Archives of Osteoporosis           (2021) 16:35 
https://doi.org/10.1007/s11657-021-00883-z
ORIGINAL ARTICLE
Predictors of hip fracture mortality in Ghana: a single-center
prospective study
Paa Kwesi Baidoo1,2 & James B. Odei3 & Velarie Ansu4 & Michael Segbefia2 & Henry Holdbrook-Smith2
Received: 21 January 2020 /Accepted: 11 January 2021
# International Osteoporosis Foundation and National Osteoporosis Foundation 2021
Abstract
Summary To determine risk factors influencing mortality in patients with proximal femur fractures in a Ghanaian hospital over a
4-year period.
Methods Incidence of mortality was assessed among 76 participants with proximal femur fractures from January to December
2014 and followed up for 4 years. Outcomes of interest were mortality at 1 month, 6 months, 1 year, and 4 years. Hazard ratios
(HRs) were calculated using Cox proportional hazards regression, adjusting for mortality risk factors.
Results Among the 76 participants (mean age 75.8 years [SD = 12.02], 36 (47.4%) males), there were 21 death cases. The mean
time of injury to surgery was 16.4 (SD = 16.2) days. Hip fractures comprised of 38 (50%) intertrochanteric, 35 (46.05%)
transcervical, and 3 (3.95%) basicervical. Mortality at 1 month, 6 months, 1 year, and 4 years were 6.6%, 13.2%, 19.7%, and
27.6%, respectively. Multiple regression analysis showed a yearly increase in age that was associated with a 1.03-fold increase in
the risk of death (p = 0.17). Comparing males to females, there was a significant difference in mortality (HR = 5.24, p = 0.03).
Participants with basicervical hip fracture versus those with transcervical hip fracture were at higher risk of dying (HR = 28.88, p
= 0.01). Patients with abnormal/low creatinine as compared to those with normal creatinine were at higher risk of dying (HR =
5.64, p = 0.005). Also, participants with an American Society of Anesthesiologists (ASA) score of III or IVwere 2.73 times more
likely to experience death than those with an ASA score of I or II (95% CI: 0.93–8.89, p = 0.08). Additionally, a higher risk of
death was associated with patients with chronic obstructive pulmonary disease (COPD) (HR = 53.45, p = 0.001) and osteoporosis
(HR = 8.75, p = 0.006).
Conclusion Being male, having basicervical hip fracture, abnormal/low creatinine, and a history of COPD and osteoporosis were
the main predictors of mortality in the study population. These findings could serve as a guide when managing patients with
proximal femur fractures to improve the outcome.
Keywords Hip fracture . Risk factors . Mortality . Ghana
Introduction
Hip fractures constitute about 20% of the trauma workload
[1]. They are associated with a significant mortality rate and
loss of independence [2] [3]. Mortality rates at 1 month, 1
* Paa Kwesi Baidoo year, and beyond however vary from one study to another.
pakvandal@gmail.com Population-based studies quote mortality rates of about 10%
and 20–31% at 1 month and 1 year, respectively [4–8].
1 Directorate of Orthopedics and Trauma, Komfo Anokye Teaching Identification of high-risk patients using risk scoring is
Hospital, Kumasi, Ghana therefore important as it provides information on prognosis
2 Orthopedics Unit, Department of Surgery University of Ghana based on the available patient data [9, 10]. According to
Medical School, Korle Bu Teaching Hospital, Accra, Ghana Jones et al. [11], this leads to (i) greater objectivity in
3 Division of Biostatistics, College of Public Health, The Ohio State predicting patient outcome, (ii) a guide to clinical decision
University, Columbus, OH, USA making before surgery, (iii) well and detailed informed con-
4 School of Public Health, Indiana University Bloomington, sent for the patient who will need surgery for these fractures,
Bloomington, IN, USA and (iv) improved outcome due to optimized treatment.
