Early Functional Outcome of Operative Treatment of Displaced Femoral Neck Fractures in Two Kenyan Orthopaedic Centres
Conditions: Fracture Neck of Femur, Hip Fracture, Femoral Neck Fracture
Sponsor: University of Nairobi

 
 
EARLY FUNCTIONAL OUTCOME OF OPERATIVE 
TREATMENT OF DISPLACED FEMORAL NECK 
FRACTURES IN TWO KENYAN ORTHOPAEDIC 
CENTRES 
(A PROSPECTIVE COHORT STUDY) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A DISSERTATION SUBMITTED IN 
PART FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF 
MASTER OF MEDICINE IN SURGERY  
UNIVERSITY OF NAIROBI 
2009 
 
 
 
 
 
 
 
 
 
By 
 
DR. OCHIENG’ SEPHENIA RADUMA  
M.B., Ch.B (Nairobi) 

 
 
ii

 
 
iii
 

 
 
iv 
DEDICATION 
 
“Chance favors the prepared mind.”  
(Louis Pasteur, 1822-1895) 
 
This work is dedicated to my dear wife Mercy Mildred and my loving children George 
Moses and Marie Anne. You made this study worthwhile. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
v
ACKNOWLEDGEMENT 
“If I have seen further, it is by standing upon the shoulders of giants.”  
(Isaac Newton, 1642-1727)          
 
To the following people, I am truly grateful for their support throughout the course of this 
study: 
1. To my supervisors, Professor John E.O. Ating’a and Mr. Kirsteen O. Awori, 
special thanks for the guidance and constructive criticism from the conception of 
this idea, through the research work, to the final preparation of this dissertation. 
No volume of words can fully express my gratitude.  
2. To Dr Omondi Oyoo, consultant rheumatologist and senior lecturer, department 
of clinical medicine and therapeutics, UON, who helped in the sourcing of the 
outcome assessment tools and guided me on how to use them in this study.  
3. To Mr. Jeremiah Chepchieng and Mr. Emmanuel Museve, who tirelessly and with 
dedication, assisted in the follow-up and evaluation of the patients in this study.  
4. To the staff of the UON medical library and the Nairobi Hospital library, 
especially Mr. Ernst Makillah, Mr. Raphael Euppah and Mr. Peter Odawa, who 
painstakingly helped with the sourcing of the necessary literature for this study. 
5. To Mr. Thomas Juma of medical records KNH, who helped with file retrieval.  
6. To Mr. Fredrick Oyugi of Kenya AIDS Vaccine Initiative (KAVI), who helped 
with data analysis.  
7. To my loving wife Mercy, who ably helped with some of the statistical formulae 
during data analysis and in the typing of this dissertation.  

 
 
vi 
8. To my ever-present colleagues in the Department of Surgery whose constructive 
criticism and constant encouragement helped nurture this study to fruition.  
 
Finally, to my parents George Moses Snr and Mary, who showed me the right path to 
walk. To my brothers and sisters; Rose, Phanuel, Elizabeth, Edwina and Vincent, I 
will always cherish your support through the difficult moments in life. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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TABLE OF CONTENTS 
 
 
 
 
 
 
 
 
 
 
 
TITLE PAGE........................................................................................................................i 
 
DECLARATION..................................................................................................................ii 
 
DEDICATION.....................................................................................................................iv 
 
ACKNOWLEDGEMENT.....................................................................................................v 
 
TABLE OF CONTENTS.....................................................................................................vii 
 
LIST OF TABLES...............................................................................................................ix 
 
LIST OF FIGURES............................................................................................................xi 
 
LIST OF ABBREVIATIONS...............................................................................................xii 
 
1. ABSTRACT..............................................................................................................1 
 
2. INTRODUCTION...................................................................................................3 
 
3. LITERATURE REVIEW..........................................................................................4 
 
4. STUDY JUSTIFICATION......................................................................................15 
 
5. STUDY OBJECTIVES............................................................................................16 
 
6. PATIENTS AND METHODS.................................................................................17 
 
DESIGN AND SETTING...........................................................................17 
 
ETHICAL CONSIDERATIONS.................................................................17 
 

 
 
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DEFINITION OF TERMINOLOGIES.......................................................18 
 
