - |
| Weekdays (ref.) | 1,512/2,089 (72) | 892/1,233 (72) | 620/856 (72) | - | - |
| During weekend | 577/2,089 (28) | 341/1,233 (28) | 236/856 (28) | 1.00 (0.82 to 1.21) | 0.966 |
| Time of day n (%) | |||||
| Daytime (8.00 to 18.00) (ref.) | 1,834/2,089 (88) | 1,076/1,233 (87) | 758/856 (89) | - | - |
| Night-time (18.00 to 8.00) | 255/2,089 (12) | 157/1,233 (13) | 98/856 (11) | 0.89 (0.68 to 1.16) | 0.378 |
| Anaesthesia, n (%) | |||||
| Spinal (ref.) | 1,850/2,089 (89) | 1,082/1,233 (88) | 768/856 (90) | - | - |
| General | 239/2,089 (11) | 151/1,233 (12) | 88/856 (10) | 0.82 (0.62 to 1.08) | 0.165 |
| Closure technique, n (%) | |||||
| Cutaneous suture (ref.) | 1,124/1,977 (57) | 559/1,179 (47) | 565/798 (71) | - | - |
| Agraves | 853/1,977 (43) | 620/1,179 (53) | 233/798 (29) | 0.37 (0.31 to 0.45) | < 0.001 |
| Mean surgery time, mins (SD) | 50 (21) | 57 (18) | 39 (21) | 0.95 (0.94 to 0.95) | < 0.001 |
| Missing, n (%) | 1 (1) | 1 (1) | 0 (0) | - | - |
| Median Hb loss, mmol/l (IQR) | 1.3 (0.8 to 1.9) | 1.2 (0.7 to 1.7) | 1.6 (1.0 to 2.1) | 1.57 (1.41 to 1.74) | < 0.001 |
| Missing, n (%) | 32 (2) | 27 (2) | 5 (1) | - | - |
| Complication, n (%) | |||||
| Delirium | 403/2,089 (19) | 263/1,233 (21) | 140/856 (16) | 0.72 (0.57 to 0.90) | 0.005 |
| Haematoma | 124/2,089 (6) | 70/1,233 (6) | 54/856 (6) | 1.12 (0.78 to 1.61) | 0.548 |
| Pneumonia | 213/2,089 (10) | 145/1,233 (12) | 68/856 (8) | 0.65 (0.48 to 0.88) | 0.005 |
| Reoperation | 90/2,089 (4) | 64/1,233 (5) | 26/856 (3) | 0.57 (0.36 to 0.91) | 0.018 |
| Urinary tract infection | 190/2,089 (9) | 121/1,233 (10) | 69/856 (8) | 0.81 (0.59 to 1.10) | 0.171 |
| Wound infection | 33/2,089 (2) | 29/1,233 (2) | 4/856 (0) | 0.19 (0.07 to 0.56) | 0.002 |
| Median time ready to discharge, days (IQR) | 4 (3 to 6) | 4 (3 to 6) | 4 (3 to 5) | 0.92 (0.89 to 0.95) | < 0.001 |
| Missing, n (%) | 77 (4) | 46 (4) | 31 (4) | - | - |
| Median time to actually discharge, (IQR) | 6 (4 to 10) | 7 (4 to 10) | 6 (4 to 9) | 0.97 (0.95 to 0.98) | < 0.001 |
| Missing | 78 (4) | 46 (4) | 32 (4) | - | - |
| Mortality, n (%) | |||||
| 30 days | 207/2,089 (10) | 118/1,233 (10) | 89/856 (10) | 1.10 (0.82 to 1.47) | 0.534 |
| 1 year | 641/2,089 (31) | 365/1,233 (30) | 276/856 (32) | 1.13 (0.94 to 1.37) | 0.198 |
FNF, femoral neck fracture; Hb, haemoglobin; OR, odds ratio; TF, trochanteric fracture.
In total, 64 patients (5%) with FNF had a reoperation. The most common indications were infection (n = 23), failure of implant (n = 16), and luxation (n = 13). In patients with TF, 26 (3%) underwent a reoperation, most commonly due to failure of cephalomedullary nailing (n = 8), surgical complications (n = 8), and chronic pain/arthrosis (n = 6).