   35 Page 2 of 8 Arch Osteoporos           (2021) 16:35 
Findings from previous studies show that Charlson osteoporosis at the time of surgery. Other information obtain-
Comorbidity Index (CCI), age, gender, pre-existing comor- ed included alcohol use, smoking history, medication history,
bidities, and admission source increase the risk of mortality and whether ambulatory or not prior to the injury. The diag-
in patients with hip fractures [12]. Whereas age, CCI, and nosis of osteoporosis was made using bone mineral density
admission source are well-documented risk factors, the role measured by dual-energy X-ray absorptiometry (DEXA) scan
of gender is still debatable. Being a male has been found to be (using the uninjured femur neck) that was done purposely for
associated with high mortality following hip fractures [13]. this study. The scan was standardized by comparing the pa-
However, other authors found no difference among the gen- tients’ bone density with that of a healthy 30-year-old of the
ders [14, 15]. This study aimed to investigate the risk factors same gender and similar size. A T-score of 2.5 standard devi-
that influence mortality in patients with hip fractures in ations or more below the average value meant the presence of
a Ghanaian hospital over a 4-year period. It is believed osteoporosis; osteopenia was defined as T-score of -1.0 to -2.5
that knowledge of these risk factors could improve the and a score of -1 and above as indicated by the World Health
clinical management and long-term outcomes following Organization (WHO) scientific group on the assessment of
these injuries. osteoporosis [17, 18].
The primary outcomes of interest were mortality at 1
month, 6 months, 1 year, and 4 years, respectively. All pa-
Patients and methods tients were managed using a standardized protocol depending
on the fracture type. The surgeries were done by or under the
A prospective cohort study was conducted from January 1, direct supervision of an orthopedic surgeon. Pharmacological
2014, to December 31, 2014, in patients who presented to and mechanical prophylaxis were started from the time of
the orthopedic unit of Korle Bu Teaching hospital. Korle Bu admission and continued for 2 weeks following discharge
is a major tertiary referral hospital in Accra, the capital city of from the hospital.
Ghana, with a bed capacity of over 2000 and receives referrals
from across the country and neighboring African countries. Statistical analysis
The Orthopedic Department is one of 17 departments at the
hospital and sees about a thousand new cases and over 10,000 To enhance data and clinical interpretation, Hb, platelets, cre-
follow-ups annually. atinine, BMI, and ASA were categorized as dichotomous var-
The ethical and protocol review committee of the School of iables. Hemoglobin levels were categorized as less than/
Medicine and Dentistry, University of Ghana approved this or equal to (≤) or greater than 10.0 g/dL; platelets, normal
study. Informed consent was obtained from all patients. (150–450 × 109 L) or abnormal (< 150 or > 450 × 109 L);
Inclusion criteria were patients over the age of 50 years, with creatinine normal, 70–120 mmol/L for males and 60–110
transcervical (31B2), basicervical (31B3), or intertrochanteric mmol/L for females; BMI; normal weight (18.5–24.9 kg/m2
(31A1, 31A2) fractures resulting from a fall. Patients with ); and overweight or obese (> 25 kg/m2). Univariate analysis
subtrochanteric (as those seen during the study period were was done initially to assess the risk of mortality using either
in patients younger than 50 years) as well as pathological Chi-squared/Fisher’s exact test for categorical data or inde-
fractures secondary to metastatic tumors were excluded. pendent t-test for continuous variables. Significant factors
were analyzed by employing multivariate Cox proportional
Data collection and management hazards regression while adjusting for covariates. Time to
surgery which is the total time from the initial injury to when
Study data obtained were collected and managed using the patient was finally operated on was used to construct the
Research Electronic Data Capture (REDCap) electronic data final adjustment model. An alpha of 0.05 was used to deter-
tools hosted at the University of California, San Francisco mine significant predictors of mortality. To aid clinical inter-
(UCSF). REDCap is a secure web-based application designed pretation, results were displayed as hazard ratios (HRs).
to support data capture for research studies, providing (i) an Statistical significance was defined as a two-sided p value <
intuitive interface for validated entry; (ii) audit trails for track- 0.05 for all analyses. All statistical analyses were done using
ing data manipulation and export procedures; (iii) automated SAS version 9.4 Software (SAS Institute Inc., Cary, NC,
export procedures for seamless data downloads to common 2004).