ELIGIBILITY CRITERIA...........................................................................19 
 
STUDY SAMPLE.......................................................................................20 
 
DATA COLLECTION................................................................................21 
 
DATA ANALYSIS.......................................................................................22 
 
7. STUDY LIMITATIONS..........................................................................................23 
 
8. RESULTS...............................................................................................................24 
 
9. DISCUSSION.........................................................................................................43 
 
10. CONCLUSIONS.....................................................................................................50 
 
11. RECOMMENDATIONS.........................................................................................52 
 
12. REFERENCES.......................................................................................................53 
 
13. APPENDICES........................................................................................................58 
 
CONSENT (ENGLISH)..........................................................................................58 
           
            CONSENT (SWAHILI)...........................................................................................59 
 
           STUDY QUESTIONNAIRE.....................................................................................60 
 
           ETHICAL APPROVAL LETTERS..........................................................................70 
 
        
          
 
 
 

 
 
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LIST OF TABLES 
TABLE 1: Demographic characteristics...........................................................................25 
TABLE 2: Injury characteristics.......................................................................................26 
TABLE 3: Treatment characteristics................................................................................27 
TABLE 4: Duration from injury to discharge from hospital............................................30 
TABLE 5: Mean pre-injury versus postoperative WOMAC scores.................................33 
TABLE 6: Mean pre-injury versus postoperative WOMAC scores in patients aged ≤ 50 
years...................................................................................................................................33 
TABLE7: Mean pre-injury versus postoperative WOMAC scores in patients aged > 50 
years...................................................................................................................................33 
TABLE 8: Difference in mean pain outcome scores according to age, sex, co-morbidity, 
treatment modality, surgical approach, type of anaesthesia and complication(s)..............34 
TABLE 9: Difference in mean pain outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged ≤ 50 
years...................................................................................................................................35 
TABLE 10: Difference in mean pain outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged >50 
years...................................................................................................................................35   
TABLE 11: Difference in mean stiffness outcome scores according to age, sex, co-
morbidity, treatment modality, surgical approach, type of anaesthesia and 
complication(s)..................................................................................................................36 
TABLE 12: Difference in mean stiffness outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged ≤ 50 
years...................................................................................................................................37 

 
 
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TABLE 13: Difference in mean stiffness outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged >50 
years...................................................................................................................................37 
TABLE 14: Difference in mean ADL outcome scores according to age, sex, co-
morbidity, treatment modality, surgical approach, type of anaesthesia and 
complication(s)..................................................................................................................38 
TABLE 15: Difference in mean ADL outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged ≤ 50 
years...................................................................................................................................39 
TABLE 16: Difference in mean ADL outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged >50 
years...................................................................................................................................40 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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LIST OF FIGURES 
FIGURE 1: Garden's III fracture of the left femoral neck.................................................8 
FIGURE 2: Garden's IV fracture of the left femoral neck................................................8 
FIGURE 3: Patients’ co morbidities.................................................................................25 
FIGURE 4: Mechanism of injury according to age..........................................................26 
FIGURE 5: Modalities of treatment according to age......................................................28 
FIGURE 6: Cemented versus uncemented arthroplasty...................................................28 
FIGURE 7: Early post-operative complications...............................................................29 
FIGURE 8: Duration of wound healing in days...............................................................29 
FIGURE 9: Duration from injury to surgery....................................................................31 
FIGURE 10: Length of hospital stay in days...................................................................31 
FIGURE 11: Changes between pre-injury and postoperative WOMAC scores..............32 
FIGURE 12: Difference in mean WOMAC outcome scores according to duration from 
fracture to surgery..............................................................................................................41 
FIGURE 13: Difference in mean WOMAC outcome scores according to length of 
hospital stay.......................................................................................................................42 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 

 
 
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LIST OF ABBREVIATIONS 
 
AMP 
 
- 
Austin Moore Prosthesis 
ADL 
 
- 
Activities of Daily Living 
ASA 
 
- 
American Society of Anesthesiologists 
AVN 
         - 
Avascular Necrosis 
ELISA             - 
Enzyme-linked Immunosorbent Assay 
FNF 
   
