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NATIONAL ORTHOPAEDIC REGISTRY MALAYSIA (NORM)

ANNUAL REPORT OF

NATIONAL ORTHOPAEDIC REGISTRY MALAYSIA (NORM) HIP FRACTURE

2009

Editors:

Dr Mohammad Anwar Hau Abdullah Dr Ahmad Tajuddin Abdullah

Registry Committee

Dr Mohammad Anwar Hau Abdullah

Dr Ahmad Tajuddin Abdullah

Dr Zulkiflee Osman

Dr Saadon Ibrahim

Dr Mohamad Yazid Din

Dr Joehaimey Johari

Dr Se To Boon Chong

Dr Tan Boon Cheong

Dr Abdul Rauf Ahmad

Dr Mohd Zamzuri Mohd Zain

Dr Pan Chee Huan

A publication of the National Orthopaedic Registry of Malaysia (NORM) and the

Clinical Research Centre, Ministry of Health Malaysia

*********************************************************************

December 2010

© National Orthopaedic Registry of Malaysia (NORM)

Publisher:

Jointly published by the National Orthopedic Registry of Malaysia (NORM) and the

Clinical Research Centre (CRC), Ministry of Health Malaysia.

National Orthopaedic Registry of Malaysia

1st Floor MMA House,

124, Jalan Pahang,

53000 Kuala Lumpur,

Malaysia.

Tel : (603) 4044 3060 / (603) 4044 3070 Fax : (603) 4044 3080 Email : [email protected]

Website : http://www.acrm.org.my/norm

Suggested citation: Mohammad Anwar Hau Abdullah, Ahmad Tajuddin Abdullah (Eds). Annual Report of the NORM- Registry, 2009. Kuala Lumpur, Malaysia: National Orthopaedic Registry of Malaysia 2009.

Disclaimer:

Data reported in this report were collected for one year period (from January to

December 2009), this report is copyrighted. Reproduction and dissemination of this

report in part or in whole for research, educational or other non-commercial purposes

are authorized without any prior written permission from the copyright holders

provided the source is fully acknowledged.

Electronic version

The electronic version of this report may be downloaded at

http://www.acrm.org.my/norm or http://www.crc.gov.my/publication/report.

Funding

The National Orthopaedic Registry of Malaysia (NORM) – Hip Fracture Registry is

funded with grants from the Ministry of Health Malaysia (MOH).

mailto:[email protected]

http://www.acrm.org.my/norm

http://www.crc.gov.my/publication/report

ACKNOWLEDGEMENTS

The National Orthopaedic Registry of Malaysia (NORM) would like to give its grateful

appreciation to everyone who has helped make this report possible.

We would especially like to thank the following:

Clinical Research Centre Dr Goh Pik Pin

Clinical Epidemiology Unit Dr Jamaiyah Haniff

Dr Dr Sharmini Selvarajah Dr Lim Chioa mei

Patient Registry Unit Dr Jaya Purany Stanley Ponniah Nurul Shuhada Binti Mohd Ali

Scottish Hip Fracture Registry

NORM Governance Board

Chairman Dato’ Dr Azmi Shafei

Director,

Division of Medical Development,

Ministry of Health Malaysia.

Members Dr Jamaiyah Haniff

Head Of Clinical Epidemiology Unit,

Clinical Research Center, Hospital Kuala Lumpur.

Dr Jaya Purany Stanley Ponniah

Head of Patient Registry Unit

Clinical Research Center, Hospital Kuala Lumpur.


Head of Department,

Department of Orthopaedic and Traumatology,

Hospital Raja Perempuan Zainab II, Kota Bharu.

Dr Ahmad Tajuddin Abdullah

Head of Department,


Hospital Sultanah Nur Zahirah, Kuala Terengganu.

Dr Saadon Ibrahim


Hospital Sultan Ismail, Johor Bharu.

Dr Se To Boon Chong


Hospital Pulau Pinang,Pulau Pinang.

Dato’ Dr Suresh Chopra,

Head of Department,


Hospital Sultanah Bahiyah, Alor Setar.

Dr Abdul Rauf Ahmad

Head of Department,


Hospital Tuanku Jaafar, Seremban.

Dato’ Dr Premchandran Menon

Head of Department,


Hospital Tengku Ampuan Afzan (HTAA), Kuantan.

Dr Pan Chee Huan

Head of Department,


Hospital Tuanku Fauziah, Kangar.

Dr Thirumal a/l Manickam

Head of Department,


Hospital Tengku Ampuan Rahimah, Klang.

Dr Nahulan A/L Theva Rajah

Head of Department,


Hospital Queen Elizabeth, Kota Kinabalu.

Dato’ Dr Ramanathan A/L Ramiah

Head of Department,


Hospital Raja Permaisuri Bainun, Ipoh.

Mr.Sivapathasundaram A/L Nadarajah

Head of Department,

Department of Orthopaedic and Traumatology

Hospital Melaka, Melaka.

Dr K. Thevarajan

Head of Department,


Hospital Sultanah Aminah, Johor Bharu.

Dr Faris Kamaruddin

Head of Department,


Hospital Umum Sarawak, Sarawak.