statistical packages; and (iv) procedures for importing data
from external sources [16]. Patient information obtained at
the time of admission included the following: age, gender, Results
hip fracture type, hemoglobin (Hb) level, platelet level, creat-
inine, body mass index (BMI), the American Society of A total of 76 patients (36 males and 40 females) with a mean
Anesthesiologist (ASA) score, and comorbidities such as age of 75.8 (SD = 12.02) years were included in the study. The
Arch Osteoporos           (2021) 16:35 Page 3 of 8    35 
mean number of days from the time of the hip fracture to couple of years after surgery, they are mostly not from Ghana
surgery was 16.4 (SD = 16.2). There were 21 deaths cumula- or Sub-Saharan Africa. Due to the difference in geographic
tively over the 4 years with no death on the table reported. No location and demography, their findings may not be general-
associations were found between hemoglobin, platelet, BMI, izable to our study population. This study was done to evalu-
and mortality rate. ate variables obtained in the process of managing patients with
The mortality rates at 1 month, 6 months, 1 year, and 4 hip fractures and presented at our hospital and the relationship
years were 6.6%, 13.2%, 19.7%, and 27.6%, respectively. between these variables and the risk ofmortality. The prospec-
Within the first year, causes of death were mainly due to tive nature of this study helped to see and evaluate the impli-
pulmonary embolism (5/15 or 33.3%), cerebrovascular acci- cations of significant pre- and postoperative complications of
dents (4/15), congestive heart failure (3/15), and pneumonia the risk of death. The findings will be valuable information for
(3/15) as contained in the death certificates provided by the clinicians and the patient or their relatives.
patients’ families. The mortality rate within the first year was Several studies have looked at mortality rates follow-
not significant among the fracture types. However, patients ing hip fractures and reported rates of between 7 and
with basicervical fractures had a higher mortality rate at 1 year 10% at one month and 20 and 31% at 1 year [4, 5, 19,
(p = 0.03) and the fourth year (p = 0.02) after the injury. The 20]. A study by Zaki et al. [21] in Egypt and another
baseline characteristics of the study participants based onmor- by Prodovic et al. [22] found the mortality rate of
tality rate at various time points are summarized in Table 1. 19.56% and 25%, respectively at 6 months. The 4-year
Hypertension (63.2%), diabetes mellitus (23.7%), and mortality rate is between 33.4 and 44.1% [23].
heart disease (18.4%) were the top comorbidities in terms of The findings of this study is comparable to that of other
prevalence. Others were osteoporosis (7.9%), osteoarthritis of authors from around the world; 1-month mortality rate of
the knee (5.3%), Parkinson’s disease (3.9%), chronic kidney 6.6% is comparable to England (9.6%), Scotland (7%), and
disease (3.9%), chronic obstructive pulmonary disease the USA (5.2–9.3%) [8, 13, 24–26]. Again, the mortality rates
(2.6%), and cancer (1.3%). Pneumonia, surgical site infection, at 6 months and 1 year are in agreement with those of other
and death are commonly encountered in-hospital complica- studies [3–5, 19]. The 4-year cumulativemortality rate is how-
tions as shown in Table 2. All 4 in-hospital deaths occurred ever lower than that reported by Wang et al. in Taiwan [23]
within the first week of surgery as a result of pulmonary em- who found a rate of 33.4% and 44.12% at 3 and 5 years
bolism (2 patients) and pneumonia (1 male and 1 female). following hip fractures in their study population.
Multivariate analysis of the data (see Table 3) showed that A study from Spain by Guzon-Illescas et al. [27] found
a yearly increase in age was associated with a 1.03-fold in- cumulative mortality rates of 9.2%, 17.4%, 24.6%, 33%, and
crease in the risk of death (p = 0.17). Comparing males to 56% at 1, 3, 6, 12, and 36 months respectively with a higher
females, there was a significant difference in mortality (HR rate in men (13.7%, 25%, 32.7%, 43.3%, and 65.6%) com-
= 5.24, p = 0.03) at 4 years post-injury. Patients with pared to women (7.9%, 15.7%, 22.3%, 30%, and 53.2%). The
abnormal/low creatinine as against those with normal creati- mortality rates following hip fractures around the world vary
nine were at higher risk of dying (HR = 5.64, p = 0.005). Also, but are generally high.