 - 
Femoral Neck Fracture/ Fracture neck of femur 
FNFs              - 
Femoral Neck Fractures 
HA 
             - 
Hemiarthroplasty 
HHS              - 
Harris hip score 
HIV 
             - 
Human Immunodeficiency Virus 
HOOS              - 
Hip disability and osteoarthritis outcome score 
KMH              - 
Kikuyu Mission Hospital 
KNH     
 - 
Kenyatta National Hospital 
LOS 
         - 
Length of in-hospital stay 
MRI 
          - 
Magnetic Resonance Imaging 
OHS           - 
Oxford hip score 
OS 
 
 - 
Osteosynthesis 
POSSUM 
 - 
Physiological and operative severity score for the enumeration of     
                                    Mortality and morbidity 
RTI 
  
 - 
Road Traffic Injuries 
SOPC 
 
 - 
Surgical Out-patient Clinic 
SPSS   
 - 
Statistical Package of Social Sciences 
THA/R    
 - 
Total Hip Arthroplasty/Replacement 
TWBC    
 - 
Total White Blood Cell Count 
UON 
 
 - 
University of Nairobi 
VTE 
 
 - 
Venous thrombo-embolism 
WOMAC 
 - 
Western Ontario and McMaster universities osteoarthritis index

 
 
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ABSTRACT 
Background: Worldwide, the incidence of fracture neck of femur (FNF) has been 
projected to increase significantly. FNF increases both morbidity and mortality especially 
to the elderly. Locally, majority of these fractures occur in young patients, mainly 
following road traffic injuries with associated greater negative socioeconomic impact. 
The functional outcome of these fractures has however not been well studied in Kenya.  
Objective: To determine the early functional outcome following operative treatment of 
displaced FNF. The factors influencing this outcome were also assessed. 
Design and setting: A six months prospective cohort study was conducted between 12th 
November, 2008 and 11th May, 2009 at Kenyatta National Hospital (KNH) and Kikuyu 
Mission Hospital (KMH), in Kenya.  
Patients and methods: Sixty consecutive patients were enrolled using a pre-tested 
questionnaire. The Western Ontario and McMaster Universities Osteoarthritis index 
(WOMAC) was used to determine the functional state pre-operatively and at three 
months post-operatively. The functional outcome measures included pain, stiffness and 
activities of daily living (ADL). Data were analyzed using the Statistical Package of 
social Sciences (SPSS). The Student’s t-test and χ2 test were used for comparison 
between variables as appropriate; a p value < 0.05 was considered statistically significant. 
The results are presented as tables, graphs, bar charts and pie charts.   
Results:  There were 41 males and 19 females. The age ranged from 18 to 96 years 
(mean: 51.6 ± 18.2). Osteosynthesis, using multiple screws or Dynamic Hip Screws was 
the main method of treatment (24 patients). Eighty eight percent of the patients had a 

 
 
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mean negative  early functional outcome score. Hemiarthroplasty and THA had a similar 
early post-operative functional outcome while OS had a poorer ADL outcome. There was 
no correlation between the pre-operative duration and functional outcome. Prolonged 
hospital stay was associated with a poor ADL outcome (p value 0.020). The use of the 
antero-lateral approach to the hip was associated with a better ADL outcome compared to 
the lateral approach in patients above 50 years of age (p value 0.007). Both spinal and 
general anaesthesia resulted in similar early functional outcome.  
Conclusions: At three months post-operatively, most patients had not fully recovered 
their pre-injury level of function and independence. Both HA and THA were associated 
with better early functional outcome compared to OS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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INTRODUCTION 
There is significant morbidity and mortality associated with fracture neck femur (FNF) 
especially in the elderly 1. In Kenya however, majority of these fractures occur in the 
young and economically productive age-group mainly as a result of road traffic injuries 
(RTI) 2. Despite advances in surgical hardware and techniques, femoral neck fractures 
(FNFs) still pose a significant clinical challenge and are also expensive to manage3. 
Several factors mainly related to the anatomy of the femur neck; especially the blood 
supply, are thought to be responsible4.  
The management of FNF has evolved over time. The problem was considered “unsolved” 
by the earlier orthopedic surgeons; Ambroise Pare and Sir Asley Cooper. The advice of 
Sir Asley Cooper (1822) was to treat the patient and let the fracture go5. Even today, 
there are a number of controversies concerning the methods of treatment of displaced 
fractures of the femoral neck and the main problem is whether to reduce the fracture and 
use internal fixation or to perform total or partial hip replacement arthroplasty5, 6. The 
main challenge is the variation in outcome and the treatment options. Studies have shown 
variation in functional outcome based on certain patient and non-patient factors which are 
known to vary from one set-up to another5-11. Thus each set-up need to assess its 
functional outcome especially based on the patient’s age to establish the modality of 
treatment with optimal outcome7, 8. In Kenya, there is paucity of data on the outcome 
following operative treatment of these fractures2, 12, 13. Today, outcome assessment has 
been necessitated by the dramatic increase in health care costs and practice-pattern 
variations3, 14-16. The purpose of this study was to determine the early functional outcome 
following operative treatment of displaced FNF at Kenyatta National and Kikuyu 
Mission hospitals in Kenya. The factors affecting this outcome were also assessed. 