NORM Steering Committee members:

Chairman Dr Ahmad Tajuddin Abdullah

Head of Department,


Hospital Sultanah Nur Zahirah, Kuala Terengganu.

Co-Chairman Dr Zulkiflee Osman

Head of Department,


Hospital Kuala Lumpur.

Members Dr Mohammad Anwar Hau Abdullah

Head of Department,



Dr Saadon Ibrahim


Hospital Sultan Ismail, Johor Bharu.

Dr Se To Boon Chong


Hospital Pulau Pinang, Pulau Pinang.

Dr Tan Boon Cheong


Hospital Pulau Pinang, Pulau Pinang.

Dr Abdul Rauf Ahmad


Hospital Tuanku Jaafar, Seremban.

Dr Mohd Zamzuri Mohd Zain


Hospital Tengku Ampuan Afzan (HTAA), Kuantan.

Dr Pan Chee Huan


Hospital Tuanku Fauziah, Kangar.



Hospital Sultanah Bahiyah, Alor Setar.

Dr Joehaimey Johari



NORM SOURCE DATA PROVIDERS 2008/2009

The current source data providers for NORM are:

No. Hospital Site investigators Second person-in-charge

1 Hospital Kuala

Lumpur

Mr Zulkiflee Osman Dr Mahazura Hj Mat Lawi

Dr. Abdul Qahhar

2 Hospital Raja

Perempuan

Zainab II Kota

Bharu

Mr Mohammad Anwar Hau

Abdullah

Dr Joehaimey Johari

Sister Nik Noriah Nik Ibrahim

3 Hospital Sultanah

Nur Zahirah Kuala

Terengganu

Mr Ahmad Tajuddin Abdullah

Dr Mustaqim Afifi @ Apipi

Dr Hazulin Mohd Radzuan

Dr Muhammad Hilmi Nasir

Dr Mohd Ariff Razani Abd

Razak

4 Hospital Tengku

Ampuan Rahimah

Klang

Dr Gurjit Singh Dr M. Thirumal

5 Hospital Sultanah

Bahiyah Alor Setar


Dr Noor Mahazrinna

Hayadin

Dr Lim Chiao Yee

6 Hospital Sultanah

Aminah Johor

Bahru

Dr Yoga Raj A/L

Parameswaran

Dr Manamohan

Chandrarajan

Dr Mohd Adham Shah

Dr Teo Pock Chin

7 Hospital Melaka

Dr Rengsen Parthiban Dr Azhar Asari

Dr Mohd. Karim Md Isa

MA Mohd Fharid Johan

SN Marina Mohamed @

Osman

8 Hospital Sultan

Ismail Johor Bahru

Dr Saadon Ibrahim Dr Mursyida Md Nujid

Dr Jayamalar

Thurairajasingam

SN Rohayah Abdul Rahman

JM Yussilawani Mamat

9 Hospital Tuanku

Fauziah Kangar

Dr Pan Chee Huan

Mr Yeap Ewe Juan

Mr Zakaria Yusoff

Dr Badrul Hashim

Dr Zakaria Yusoff

MA Shahizam Shafiee

SN Norseha Baharom

10 Hospital Raja

Permaisuri Bainun

Ipoh

Dr Manoharan Dr Selvynlloyd

Dr Iyngkaran Arasalingam

11 Hospital Tengku

Ampuan Afzan

Kuantan

Dato' Dr N Premchandran

Dr. Mohd Zamzuri Mohd

Zain

Dr Alaudin Haris Osman

Dr Jeffrey Jaya Raj

Dr Ahmad Hafiz bin Zulkifly

12 Hospital Ampang Dr Ng Yue Oon Dr Lynn Azura Md Sham

Dr Samyu Ali

13 Hospital Tuanku

Ja’afar Seremban

Dr Abdul Rauf Ahmad Dr Ng Tiong Soon

Dr Johann Johari

Sr Khamisah A. Ghani

Sr Rohana Zakaria

14 Hospital Pulau

Pinang

Dr Se To Boon Chong Dr Tan Boon Cheong

Dr Ooi Chee Lean

Dr Chan Kok Yu

15 Hospital Serdang Dr Khoo Shaw Woei Dr Imma Isniza

Dr Harminder Singh

Randhawa

16 Hospital Selayang Dr Ng Swee Soon Dr Ritzwan Ismayatim

Dr Amir Fariz Zakaria

17 Hospital Queen

Elizabeth Kota

Kinabalu

Dr Nahulan A/L Theva Rajah Dr CS Kumar

18 Hospital Umum

Sarawak

Dr Faris Kamaruddin Dr Aaron Gerard Paul

MA Mikim A/K Radem

9

PREFACE

The National Orthopaedic Registry Malaysia has been collecting data since mid 2008

and it is with great pleasure and pride that we see this report materialised.

I would like to thank all those who have collected, verified and analysed the data. The co-

operation and energy demonstrated in units throughout the country indicates the

importance they place on improving patient management

The success of this report is due to continuous support and cooperation from various

people and agencies. The effort of the entire group must be congratulated and it has

been my sincere hope that this registry is able to sustain in coming years.