There were no differences between 30-day and one-year mortality in patients with FNF or TF. Mortality rates are displayed using the Kaplan-Meier estimator in Figure 3 and Figure 4. An additional multivariable analysis was performed to analyze the relationship between fracture type and mortality, adjusting for potential confounders.19 The 30-day and one-year mortality was corrected for age, sex, ASA grade, COPD, dementia, albumin, GFR, haemoglobin at admission, residential status, and KATZ-ADL (Supplementary Tables ii and iii). Nevertheless, after multivariable correction for these variables, 30-day and one-year mortality did not differ between patients with FNF and TF (OR 1.07, 95% CI 0.78 to 1.47 for 30-day mortality and OR 1.00, 95% CI 0.81 to 1.24 for one-year mortality).
Fig. 3.
Kaplan-Meier curve of the 30-day mortality rates in patients with a femoral neck fracture and in patients with a trochanteric fracture with 95% CI.
Fig. 4.
Kaplan-Meier curve of the one-year mortality rates in patients with a femoral neck fracture and in patients with a trochanteric fracture with 95% CI.
Discussion
Differences between patients with FNF and patients with TF have not been extensively studied. The aim of this study was to assess the differences in baseline characteristics and clinical outcomes of patients with FNF or TF, as it is currently unclear whether these two populations can be considered as equal in these aspects.
The incidence rate of FNF was 41% (n = 856) in this study. In the literature, reported incidence rates of FNF vary between 25% and 57%.6-12 However, inclusion criteria among the reported articles are different. For example, the study with the highest percentage of FNF (57%) includes all patients over the age of 18 years,7 while all other studies use an age limit of at least 60 years.6,8-10,12 The relative increase in TF could be explained by their higher incidence in older individuals and the overall ageing of the population. Previous studies and current guidelines advise cemented HA as the surgical treatment for displaced FNF in the elderly, and sliding hip screws or cephalomedullary nailing for TF.3,5,22 These recommendations are in line with the chosen surgical treatments in this study cohort. FNFs were treated with HA (86%, n = 1,065), sliding hip screw (13%, n = 158), or cephalomedullary nailing (1%, n = 10). HA for FNF may reduce the risk of mortality and reoperation compared with internal fixation of undisplaced fractures.23 TFs were treated with cephalomedullary nailing (99%, n = 853) and sliding hip screws (1%, n = 3).
Baseline characteristics
Univariable analysis of baseline characteristics showed that patients with TF were older, less often male, more often had COPD and dementia, had lower haemoglobin levels on admission, and had lower Katz-ADL scores in comparison to patients with FNF.
Previous studies have shown that the population of patients with TF compared to patients with FNF are more likely to be older.7,10 This is in line with our results. In a large Italian observational study with 71,920 patients, 76.3% of all the hip fracture patients were female.9 The high prevalence of females among hip fracture patients was also observed in this cohort study, with 70% of all hip fracture patients being female (n = 1,453). Previous research has shown that the sex distribution regarding both types of fractures was similar.9,24 However, in this study, patients with TF were significantly more often female in comparison to patients with FNF (74% vs 66%).
The correlation between comorbidities and the type of proximal femoral fractures has been described once before: Díaz and Navas10 found that patients with TF had significantly more comorbidities than patients with FNF. Our cohort study shows significantly more COPD and dementia in the TF group. Díaz and Navas10 found no association between patients with TF and COPD or dementia. This may be due by their relatively small study population of 923 patients in total. A higher incidence of COPD in patients with TF was also described in a previous cohort study.12
Patients with TF had lower haemoglobin levels at admission in comparison to patients with FNF (7.6 vs 8.0). Hypothetically, TFs continue to lose blood from the bone marrow until surgical treatment, while the bleeding from FNFs is staunched by the capsule of the hip joint.
The lower Katz-ADL scores in the TF group in our study could be explained by higher age, COPD, and dementia, and are therefore hypothetically based on the underlying higher rate of comorbidities. Lower Katz-ADL scores in patients with TF have not yet been previously described in literature.