 
 
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LITERATURE REVIEW 
 
INCIDENCE AND PREVALENCE  
Worldwide, the number of hip fractures has been projected to rise from 1.7 million in 
1990 to 6.26 million by the year 205017. This is due to the improvement in life 
expectancy and hence an increase in population in nearly all countries17-19. In Finland, the 
age-specific incidence rose from 273/100,000 in 1970 to 412/100,000 in 1991 among 
women aged 50 or over and from 108/100,000 to 194/100,000 among Finnish men, 
respectively19. In the USA, the incidence of hip fractures exceeds 250,000 per year with 
an estimated cost of $8.7 billion.    
Nyarango2 in a study conducted at KNH found the majority of FNF to occur in the 40-49 
years age class with a male preponderance. Ochiel13 noted the peak age group to be 18-50 
years with a male preponderance.  Studies from other centers however, reports that the 
majority of FNF occurs amongst females above 70 years of age17, 19.  
 
ETIOLOGY AND PATHOPHYSIOLOGY  
Femoral neck fractures in the elderly occur more frequently following falls or chronic 
stress instead of a single traumatic event2, 4, 13, 20. Osteoporosis is the most important risk 
factor contributing to these fractures in old patents. This is mainly due to senility but can 
also be attributed to prolonged corticosteroid use21, 22. Medical conditions such as 
hyperthyroidism and diabetes mellitus have also been found to be associated with an 
increased risk of fracture and associated complications5, 6, 23, 24. On the other hand, the 

 
 
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risk of fall is increased by physical deconditioning, malnutrition, impaired vision or 
balance, neurologic problems, and slower reflexes25.  
FNFs in children, adolescents and young adults usually result from high-energy trauma 
associated with multiple concomitant injuries2, 13, 26. Nyarango2 found that most FNF 
results from Road Traffic Injuries (RTI) while Ochiel13 noted majority of the fractures to 
occur following a fall with minor trauma. Studies from other centers however, reports 
that the majority of FNF results from falls 17, 19. Locally, about a third of trauma cases 
results from road traffic injuries27. 
 
FUNCTIONAL ANATOMY OF NECK OF FEMUR 
The femoral neck contributes to both the stability and mobility of the hip joint 4. The 
femoral neck has essentially no periosteal layer; hence, all healing is endosteal in origin. 
The synovial membrane incorporates the entire femoral head and the anterior neck, but 
only the proximal half of the posterior neck. The synovial fluid bathing the fracture may 
interfere with the healing process. Angiogenic-inhibiting factors in synovial fluid can 
inhibit fracture repair3.  
The blood supply to the head and neck of femur varies with age and significantly 
influences fracture healing8, 28, 29. Crock28 divided the blood supply to the proximal end of 
the femur into 3 major groups. The first, an extracapsular arterial ring located at the base 
of the femoral neck formed by branches from the medial and lateral femoral circumflex 
arteries and a second ring of vessels  formed as the ascending cervical vessels approach 
the articular margin of the femoral head from which the epiphyseal arteries are formed. 
These branches course recurrently along the joint capsule past the femoral neck to supply 
the femoral head. The lateral epiphyseal arterial group supplies the lateral weight-bearing 