I also take this opportunity to thank the Clinical Research Centre Ministry of Health

Malaysia, to have trust in us and to provide us with the funding for us embark in this

project. This annual report is a testament of all your combined effort.

Thank you,

Dr Ahmad Tajuddin bin Abdullah


Chairman National Orthopaedic Registry of Malaysia

Ministry of Health Malaysia

10

ABBREVIATIONS

ASA American Society of Anaesthesiologists

CRC Clinical Research Centre

CRF Case Report Form

csv Comma separated value

Dr Doctor

GA General Anaesthesia

HTAA Hospital Tengku Ampuan Afzan

ICT Information and Communication Technology

LMWH Low Molecular Weight Heparin

MJM Medical Journal of Malaysia

MOH Ministry of Health

NOHFR National Orthopaedic Hip Fracture Registry

NORM National Orthopaedic Registry of Malaysia

OT Operation Theatre

PTH Parathyroid Hormone

RTA Road Traffic Accident

SDP Source Data Provider

SERMS Selective Estrogen Receptor Modulators

SMS Short Messaging System

txt Text-delimited format

xls Excel workbook

11

About National Orthopaedic Registry

The National Orthopaedic Registry of Malaysia (NORM) is a service supported by the

Ministry of Health (MOH) to collect information about orthopaedic disease in Malaysia especially

diabetes and hip fracture. This will enable us to know the incidence of the orthopaedic disease to

evaluate its risk factors and treatment provided within the country. This information is useful in

assisting the MOH, Non-Governmental Organizations, private healthcare providers and industry

in planning and evaluation, leading to better orthopaedic disease prevention and control.

NORM is funded by Ministry of Health Malaysia (MOH) and was initiated by a group of health

professionals from orthopaedic, public health specialists and epidemiologist in July 2007.

Currently, 17 CRC’s hospitals and 1 Non-CRC hospital nationwide are contributing as Source

Data Provider (SDP):

The source data providers are:

1. Hospital Ampang 2. Hospital Kuala Lumpur 3. Hospital Melaka 4. Hospital Pulau Pinang 5. Hospital Queen Elizabeth 6. Hospital Raja Perempuan Zainab II 7. Hospital Raja Permaisuri Bainon 8. Hospital Selayang 9. Hospital Serdang 10. Hospital Sultan Ismail 11. Hospital Sultanah Aminah 12. Hospital Sultanah Bahiyah 13. Hospital Sultanah Nur Zahirah 14. Hospital Tengku Ampuan Afzan 15. Hospital Tuanku Ampuan Rahimah 16. Hospital Tuanku Fauziah 17. Hospital Tuanku Jaafar 18. Hospital Umum Sarawak

The idea of NORM is to be a national population-based registry on orthopaedic diseases in

Malaysia. In view of this, NORM has opened its initiation to all orthopaedic departments with the

most facilities and hopes to get the private hospital’s contribution in this for better patient care.

12

NORM Organization

NORM Organization Chart

The organization of the NORM is shown below. The description of the duties and functions of

each entity depicted follows.

Terms of References

Flow Chart of Registry Organisation

3B. CENTRE REGISTRY OFFICE

Centre for the collection of data, analysis of data, and feedback of information

This is staffed by the Clinical Registry Manager/Epidemiologist, CRA, Statistician, IT personnel and other supporting staffs

To motivate, direct and communicate with its staff on registry management & operations.

3A. STEERING / EXECUTIVE COMMITTEE

Ensure the register is run according to its stated aims, objectives and protocols

Ensure the rights of patients are respected

Oversee the progress of the project

Oversee the use of register data

Provide leadership and decision making on the registry

Establish a centre registry office to serve as administration and management centre

Facilitate access to data sources

1. EXPERT PANEL

Provide scientific & clinical advice to the project

Guide future development of registry

Ensure good technical and scientific basis of the registry

Decide initial data collection process and its contents

Consists of specialists related to the field of registry

Conduct literature review

Conduct quality control on the CRF & Data

Interpreting results generated by the statistician

Report writing

Facilitate access to data source by centre office

2. PRINCIPAL INVESTIGATOR (PI)

The PI is the chairperson of the expert panel & steering/executive committee

PI leads, manages & coordinates activities of the whole registry

PI is selected from the primary study centre of the registry

13

5. SPONSORS

Responsible to the DG of Health for the effective, efficient and responsive operations of the database

Provide the financial, human and information resources required.

E.g. CRC, NIH, Specialist Department of MOH, Pharmaceutical Companies, Private Associations, Universities…etc.

4. RESEARCH ETHICS COMMITTEE APPROVAL

Seeking ethical approval for clinical research or waver of informed consent in registry project

8. SOURCE DATA PROVIDER (SDP)

Data collection

Includes all participated study sites

May involve other data sources e.g. Jabatan Pendaftaran Negara (JPN) for national all-cause mortality information

Staffed by Site coordinators & RA

7. VENDOR FOR DATA

STORAGE & SECURITY

9. USERS GROUP

Includes the public health practitioner, health care provider, health service planner & decision maker, researchers and on occasions, the public community.