Perioperative factors and clinical outcomes
Patients with TF had less time to surgery and shorter operating time. They also had significantly less delirium, pneumonia, and fewer reoperations and wound infections in comparison with patients with FNF. Additionally, patients with TF were ready for discharge earlier and had shorter admission time in the hospital.
In this cohort, 93% (n = 1,148) of the patients with a FNF and 98% (n = 835) with TF were operated on within 48 hours after admission. Two possible explanations could account for the observation that patients with TF had shorter time to surgery in comparison to patients with FNF. First, the surgical procedure for TF, most often cephalomedullary nailing, is considerably shorter than the surgical procedure for FNF.25 In accordance with the literature, patients with TF had significantly shorter mean operating time (39 mins (SD 21)) than patients with FNF (57 mins (SD 18)).25 Second, cephalomedullary nailing for type A1 TF can also be performed by experienced surgical residents, whereas HA most often requires the expertise of an experienced trauma surgeon.
In this cohort study, 19% (n = 403) of all patients developed delirium after hip surgery. The overall incidence of delirium in this cohort was relatively low in comparison with the incidence rates (19% vs 24%) in the literature.26 Patients with TF had a lower incidence of delirium in comparison with patients with FNF (16% (n = 140) vs 21% (n = 263)). Hypothetically, the lower incidence of delirium in patients with TF may be due to shorter time to surgery, shorter operating time, fewer complications, and a shorter hospital stay.
In a recently published meta-analysis, the accumulated incidence rate of pneumonia after hip fracture surgery was 8.9%.27 The incidence rate of pneumonia in this cohort study (10%, n = 213) is slightly higher, which could be due to the fact that in this cohort study only patients aged 70 years and older were included.
Patients with TF had fewer reoperations (3%, n = 26) in this cohort study in comparison to patients with FNF (5%, n = 64). This is in line with a previous published cohort study by Lin and Liang,12 who found a reoperation rate of 9.0% in patients with FNF and 6.2% in patients with TF.
Results of this study showed significantly fewer wound infections in patients with TF (0.4%, n = 3) in comparison with patients with FNF (2.1%, n = 26). Patients with FNF exhibited a slightly higher implant failure rate (1.4%, n = 17) compared to TF (1.1%, n = 9). The lower incidence of wound infections, implant failure, and luxation in patients with TF in this study, is believed to account for the reduced incidence of reoperations in patients with TF in comparison to patients with FNF.
Patients with TF had fewer wound infections; at the time of writing there are no studies directly comparing wound infection rates between patients with FNF and patients with TF. Previous literature has described postoperative infection rates of 1.7% to 7.3% after HA,28 and 2.2% after cephalomedullary nailing.29 It is possible that the smaller wound surface and minimal tissue manipulation with cephalomedullary nailing in patients with TF could explain the significantly lower rate of postoperative wound infections.
Patients with TF had a shorter length of hospital stay, which could be explained by the lower incidence of complications in this group.
Mortality
There was no difference in 30-day and one-year mortality rates between patients with FNF and TF. The overall reported 30-day and one-year mortality rate in this study were 10% (n = 207) and 31% (n = 641), respectively. This is in accordance with previously reported 30-day mortality rates between 7.3% and 13.3% and one-year mortality rates between 23.2% and 33.0%.24,30,31 In this study, patients with TF had significantly more comorbidities at baseline, while patients with FNF had more complications. Hypothetically, the differences in baseline characteristics counterbalance the mortality outcome. Therefore, an additional multivariable analysis was performed to study the association between fracture type and mortality, adjusting for potential confounders.19 Nevertheless, after multivariable correction for these confounders, 30-day and one-year mortality did not differ between patients with FNF and TF (Supplementary Tables ii and iii).