participants with an American Society of Anesthesiologists The widely observed differences in mortality rates
(ASA) score of III or IV were 2.73 times more likely to expe- from different parts of the world could be ascribed to
rience death than those with an ASA score of I or II (95% CI: different selection criteria, diversity of the study popu-
0.93–8.89 p = 0.08) at 4 years after surgery. Additionally, a lation, their characteristics, and the peri-operative insti-
higher risk of death was associated with patients with chronic tutional care [21]. In this study, the in-hospital mortality
obstructive pulmonary disease (COPD) (HR = 53.45, p = rate of 5.3% compares with 0.6% to 11.4% found by
0.001) and osteoporosis (HR = 8.75, p = 0.006). The influence others [28–30] which probably reflects the better health
of COPD existed throughout the study period as the strongest status and younger population in our cohorts. Factors
predictor of early mortality. found to increase in-hospital mortality are male gender,
living with sepsis, pneumonia, cerebrovascular diseases,
pulmonary embolism, two or more comorbidities, heart
Discussion failure, and end-stage renal disease [31].
A relationship seems to exist between fractures and aging
Hip fractures are among the common and serious fractures in as the risk of hip fractures (a major predictor of mortality) rises
the elderly population. This study was done to find out which exponentially with age [31]. As shown in this study, age was
patient parameters at the point of admission predict the risk of not a significant predictor of mortality initially, but a yearly
mortality in elderly independent home dwellers that sustained increase in age was associated with a 1.03-fold risk of death at
hip fractures. While some studies have examined parameters 4 years. The finding could be a result of the poor physiological
that predict the risk of mortality in-hospital or within the first
   35 Page 4 of 8 Arch Osteoporos           (2021) 16:35 
Table 1 Baseline characteristics of participants in the hip fracture study by death status at different time points
One Month Six Months One Year Four Years
Alive Dead p Value Alive Dead p Value Alive Dead p Value Alive Dead p Value
Characteristicsa n = 71 n = 5 n = 66 n = 10 n = 61 n = 15 n = 55 n = 21
Age (years) 75.38 82.40 0.21 75.42 78.60 0.44 74.74 80.33 0.11 74.03 80.57 0.03*
Height (cm) 166.9 163.2 0.55 166.8 165.8 0.82 167.0 165.3 0.65 166.3 167.8 0.66
Weight (kg) 70.92 73.80 0.66 70.56 74.70 0.38 70.36 74.13 0.35 64.49 75.33 0.10
Body mass index (kg/m2) 25.53 27.41 0.38 25.45 27.01 0.32 25.29 27.14 0.17 25.26 26.70 0.22
Time to surgery (days) 16.77 11.00 0.45 17.08 11.90 0.14 16.90 14.33 0.45 17.58 13.29 0.18
Sex (%) 0.04* 0.24 0.52 0.18
Female 49.30 100.0 51.52 60.00 50.82 60.00 49.09 42.96
Male 50.70 0.00 48.48 40.00 49.18 40.00 50.91 57.14
BMI group (%) 0.06 0.09 0.32 0.35
Normal 53.52 20.00 51.52 50.00 52.46 46.67 52.73 47.62
Overweight 14.08 20.00 13.64 20.00 36.07 26.67 36.36 28.57
Obese 32.39 60.00 34.85 30.00 11.48 26.67 10.91 23.81
Hip fracture type (%) 0.11 0.06 0.03* 0.02*
Transcervical 43.66 80.00 42.42 70.00 40.98 66.67 40.00 61.90
Basicervical 4.23 0.00 4.55 0.00 4.92 0.00 3.64 4.76
Intertrochanteric 52.11 20.00 53.03 30.00 54.10 33.33 56.36 33.33
Pre HB (%) 0.42 0.32 0.27 0.17
Less than/equal 10 22.54 20.00 22.73 20.00 22.95 20.00 20.00 28.57
More than 10 77.46 80.00 77.27 80.00 77.05 80.00 80.00 71.43
Post HB (%) 0.11 0.18 0.49 0.11
Less than/equal 10 63.38 100 63.64 80.00 63.93 73.33 61.82 76.19
More than 10 36.62 0 36.36 20.00 36.07 26.67 38.18 23.81
Platelet (%) 0.35 0.10 0.12 0.10
Abnormal 2.82 0.00 3.03 0.00 3.28 0.00 3.64 0.00
Low 16.90 0.00 18.18 0.00 18.03 6.67 18.18 9.52
Normal 80.28 100.0 78.79 100.00 78.69 93.93 78.18 90.48
Creatinine (%) 0.16 0.10 0.05 0.01*
Abnormal 22.54 20.00 21.21 30.00 19.67 33.33 16.36 38.10
Low 11.26 20.00 12.12 10.00 13.12 6.67 12.73 9.52
Normal 66.20 60.00 66.67 60.00 67.21 60.00 70.91 52.38
ASA score (%) 0.0002* 0.0002* < 0.0001* < 0.0001*
I 15.49 0.00 16.67 0.00 16.39 6.67 18.18 4.76
II 57.75 20.00 59.09 30.00 62.30 26.67 63.64 33.33
Arch Osteoporos           (2021) 16:35 Page 5 of 8    35 
Table 2 In-hospital complications
Complications Frequency Percent
No complication 59 77.6
Death 4 5.3
Deep vein thrombosis 2 2.6
Pneumonia 5 6.6
Urinary tract infection 2 2.6
Surgical site infection 4 5.3
Hematoma 3 3.9
Other 7 9.2
reserves as a person ages, in coping with these injuries and the
subsequent management [26, 32].