Feedback on information gathered by the registry and contributes to future planning and investment justification.

6. GOVERNANCE BOARD

Membership should represent all stakeholders including source data providers, users groups and representative from the steering committee and the centre registry office

Chaired by a neutral party

Determines the policy and protocols for the operation of the registry

Ensure the registry meets the needs and expectations of all interested parties

Galvanise commitment of all stakeholders

To approve any additional research projects

14

NORM Office The collection, and analysis of data, and feedback of information are performed in a single centre

referred to as the NORM Office. This unit is managed by staff nurse and other supporting

personnel provided by CRC. The Clinical Research Centre (Kelantan) is currently the designated

NORM Office.

Objectives of the NORM – Hip Fracture are to:

1. Determine the number and type of hip fractures among patients ages 50 years and above

admitted into orthopaedic wards in MOH hospitals

2. Determine the cost/burden of treating hip fracture in terms of a) Average length of stay. b) Percentage of patients that underwent surgery. c) The average waiting time for surgery.

3. Determine the demographic of the hip fracture patients admitted into MOH hospitals in

terms of:

a) Gender proportion b) Age distribution c) Ethnic proportion d) Socio-economic status e) Pre-fracture residence f) Mechanism of Injury g) Pre-fracture morbidity.

4. Determine immediate treatment outcomes and complications, and functional outcome at six

months post treatment.

5. Determine the current practice among orthopaedic surgeons in MOH hospitals

a) Timing of surgery b) Type of surgery (Implant used) c) Antibiotic prophylaxis d) Thrombo-embolitic prophylaxis.

6. Facilitate service improvements.

7. Stimulate and facilitate hip fracture research.

15

8. Users

These are the individuals or institutions to which the regular database reports are addressed. They include

Orthopaedic professional

Health care provider

Public health practitioner

Industry

Decision maker

Researcher

Press and public

16

EXECUTIVE SUMMARY

The National Orthopaedic Registry of Malaysia (NORM) on Hip Fracture for patients age 50 and above was

established in 2008. Its main objectives was to establish a national database of patients treated for hip fracture

(especially for ages 50 and above) in 18 orthopaedics departments within MOH hospitals and to review the

patients’ demography, social background, hip fracture patterns, clinical practices and outcome. The following is

the descriptive annual report on the data collected from 1st January to 31st December 2009:

1. The total number of cases analysed was 510.

2. Two-third (345 out of 510 cases) of the patients were female and 75.1% of them were from the post-menopausal women (mean age attained menopause was 50.4 year).

3. The mean age of the patients at the time of presentation (admission) was 74.5 years with the peak age-

group was 70 to 79 year-old.

4. The ethnic distributions among the patients were not in line with the country’s population racial ratio. There

were 44.5% Chinese, Malays 40.0% Malays and 13.9% Indian from this database.

5. Ninety-seven percent of patients lived in their home either independently or with carer(s), and majority (70.8%) of them were able to function and walk without any aids prior to the hip fracture.

6. However, seventy percent (n=365) of the patients from the database were having some form of co-morbid

illness at the time of admission; the most common pre-morbid illness were hypertension (74.0%) and diabetes mellitus (46.6%).

7. 12.2% of the patients were on some form of anti-osteoporotic medication; and among those on anti-

osteoporotic medications, 77.4% and 46.8% of them were taking calcium and vitamin D supplement respectively.

8. There were only 5.3% of the patients have had previous hip fracture prior to the current admission.

9. For the current admission, 84.5% of the patients attributed “fall” as the cause of the hip fracture. 10. There were 82.5% of the patients underwent surgical treatment. And 17.5% (n=89) of the patients were treated

non-surgically. The most common reasons for conservative treatment were patient refusal (34.5%) and patients

were medically unfit (32.2%).

11. Among those who were treated surgically, the surgeries were considered as delayed in 81.3% (340 out of 418 patients); the main reasons for the delay were lack of OT 49% and patients’ medical condition needed further optimisation (24%). However, there were 8% cases were due to financial problems.The most preferred method of fracture treatment was using DHS/DCS (54.1%), and there were 7.0% of the patients underwent total joint replacement.

12. GA (28.9%) and spinal anaesthesia (66.3%) were the preferred mode of anaesthesia.

17

13. About two third (63.1%) of the surgeries were performed by consultants or specialists and 61.7% surgical

assistant were medical officers.

14. There were 88.7% of the patients did not received any form of thromboprophylactic.

15. Among the patients on chemical thromboprophylaxis; low molecular weight heparin (LMWH) was the most popular form of thromboprophylaxis (151 patients).

16. Surprisingly, 16.5 %(n=78) of patients who underwent surgery did not receive any form of antibiotics prophylaxis. The most common prophylactic antibiotic used was Cefuroxime (71.2%).

17. It is notable that, 97.4% of patients were successfully treated and discharged.

18. In terms of length of hospital stay, 58.6% of patients stayed less than two weeks. However, about 18.2% of them were admitted for more than four weeks.