 
 
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portion of the femoral head. Fractures of the femoral neck or damage to the capsule can 
disrupt these supplying vessels. Widely displaced intracapsular fractures tear the 
synovium and the surrounding vessels. The epiphyseal vessels are joined by the inferior 
metaphyseal vessels and vessels from the ligamentum teres. The latter vessels which may 
at times be completely atretic at puberty form the third ring4, 8, 28, 29.  
In the skeletally mature individuals, the barrier of the epiphyseal plate breaks down 
allowing vascular anastomosis between the epiphyseal, vessels in the ligamentum teres 
and the metaphyseal vessels29. The retinacular arteries on the surface of the femoral neck 
and the ligamentum teres artery are sensitive to changes in intracapsular pressure4, 8, 30.  
Increased pressure from an intracapsular bleed compromises this circulation thus 
contributing to poor healing. Because of the inelastic character of the joint capsule, small 
increases in volume can result in large increases in joint pressure4, 8, 30. These factors, 
along with the precarious blood supply to the femoral head make healing unpredictable 
and complications fairly common4, 8. 
Furthermore, the biomechanics of the hip joint have been shown to influence healing of 
FNF.  Forces acting on the upper part of the femur including the body weight and load 
from muscular action play a significant role in healing of femoral neck fractures8, 20, 31, 32. 
Blount32 in addition, demonstrated the significance of the biomechanics at the hip and the 
role played by an external support such as a walking stick.    
 
 
 
 
 

 
 
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MANAGEMENT  
 
 Pre-hospital and emergency care 
The management of patients with FNF requires a multidisciplinary approach with the 
life-threatening conditions being addressed first before specific treatment is given to the 
fracture8, 33. The patient should be immobilized until confirmation of the nature of the 
fracture since weight bearing can easily convert an incomplete fracture into a complete 
one4. The initial resuscitation follows the principles outlined in the Advanced Trauma 
Life support (ATLS®) guidelines33. Laboratory studies have shown that immediate 
reduction of a displaced fracture results in improved blood supply and hence better 
healing4, 8. 
 
Imaging studies 
Plain radiography is the preferred initial imaging modality in evaluating femoral neck 
fractures because of its near universal availability, ease of acquisition, and documented 
correlation with surgical results over many years of use4. Some femoral neck fractures are 
not visible on plain radiographs obtained during the initial evaluation. If the clinical 
suspicion is strong, these cases can be further evaluated with magnetic resonance imaging 
(MRI), which is also useful in follow-up for FNF complications; or bone scintigraphy 
which though non-specific, in the right clinical setting such as known trauma however, is 
highly sensitive for the detection of fractures4. Computerized tomography (CT) scan is 
useful for assessing fracture comminution preoperatively and in determining the extent of 
union (or lack thereof) postoperatively4.  
 
 

 
 
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Classification of femoral neck fractures  
Although there are many classification systems for FNF 20, 26, 31, 34-36, Garden’s 
classification36 is the most widely used today. Stage I and stage II Garden fractures are 
not displaced and considered stable fractures with favorable prognoses36. Stage III and 
stage IV Garden fractures (Figures 1 and 2) are displaced and are considered unstable 
with a poor prognosis36. Clinically differentiating the various Garden’s classes is difficult 
hence classifying FNF as displaced or non-displaced is more accurate. The Pauwels’ 
classification is based on the angle of fracture line with the degree of angulation being 
directly proportional to the risk of displacement31, 35. 
 
Figure 1: Garden's III fracture of the left femoral neck 
 
 
 
 
 
Figure 2: Garden's IV fracture of the left femoral neck 
 
 

 
 