There are some controversies in terms of the relationship
between gender and mortality. This study found a significant
relationship in mortality rates among males compared to fe-
males. Indeedmales were 5.24 times at risk of dying at 4 years
after the injury (HR = 5.24, p = 0.026), and this is in contra-
vention to findings from Li-Chu Wu et al. and other authors
[13, 20] but agrees with Singh-Manoux et al. and other authors
[33] who found men to be at higher risk than females [31, 34,
35]. Reasons for this observed variance may be multi-factorial
such as differences in the study cohorts. A review of the sub-
group fracture types within the first year showed no significant
difference in the mortality rate, an observation also made by
Amphansap et al. [36]. However, patients in our study with
basicervical fractures had almost a 29% chance of dying at 4
years following their injury. A study from Greece found the
mortality rate to be high in cohorts with trochanteric
fractures at 5 years and 10 years and concluded that
the type of hip fracture is an independent predictor of
mortality in the long term [37].
The relationship between osteoporosis and mortality was
demonstrated in this cohort and persisted up to the fourth year.
Osteoporosis is a “bone disease resulting from the body loos-
ing too much bone, or producing too little bone or both” [38].
The chances of a fracture increases as the bone becomes weak-
er and less dense [39]. Bone mass in both genders increases
until about 30 years of age, after which it declines, and this
process is more pronounced in females due to reduced estro-
gen levels [39]. The International Osteoporosis Foundation
estimates that globally, one in three females and one in five
males over 50 years will experience osteoporosis-associated
fracture [40]. Osteoporosis and the fracture itself may directly
or indirectly increase mortality risk exponentially.
The American Society of Anesthesiologists (ASA) score is
a system used to assess the health status of surgical patients,
and their relationship with postoperative complications is well
documented [41, 42]. The ASA score does not only correlate
with morbidity and mortality but also with the length of stay,
Table 1 (continued)
One Month Six Months One Year Four Years
Alive Dead p Value Alive Dead p Value Alive Dead p Value Alive Dead p Value
III 25.35 20.0 22.73 40.00 21.31 40.00 18.18 42.86
IV 1.41 60.00 0.7 30.00 0.00 26.67 0.00 19.05
Pre-existing conditions
COPD 0.004* 0.02* 0.04* 0.07
No 100.0 60.00 100.0 80.00 100.0 86.67 100.0 90.48
Yes 0.00 40.00 0.00 20.00 0.00 13.33 0.00 9.52
Osteoporosis 0.30 0.15 0.01* 0.005*
No 92.96 80.00 93.94 80.00 96.72 73.33 98.18 76.19
Yes 7.04 20.00 6.06 20.00 3.28 26.67 1.82 23.81
aMean for parametric continuous variables or percentages for categorical variables are listed; p values calculated using Fisher’s exact test (categorical variables), and two-sample t-test (parametric
continuous variables). ASA American Society of Anesthesiologists. *Significance at p < 0.05 and were included in the multivariate analysis
   35 Page 6 of 8 Arch Osteoporos           (2021) 16:35 
Table 3 Results of multivariate Cox proportional hazard model At 6 months, 1 year, and 4 years post-surgery
Six months One year Four years
Variable HR 95% CI p Value HR 95% CI p Value HR 95% CI p Value
Age 1.01 0.93–1.08 0.883 1.02 0.96-1.08 0.527 1.03 0.99–1.08 0.172
Sex (ref = female)
Male 3.07 0.46–30.56 0.279 3.74 0.76–24.22 0.126 5.24 1.32–25.61 0.026*
Hip fracture type (ref = transcervical)
Basicervical 0.00 0.00–357.01 0.996 0.00 0.00–240.98 0.995 28.88 1.14–384.97 0.014*
Intertrochanteric 2.11 0.35–13.08 0.404 2.63 0.62–12.04 0.190 2.50 0.75–8.69 0.136
Creatinine (ref = normal)
Abnormal/low 3.79 0.75–22.93 0.112 4.35 1.14–19.14 0.036* 5.64 1.78–19.2 0.005*