18

CONTRIBUTING EDITORS

Technical support personnel

Database Administrator Ms Lim Jie Ying

Clinical Data Manager Ms Teo Jau Shya

Statisticians Encik Mohamad Adam Bin Bujang

19

Table of Contents

SECTION 1: PATIENT DETAILS AND DEMOGRAPHIC 21 SECTION 2: PRE-FRACTURE STATUS (IMMEDIATELY PRIOR TO FRACTURE) 22 Table 2.1: Pre-Fracture status (immediately prior to fracture), Hip Fracture,, National Orthopadic Registry National Orthopedic Registry Malaysia (NORM) 2009. 22 SECTION 3: FRACTURE TYPE 25 Table 3.1: Distribution of pathological fracture and fracture types at Pre-Operative Phase, Hip Fracture, National Orthopadic Registry Malaysia (NORM) 2009 25

SECTION 4: PRE-OPERATION PHASE 26 SECTION 4: TREATMENT 27 Table 4.1: Type of treatment, Hip Fracture, National Orthopadic Registry Malaysia (NORM) 2009. 27 Table 4.2: Conservative reasons, Hip Fracture, National Orthopadic Registry Malaysia (NORM) 2009. 27

Table 4.3: Operation Status after 72 hrs to theatre and operation type list, Hip Fracture, National

Orthopaedic Registry Malaysia (NORM) 2009. (Surgery, N = 418) 28

Figure 4.2: Delayed reasons after 72 hours to theatre and operation type list, Hip Fracture, National

Orthopadic Registry Malaysia (NORM) 2009. (Surgery, n= 340) 29

Table 4.4: Treatment detail (side and operation type) Hip Fracture, National Orthopadic Registry Malaysia

(NORM) 2009. 29

Table 4.5: Treatment detail (ASA grade) Hip Fracture, National Orthopadic Registry Malaysia (NORM)

2009. 30

Table 4.6: Treatment detail (anaesthetic type), Hip Fracture, National Orthopadic Registry Malaysia

(NORM) 2009. 31

Spinal (66.3%) and General Anaesthesia (28.9%) were the preferred mode of anaesthesia. 31

Table 4.7: Treatment detail (grade of staff), Hip Fracture, National Orthopadic Registry Malaysia (NORM)

2009. 31

Table 4.8: Treatment detail (type of chemical thrombop. and antibiotic prophylaxis), Hip Fracture,

National Orthopadic Registry Malaysia (NORM) 2009. 33

SECTION 5: POST OPERATIVE 34 Table 5.1: Post Operative, Hip Fracture, National Orthopadic Registry Malaysia (NORM) 2009 34

20

CHAPTER 1: PATIENT CHARACTERISTICS

21

Section 1: Patient Details and Demographic

In 2009, a total number of 510 patients recoded in the National Orthopaedic Registry of Malaysia-

Hip Fracture. Two-third (345 out of 510 cases) of the patients were female whereas 32.4%

(n=165) were male.

0

5

10

15

20

25

30

35

40

45

50-59 60-69 70-79 80-89 ≥90

Age Group (Year)

Per

cen

tag

e (%

)

Figure 1.1: Distributions of Hip Fractures patient by age group, National Orthopaedic Registry of Malaysia (NORM, 2009) The mean age of the patients at the time of presentation (admission) was relatively old at 74.5 years with standard deviation of 9.9. It was clearly known that, 8.6% were aged between 50-59 years old; 20.0 % were aged between 60-69 years old; 41.4. % were aged between 70-79 years old; 23.9 % were aged between 80-89 years old and the remaining 6.1 % were aged over 90 years old. The peak age-group was recorded at 70 to 79 year-old.

Malay

40.0%

Chinese

44.5%

Non Malaysian

0.2%Others Malaysian

1.4%Indian

13.9%

Malay

Chinese

Indian

Others Malaysian

Non Malaysian

Figure 1.1: Distributions of Hip Fractures patient by ethnicity, National Orthopaedic Registry of Malaysia (NORM, 2009)

22

In terms of ethnicity, the majority of cases were Chinese (44.5%) followed by Malay (40.0 %,) and Indian (13.9 %). However, these figures may not represent the ethnic distribution of our country’s population racial ratio where Malays are made up an estimated 50.4% of the total population of 26.64 million, Chinese 23.7%, Indian 7.1%, and non-Malay Bumiputra 11%)1.

Section 2: Pre-Fracture status (immediately prior to fracture)

In regards to the dependency and walking ability of the patients, it is notable that majority of them lived in their home either independently or with carer(s) with the rate of 97 % whereby 70.4% of them were able to function and walk without any aids prior to the hip fracture.

Table 2.1: Pre-Fracture status (immediately prior to fracture), Hip Fracture,, National

Orthopaedic Registry Malaysia (NORM) 2009.