In this study, patients with TF had a more extensive medical history, but patients with FNF had more postoperative complications. However, correcting for these baseline differences in medical history, mortality remained not significantly different between the two types of hip fractures. This could lead one to assume that, if only the influence of complications remains, there is no difference in mortality regardless of the complications. However, it is well established in the literature that complications such as delirium and wound infections in hip fracture patients cause higher mortality.32,33 An explanation may be that the risk factors for complications and mortality strongly overlap.19,32,33 In theory, this results in an indirect correction for complications in the multivariable analysis. Further research is needed into the causes of mortality, and the influence of baseline factors and complications for both patients with TF and patients with FNF.
The major strength of our study is that it is, to the best of our knowledge, the first study to extensively assess the differences in clinical outcomes between patients with FNF and patients with TF. Based on the results, it is debatable whether proximal femoral fractures are still one disease/aetiology or whether these should be divided into FNF and TF. An additional strength is that we were able to examine a large number of patients with extensive baseline and perioperative factors in a consecutive prospective hip fracture database with a minimal rate of missing data.
There are some limitations to our study: first, the study was observational in nature, meaning it could identify associations but not establish causation. This limits our ability to determine whether the observed relationships are due to direct effects, confounding factors, or other biases. Furthermore, this is an observational cohort study based on patients’ medical charts, which means that unreported data could not be included in our analysis. The final major limitation of is that patients who received a THA in the FNF group were excluded. As mentioned earlier, patients who opt for a THA are generally fitter and younger.4 This can distort the results and make the FNF group seem more frail than they actually are. Nevertheless, the TF group appeared to be older and have a worse medical history. This difference may therefore be even greater in reality. However, only 4% (n = 51) of patients with a FNF were excluded based on a THA, which also limits the influence on the final results.
In summary, elderly patients with TF exhibited an inferior baseline status in comparison to patients with FNF. Nonetheless, patients with TF showed a lower incidence of postoperative complications. Notably, no differences in mortality rates were observed between patients with the two types of proximal femoral fractures. Patients with FNF should be monitored more extensively during admission than patients with TF, due to the higher incidence of complications.
Take home message
- Elderly patients with trochanteric fractures exhibited a comparatively inferior baseline status in comparison to patients with femoral neck fracture, but patients with trochanteric fractures showed lower incidence of postoperative complications.
- No differences in mortality rates were observed between patients with the two types of proximal femoral fractures even after correcting for confounders.
- Based on this study, it can be discussed whether proximal femoral fractures are still one disease/aetiology or should be divided into femoral neck fractures and trochanteric fractures.
Author contributions
E. de Haan: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing
B. van Oosten: Visualization, Writing – original draft, Writing – review & editing
V. A. J. I. M. van Rijckevorsel: Conceptualization, Data curation, Project administration, Writing – original draft, Writing – review & editing
M. Kuijper: Methodology, Software, Writing – original draft, Writing – review & editing
L. de Jong: Conceptualization, Data curation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing
G. Roukema: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
The authors have no conflicts of interest to disclose.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
Acknowledgements
This article is published on behalf of the Author collaborator group Dutch Hip Fracture Registry Collaboration (DHFR).
Ethical review statement
The local Medical ethics committee approved the study and the study was registered in the Dutch Trial Register (nr NL 8313).
Open access funding
The open access fee for this article was self-funded.
Supplementary material
Specification of regression models for multiple imputation with chained equations, and the multivariable analyses for 30-day and one-year mortality.
© 2025 de Haan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Contributor Information
Eveline de Haan, Email: e.eveline.de.haan@gmail.com.
Benthe van Oosten, Email: benthevanoosten@gmail.com.
Veronique A. J. I. M. van Rijckevorsel, Email: veroniquevanrijckevorsel@gmail.com.
Martijn Kuijper, Email: KuijperT@maasstadziekenhuis.nl.
Louis de Jong, Email: dejonglouis@hotmail.com, dejonglouis2@gmail.com.
Gert Roukema, Email: RoukemaG@maasstadziekenhuis.nl.
Collaborators: F. van Beek, J. M. van Buijtenen, B. I. Cleffken, T. M. Kuijper, A. G. J. van Marle, N. W. L. Schep, G. B. Schmidt, N. M. R. Soesman, J. Vermeulen, C. H. van der Vlies, and O. Wijers
Data Availability
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.