ASA score (ref = II or II)
III or IV 3.75 0.75–25.04 0.128 3.13 0.84–13.92 0.103 2.73 0.93–8.89 0.078
COPD (ref = no)
Yes 47.73 3.24–1104.36 0.007* 53.05 4.19–832.14 0.002* 53.45 4.71–629.35 0.001*
Osteoporosis (ref = no)
Yes 7.95 0.75–82.94 0.068 8.89 1.46–57.14 0.016* 8.75 1.83–43.14 0.006*
Ref reference group,HR hazard ratio,CI confidence interval,ASAAmerican Society of Anesthesiologists,COPD chronic obstructive pulmonary disease.
*Significance at p < 0.05
operation and recovery time, healthcare cost, post-operative multicenter studies. The findings, therefore, may not be gen-
infection, and others [43, 44]. In this study, most of the mor- eralized for the entire population. With a mean time of injury
tality was in patients with an ASA score of III or IV, and the to surgery of 16.4 (SD = 16.2) days (mainly due to delay in
effect again persisted beyond the first year of surgery. The coming to the hospital following the injury or lack of funds as
reason was probably because the patients have severe system- most patients pay out of their pockets for most orthopedic
ic disease that may be a constant threat to their life. Close procedures), we will recommend the establishment of a frac-
attention should be paid to elderly patients with higher ASA ture liaison service (FLS) in the country and the need for free
scores to minimize these complications. orthopedic care especially for the elderly and the poor to im-
Chronic obstructive pulmonary disease (COPD) is associ- prove the clinical outcomes of patients with hip fractures.
ated with long-term poor airflow and breathing difficulties,
and this worsens over time [45, 46]. It may be complicated
by chest infections, pulmonary hypertension, and congestive Conclusion
heart disease [47]. These conditions acting together with other
comorbidities or alone may ultimately lead to death, and this Male gender, a previous history of COPD and osteopo-
may explain the observed persistence of risk of death over the rosis, and having basicervical fractures and an
study period. COPD was the strongest predictor of early mor- abnormal/low creatinine were the main predictors of
tality. Most studies including this present study have shown mortality in this study population among Blacks in
that abnormal (low or high) creatinine levels (amarker of renal Ghana. This information is very important as it allows
dysfunction) are associated with long-term mortality follow- healthcare providers, patients, and their families to con-
ing a hip fracture [48, 49]. It can be deduced from our study sider and understand the outcomes with respect to care
that the risk of mortality in patients with abnormal serum following a hip fracture. To make our study more gen-
creatinine levels was about 4.35 to 5.64 times higher at 1 eralizable to the entire country, it is recommended that a
and 4 years post-injury respectively. nationwide multicenter study be conducted to help un-
The strength of this current study is the prospective nature
and also been the first in Ghana to examine the predictors of
derstand some of these associations.
mortality following hip fractures in a major referral hospital.
The limitations included the small sample size which could
Declarations
possibly have affected the power to detect some relationship
between some of the variables. Also, since this was a single- Informed consent Informed consent was obtained from all individual
center study, our findings may differ from that from larger participants included in the study.
Arch Osteoporos           (2021) 16:35 Page 7 of 8    35 
Conflict of interest None. 18. Report of a WHO Study Group (1994) Assessment of fracture risk
and its application to screening for postmenopausal osteoporosis.
World Health Organ Tech Rep Ser 843:1–129
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