Profile n %

Residency

+Home 488 95.7

Sheltered housing 1 0.2

Residential care 0 0.0

Nursing home 16 3.1

Permanent hospital 2 0.4

Acute hospital 1 0.2

Others 2 0.4

Total 510 100.0

Dependency (Na = 14)

Independent 332 66.9

Has career but not daily 7 1.4

Has career once daily 5 1.0

Live with carer(s) 151 30.4

Patient in main carer 1 0.2

Short term acute care 0 0.0

Total 496 100.0

Walking ability

Indoor (na = 6)

Without aids 357 70.8

With aids 122 24.2

Unable to walk 25 5.0

Total 504 100.0

Outdoor (Na = 37)

Without aids 333 70.4

With aids 114 24.1

Unable to walk 26 5.5

Total 473 100.0

Accompanied to walk

Indoor 20 17.4

23

Outdoor 29 25.2

Both indoor and outdoor 66 57.4

Total 115 100.0 Footnote Na-not available *Denominator is 510

Comorbidity of the patients was also taken into account at the time of admission which illustrates

the effect of all other diseases an individual patient might have other than the primary disease of

interest.

74

4.11.9 0.8

9.6

35.9

46.6

0

10

20

30

40

50

60

70

80

Diabete

s

Hypertentio

n

Eye p

roblem

Hearing pro

blem

Parkinso

nism

Stroke

Others

Premorbid illness

Per

cent

age

(%)

Figure 2.1: Pre-Fracture status (pre-morbidity illness), Hip Fracture,, National Orthopaedic Registry Malaysia (NORM) 2009.

In this case, 71.6 % (n=3665 from the total umber of patients reported were having some form of

co-morbid illness. It became evident that most of the patients suffered from hypertension which

makes up 74.0% (n=270) while diabetics mellitus with 46.6% (n=170) come in as the second

highest. Co-morbid illness such as stroke (9.6 %), respiratory (5.9 %), eye problem (4.1&),

hearing problem (1.9%) and Parkinsonism (0.8%) were also reported. The remaining 35.9 %

(n=131) were categorised under others. .

24

A total of 27 (5.3%) patients were reported having previous hip-fracture prior to the current admission out of which only 12.2% of the patients were on some form of anti-osteoporotic medication; and among those on anti-osteoporotic medications, 77.4% and 46.8% of them were taking calcium and vitamin D supplement respectively. Table 2.4 Pre-Fracture status (immediately prior to fracture), Hip Fracture, National Orthopaedic Registry Malaysia (NORM) 2009.

Status n %

Previous hip fracture (no = 480, Na = 3)

27 5.3*

Anti-osteoporosis medication (no = 437, Na = 11)

62 12.2*

Types of anti-osteoporosis medication

Calcium 48 77.4

Vitamin D 29 46.8

Bisphosphonate 6 9.7

Calcitonin 3 4.8

SERMS 0 0.0

PTH 0 0.0

Others 2 3.2 Footnote: *Calculated using denominator of 510 Denominator for types of anti-osteoporosis medications Na-not available

Bisphosphonate (9.7%), Calcitonin (4.8 %) and others (3.2%) make up the rest of anti-

osteoporotic medication taken prior to admission. None of the patients were recorded on anti-

osteoporotic medications in the form of SERMS and PTH.

25

Section 3: Fracture Type

Table 3.1: Distribution of pathological fracture and fracture types at Pre-Operative Phase,

Hip Fracture, National Orthopaedic Registry Malaysia (NORM) 2009.

Footnote: *Could not get exact 100.0% due to rounding error. In general, the predominant mechanism of hip fracture that was reported is fall (85%). This is followed by spontaneous (8.1%) and RTA (6.9%).

7.8

19.4

8.3

17.3

44.4

22.2

43.7

27.8

36.1

25.7

5.6

27.8

5.52.85.6

0

20

40

60

80

100

120

Pe

rce

nta

ge (

%)

50-59 60-69 70-79 80-89 ≥90

Age Group

Spontaneous

RTA

Fall

*Calculated using denominator of 498 Denominator for types of anti-osteoporosis medications is 62

Figure 3.2: Distribution of mechanism of injury, Hip Fracture, National Orthopaedic Registry Malaysia (NORM) 2009.

Fracture types n %

Pathological fracture:

Single 66 98.5

Both 1 1.5

Total 77 100.0

Fracture types

Undisplaced intracap. 44 10.1

Displace intracap. 55 12.6

Basocervical 24 5.5

Inter. 2 fragments 134 30.8

Inter. Multifragment 68 15.6

Subtrochanteric 31 7.1

Others 79 18.2

Total 435 ≈100.0*

26

Section 4: Pre-operation phase

In present-day surgical practice, fracture patterns are highly taken into consideration in which this question will guide the postoperative management. Table 3.1: Pre-Operative Phase, Hip Fracture, National Orthopaedic Registry Malaysia (NORM) 2009.

The fracture patrons were categorised under three different categories. Extracapsular was the

highest fracture pattern been reported with 63.3 %( n=296). Among all the fractures,

intertrochanteric fracture being the most common fractured type (44.3%). Intertrochanteric

fracture was recorded at 3.8 % followed by subtrochanteric fracture and basocervical fracture

(6.5% and 5.9 % respectively).

Meanwhile, 32.2 % (n=168) were diagnosed to be having Intracapsular fracture pattern with 8.8 % (n=46) fall under undisplaced intracap type and 23.4 % (n=122) fall under displace intracap type. It is also notable that 11.1% (n=58) patients were admitted with unspecified fracture pattern.