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Management options and determinants 
Currently, the options available for treatment of FNF are either surgical or conservative. 
Surgical treatment includes Hemiarthroplasty (HA), Total Hip Arthroplasty/Total Hip 
Replacement (THA/R) or Osteosynthesis (OS) 4, 8, 9, 37. Factors considered in choosing the 
appropriate treatment modality include the chronological age of the patient, the 
comorbidities, fracture pattern/ grade, availability of appropriate surgical facilities and 
expertise, as well as the socio-economic status8, 9, 37. The Sernbo score reflecting the 
patients’ age, home circumstances, walking ability and mental status is used in some 
centers to choose between THA and HA9.  
Osteosynthesis with hook pins, screws or sliding screw and plate can be used in patients 
below 50 years of age, patients with Garden’s grade I and II fractures irrespective of age 
as well as those below 70 years of age with Garden’s grade III FNF8, 9, 37. Total hip 
arthroplasty should be considered in the case of acute displaced femoral neck fractures in 
previously active elderly individuals with acetabular articular cartilage changes. Other 
indications for THA may include rheumatoid arthritis, Paget´s disease, mental deficiency, 
short life expectancy in otherwise active individuals, and Garden’s grade IV FNF in those 
less than 50 years of age9, 38. It is also recommended to patients with normal functional 
capacity and high functional demands 39. 
 Hemiarthroplasty is considered the treatment of choice for patients with grade III and IV 
Garden fractures and when the general condition of the patient is not optimal for a major 
procedure like THA4, 6, 37.  
Non-operative management is still a feasible option for the truly non-ambulatory, 
demented or/and aged patients with FNF40.  
 

 
 
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FUNCTIONAL OUTCOME  
General overview 
How well patients are able to regain their pre-injury level of function and independence is 
a good indicator of the efficacy of the treatment with regard to the socioeconomic 
aspects41. Functional status on admission predicts the occurrence of a hospital-acquired 
complication, and functional recovery has also been used to determine the effect of 
rehabilitation of hip fracture patients 41, 42. The two major functional outcome measures 
usually assessed are pain and mobility 5, 6, 43. Lu Yao et al 6 graded pain into four 
categories; none where there is no pain, minimal when no analgesic is required, 
occasional when analgesic is sometimes used and severe when analgesics are regularly 
used. They also classified mobility into good (able to walk with minimal or no aid) and 
poor (requires a walker or human assistance or are confined to a wheel chair or are 
unable to walk). D’Arcy et al5 combined pain and mobility into four grades.  
 
Functional outcome determinants 
The overall functional outcome is influenced by several factors broadly classified as 
patient and non-patient factors. The patient factors include age, 6, 7, co-morbidities6, 7, 23, 
24, 37, pre-fracture functional status39, and both local and systemic complications such as 
anaemia, infection, haemarthrosis, sciatic nerve palsy, dementia/ confusion, venous 
thromboembolism, orthostatic pneumonia, avascular necrosis of the femoral head, and 
non union7- 9, 44, 45 . The non-patient factors include the type of operation and the surgical 
approach6, 7, 9, 12, 46, concomitant medication (e.g. oral corticosteroids) 22 and discharge 
destination48. The type of anesthesia used41, 47, or the period between injury and operative 
intervention (duration to surgery) 49, 50 has no significant effect on functional outcome. 

 
 
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Patient factors: Several studies have shown that there is a dose-effect-like relationship 
between advancing age and poor functional outcome6, 7, 10. Sex has not been shown to 
influence functional outcome6, 7, 10, 44 though being female has been associated with 
increased post-operative complications44. Several studies found the presence of co-
morbidities or postoperative complications to be associated with poor functional 
outcome6, 7, 9, 23, 24, 37, 41, 44, 45, while other studies found no effect of post-operative 
complications on functional outcome8, 51. Anaemia independently impact negatively on 
mobility45.  Pre-fracture functional status independently influences functional outcome 10, 
41, 42, 44. However, timing of surgery has no influence on functional outcome49, 50. In a 
study of 1206 patients aged fifty years and more, Orosz et al49 found that early surgery is 
not associated with improved function though it resulted in reduced rate of complications 
and length of hospital stay (LOS). 
 
Non-patient factors: Several comparative prospective studies on the use of different 
types of pins, screws, or nails have not reported any significant differences in outcome52-
54. Christie et al54 found no statistically significant difference in mobility but they were in 
favor of screws due to better union of the fracture and the lower infection rates. Khan et 
al11 and Godsiff et al55 in separate studies found lower side effects involving the 
cardiopulmonary system and technically easier revision following treatment of displaced 
intracapsular FNF with an uncemented implant compared to a cemented HA. In these 
studies, however11, 55 early loosening associated with worse pain and poor function were 
found with uncemented compared to a cemented implant.  
THA in selected cases of acute femoral neck fracture may provide consistent pain relief 
and a good functional outcome without any increase in complications48.  