Fracture pattern n %

Intracapsular

Undisplaced intracap. 46 8.8

Displace intracap. 122 23.4

Extracapsular

Basocervical 31 5.9

Intertrochanteric fracture. 2 fragments

159 30.5

Intertrochanteric fracture. Multifragment

72 13.8

Subtrochanteric 34 6.5

Unspecified 58 11.1

27

Section 4: Treatment

Table 4.1: Type of treatment, Hip Fracture, National Orthopaedic Registry Malaysia

(NORM) 2009.

Treatment detail n %

Type of treatment: (Na = 3)

Surgery 418 82.5a

Surgery by age group

50-59 39 9.3

60-69 83 19.9

70-79 178 42.6

80-89 97 23.2

≥90 21 5.0

Total 418 100.0

Conservative 89 17.5a

Conservative by age group

50-59 5 5.6

60-69 18 20.2

70-79 31 34.8

80-89 25 28.1

≥90 10 11.2

Total 89 100.0 Footnote: calculated using denominator of 507

Na-not available

In general, the greatest percentage of patients with hip fracture clustered at the age group 70-79. In total, there were 82.5% (n=418) of the patients underwent surgical treatment for the hip fracture, and 17.5% (n=89) of the patients treated non-surgically. Among patients treated conservatively, 39.3% were > 80 years old, compared with 28.2% of those treated surgically.

Table 4.2: Conservative reasons, Hip Fracture, National Orthopaedic Registry Malaysia

(NORM) 2009.

Treatment detail n %

Reason for conservative: (n = 89, Na = 2)

Patient medically unfit 28 32.2a

Medically unfit by age group

50-59 0 0.0

60-69 4 14.3

70-79 10 35.7

80-89 7 25.0

≥90 7 25.0

Total 28 100.0

28

Patient refused 30 34.5a

Patient refused by age group

50-59 2 6.7

60-69 5 16.7

70-79 14 46.7

80-89 8 26.7

≥90 1 3.3

Total 30 ≈ 100.0b

Financial problem 1 1.2a

Financial problem by age group

50-59 1 100.0

60-69 0 0.0

70-79 0 0.0

80-89 0 0.0

≥90 0 0.0

Total 1 100.0

Others 28 32.2a Footnote: aCalculated using denominator of 87 bCould not get 100% due to rounding error Na-not available

The most common reasons for conservative treatment were patient refusal (34.5%) and patients

were medically unfit (32.2%).

Table 4.3: Operation Status after 72 hrs to theatre and operation type list, Hip

Fracture, National Orthopaedic Registry Malaysia (NORM) 2009. (Surgery, N = 418)

Status: n %

No delay 78 18.7

Delay 340 81.3

Total 418 100.0

Operation type list (na = 38, missing = 92)

Planned trauma 161 42.4

Emergency 39 10.3

Elective 180 47.4

Total 380 ≈ 100.0a Footnote: aCould not get 100% due to rounding error na-not available

Among those who were treated surgically, the surgeries were considered as delayed in 81.3%

(340 out of 418 patients).

29

Initially treated

conser.

5%

Consent problem

3%

Financial problem

8%

Theatre

unavailable

49%

Medically unfit

24%

Others

10%

Delayed in

diagnosis

1%

Delayed in diagnosis Theatre unavailable Medically unfit Initially treated conser.

Consent problem Financial problem Others

Figure 4.2: Delayed reasons after 72 hours to theatre and operation type list, Hip Fracture,

National Orthopaedic Registry Malaysia (NORM) 2009. (Surgery, n= 340)

The main reasons for the delay were lack of OT time (53.8%) and patients’ medical condition

needed further optimisation (27.1%). There were 9.4% (32 cases) due to financial problems.

Table 4.4: Treatment detail (side and operation type) Hip Fracture, National Orthopaedic

Registry Malaysia (NORM) 2009.

n row % n row % n row %

Side (Na = 98) 409 99.3 3 0.7 412 100.0

Operation type n % n % n col %

Pin and screw 10 2.52 1 11 2.7

DHS/DCS 220 55.42 3 223 54.1

Intramedullary device 23 5.79 0 23 5.6

Uncemented hemiarth.

33 8.31 1

34 5.8

Cemented hemiarth. 42 10.58 0 42 10.2

Bipolar hemiarth. 29 7.30 0 29 7.0

Cemented THJR 17 4.28 0 17 4.1

Comment [c1]: Recommend analysis of % is done by the column. At least for single.

Comment [c2]: For both side, since n=3, suggest to just list out (maybe at the bottom of the table) each person has what surgery done. Eg 1 patient has DHS/DCS both side 1 patient had pin and screw one side, and uncemented hemiarth one side etc

30

Uncemented THJR 3 0.76 0 3 0.7

Hybrid THJR 3 0.76 0 3 0.7

Girdlestone 0 0 0 0 0.0

Others 17 4.28 0 17 4.1

Not available 3 0.76 1 4

Total 400 Footnote: *Out of 402, 3 patient has both sides eg suggested table

Operation type n %

Pin and screw 10 2.52

DHS/DCS 220 55.42

Intramedullary device 23 5.79

Uncemented hemiarth.

33 8.31

Cemented hemiarth. 42 10.58

Bipolar hemiarth. 29 7.30

Cemented THJR 17 4.28

Uncemented THJR 3 0.76

Hybrid THJR 3 0.76

Girdlestone 0 0

Others 17 4.28

Not available 3 0.76

100

Both sided

Both side DHS/DCS

One side x , one side y

One side x, one side z

Table 4.5: Treatment detail (ASA grade) Hip Fracture, National Orthopaedic Registry Malaysia

(NORM) 2009.

Suggest the table to be designed this way:

All

ASA grade n col %

1 69 24.9

2 158 57.0

3 47 17.0

4 3 1.1

5 0 0.0

Total 277 100.0 2 of the patients in ASA 1 had surgery at both side

Formatted: Not Highlight

31

1 of the patients in ASA 2 had surgery at both side Majority of the patient; 81.9% were in ASA 1 or 2 at the time of surgery.

Table 4.6: Treatment detail (anaesthetic type), Hip Fracture, National Orthopaedic Registry

Malaysia (NORM) 2009.

Anaesthetic type n %

GA 121 28.9

Spinal 277 66.3

Epidural 74 17.7

Intrathecal opiate 0 0.0

Sedation 2 0.5

Regional block 5 1.2

Wound infiltration 0 0.0

Total 479 Footnote: aCalculated using denominator of 418 (number of treatment Surgery)

Spinal (66.3%) and General Anaesthesia (28.9%) were the preferred mode of

anaesthesia.

Table 4.7: Treatment detail (grade of staff), Hip Fracture, National Orthopaedic Registry

Malaysia (NORM) 2009.

Grade of staff n %

Surgeon (na = 3)

Consultant 67 16.1

Specialist 195 47.0

Clinical specialist 5 1.2

Medical officer 148 35.7

Others 0 0.0

Assistant (na = 5)

Consultant 11 2.7

Specialist 43 10.4



House officer 95 23.0

Others 6 1.5

32

Anaesthetist (na = 18)

Consultant 15 3.8

Specialist 103 25.8



House officer 8 2.0

Others 0 0.0

Anaesthetist’s assist. (na = 119)

Consultant 0 0.0

Specialist 6 2.0



House officer 14 4.7

Others 109 26.5

About two third (64.3%) of the surgeries were performed by orthopaedic consultants or

specialists and the most frequent surgical assistant was medical officer (68.9%). 56.5% of the

anaesthesia were instituted by the medical officers.

33

Table 4.89: Treatment detail (type of chemical thrombop. and antibiotic prophylaxis), Hip

Fracture, National Orthopaedic Registry Malaysia (NORM) 2009.

Treatment detail Descriptive summary

n %

Type Chemical thromboprop. (n = 179, na = 12)

Heparin 16 9.6

LMW heparin 151 90.4

No. Of doses: Chemical thromb. (n = 179)

Mean (SD); Min, max 7.8 (5.7); 1, 30

Median IQR (1stQ, 3rdQ) 6.0 IQR (4, 10)

Antibiotic prophylaxis (na = 36)

Yes 393 82.9

No 78 16.5

Contraindicated 3 0.6

Antibiotic prophylaxis: (n = 393)

Ampicillin 20 5.1

Amoxicillin 8 2.0

Cloxacilin 24 6.1

Cephalexin 1 0.3

Cefuroxime 280 71.2

Cefoperazone 21 5.3

Ceftriaxone 27 6.9

Ceftazidime 1 0.3

Gentamicin 2 0.5

Sulbactem 6 1.5

Others 15 3.8

82.9% of patients who underwent surgery were given some form of antibiotics prophylaxis, and

the most common prophylactic antibiotic used was cefuroxime.(71.2%).

34

Section 5: Post Operative

Table 5.1: Post Operative, Hip Fracture, National Orthopaedic Registry Malaysia (NORM) 2009

Post operative phase Descriptive summary

n %

Discharge status (na = 5, missing = 1)

Alive 491 97.4

Death 13 2.6

Discharge destination (missing = 1)

Home 454 89.2

Sheltered housing 2 0.4

Residential care 14 2.8

Nursing home 1 0.2

Permanent hospital 3 0.6

Acute hospital 12 2.4

Mortuary 13 2.6

Others 10 2.0

Total 509 100.0

35

The overall length of hospital stay in patients with hip fracture was 13.6 days. It was notable that 97.4% of the patients were discharged alive from orthopaedic; 2.4% were transferred to another acute hospital; 89.2% of them were able to be discharged home. However, there were 2.6% of the patients (13 patients) died of various causes during the hospitalisation.

Figure 4.3: Duration of hospital stay, Hip Fracture, National Orthopadic Registry Malaysia (NORM) 2009. Most patients stayed 7-13 days; 58.6% stayed 13 days or less.

1. “Key Statistics and Key Data” Department of Statistic Malaysia. www.statistics.gov.my

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