 
 
12
Several studies comparing THA and OS have found better functional outcome with 
THA39, 56- 58. However, THA is associated with more intraoperative blood loss, longer 
operation time and increased post operative infection rates39, 51, 56- 58. A study by Jónsson 
et al58 involving 47 patients, reported that the patients who were treated with THA used 
less outdoor walking aids, and were more likely to do their own shopping than patients 
treated with OS.   
In a randomized comparative study on the functional outcome between OS and HA, 
Söreide et al59 found no significant differences, while in a meta-analysis of one hundred 
and six published reports, Lu-Yao et al6 found better pain relief and better mobility with 
HA compared to OS. Some other studies also recommend HA as more suitable for the 
treatment of FNF 9, 46. Rogmark et al9 in a prospective randomized study of 409 patients 
aged 70 years and above found better mobility and pain relief in the arthroplasty group 
compared to the OS group. In the OS group after two years, 36% had impaired walking 
and 6% had severe pain compared with 25% and 1.5% respectively, in the arthroplasty 
group. Bhandari et al51 in a meta-analysis of 14 randomized controlled trials found no 
significant difference in functional outcome between OS and arthroplasty. 
Studies comparing the functional outcome between HA and THA have shown varying 
results. Squires et al60 found poorer functional outcome following HA compared to THA 
while Narayan et al61 found no statistically significant difference. Smrke et al62 found, HA 
to give a better range of motion compared to THA but the total Harris hip score showed 
no statistically significant difference. Ravikumar et al63, found that both OS and HA 
resulted in the poorest functional outcome compared to THA. 
Sikorski and Barrington46 in a prospective randomized study of 218 patients found better 
functional outcome with a posterior approach compared to anterior approach in those 

 
 
13
treated using Thompson’s arthroplasty though the posterior approach was associated with 
a significantly higher mortality. Similar findings were reported by Montgomery et al64. 
Warrakah12, in a study on patients treated with Austin Moore HA found the lateral 
approach to be associated with better functional results (82% satisfactory) compared to 
the anterolateral (66% satisfactory) and anterior approaches (50% satisfactory). 
Taine et al found that those in residential homes had better functional outcome compared 
to those discharged to nursing homes48.  
 
Functional outcome assessment  
Outcome assessment has been made necessary by the dramatic increase in health care 
costs and practice-pattern variations3, 15, 16. As the reliability of orthopaedic surgical 
procedures improves, the outcome assessment is shifting from the success or failure of a 
procedure towards patient satisfaction and quality-of-life indicators. For an outcome 
measure to be meaningful, it must be psychometrically evaluated and shown to be 
reliable, valid and sensitive to change. Several quality-of-life surveys are available and 
include the generic, disease-specific and hip joint-specific surveys15, 16, 65. 
The generic quality-of-life outcome measures are used to assess health status or health-
related quality of life and include the 36-item Short form health survey (SF-36), 12-item 
Short form health survey (SF-12), the Nottingham health profile questionnaire and the 
EuroQol questionnaire15, 16.  
The disease specific quality-of-life outcome measures are used to assess aspects of a 
specific condition and include the Western Ontario and McMaster Universities 
(WOMAC) hip disability index and the arthritis impact measurement scale.  
The hip specific outcome measures include the Harris hip score (HHS), the Charnley 
score, the Oxford hip score (OHS) and the Hip dysfunction and osteoarthritis outcome 

 
 
14
score (HOOS) 8, 15, 16, 43. The HHS and Charnley score are less patient-oriented unlike the 
WOMAC, OHS and HOOS. The HHS, Charnley score and OHS were developed to 
assess patients undergoing THR irrespective of the underlying pathology while the 
HOOS can be used to assess any intervention on any hip pathology15.  
The WOMAC index has been found to be valid, reliable, responsive, easy to complete 
and simple to score. It also has a high internal consistency and acceptable test-retest 
reliability. It has been used successfully not only for osteoarthritis, but also for other hip 
conditions including FNF15, 50. The HOOS LK 2.01 questionnaire contains all WOMAC 
LK 3.0 questions in unchanged form but with a better patient responsiveness14-16.  It has 
two additional subscales; sports and recreation function and hip related quality of life, 
which assess more strenuous activities not tolerable by most patients at three months 
post-operatively14-16. 
Since the results from outcome studies can be affected by patient co-morbidity and peri-
operative factors, the orthopaedic physiological and operative severity score for 
enumeration of mortality and morbidity (orthopaedic POSSUM) was developed to 
address this issue14, 15. Unfortunately, it over predicts mortality and can only be used in 
retrospect and not pre-operatively66. The ASA classification is simple and reliable in 
predicting post-operative outcome and it can be used pre-operatively66, 67. 
 
 
 
 

 
 
15
STUDY JUSTIFICATION 
Outcome assessment has been necessitated by the dramatic increase in health care costs 
and practice pattern variation 41. Most femoral neck fractures are reported to occur in the 
elderly especially in western European series17, 
19. These patients are often 
physiologically compromised and must be immediately mobilized to avoid further 
morbidity and mortality4.  
In Kenya however, Nyarango2 and Ochiel13 found that FNFs are more common in the 
young economically active individuals. Thus, FNF has a negative socio-economic impact 
locally. How well these patients are able to regain their pre-injury level of function and 
independence is a measure of the success or failure of the treatment regime. Studies have 
shown variation in functional outcome based on certain patient and non-patient factors 
which are known to vary from one set-up to another5- 11. Yet the functional outcome for 
these fractures has not been well studied in this set-up.  
Thus, an understanding of the early functional outcome will be useful to the health care 
providers in the formulation of appropriate treatment protocols, as well as in 
prognostication. 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
16
STUDY OBJECTIVES 
BROAD OBJECTIVE 
To determine the early functional outcome of operative treatment of displaced fracture 
neck of femur at Kenyatta National and Kikuyu Mission Hospitals. 
 
SPECIFIC OBJECTIVES 
1. 
To establish the demographic patterns and injury characteristics of patients 
undergoing operative treatment of displaced FNF at KNH and KMH. 
2. 
To establish the treatment patterns of displaced fracture neck of femur managed 
operatively at KNH and KMH. 
3. 
To establish the early functional outcome of displaced fracture neck of femur 
managed operatively at KNH and KMH. 
4. 
To establish how the following factors affected the early functional outcome of  
operative treatment of displaced FNF at KNH and KMH; 
a) 
Age and sex. 
b) 
Co-morbidities. 
c) 
Pre-fracture functional status. 
d) 
Time taken to surgical intervention.  
e) 
Length of hospital stay.  
f) 
Type of surgical operation and surgical approach. 
g) 
Early complications. 
 
 

 
 
17
PATIENTS AND METHODS 
DESIGN AND SETTING 
This was a six-month prospective cohort study conducted at the orthopedic trauma wards 
and the surgical out-patient clinics (SOPC) of Kenyatta National and Kikuyu Mission 
Hospitals between November 12th, 2008 and May 11th, 2009. Kenyatta National Hospital 
is the largest referral and teaching hospital in Kenya while Kikuyu Mission Hospital is a 
peri-urban district hospital with a one hundred bed capacity and a busy orthopaedic and 
trauma unit. 
 
ETHICAL CONSIDERATIONS68 
a) This study was conducted only after approval by the Kenyatta National 
Hospital/University of Nairobi Ethics and Research Committee (KNH/UON-ERC) 
and the Kikuyu Mission Hospital’s board of management.  
b) There was a modification of the study title from the initial one presented for 
approval to Kikuyu Mission Hospital, without a change in the aims and objectives of 
the study. An approval letter to that effect was sought and granted. 
c) Patients or their parents/guardian gave written informed consent to take part in the 
study before being included. 
d) The information collected from the patients is being handled with utmost      
confidentiality and used solely for the purpose of the study.  
 
 
 

 
 
18
DEFINITION OF TERMINOLOGIES 
The duration of stay to surgery was the period between admission and definitive surgical 
operation; while the total length of stay was from admission to discharge from hospital. 
Fall with mild trauma referred to a fall on a relatively flat ground (mainly tripping) or 
from a height lower than 4.5 meters; while fall with severe trauma referred to a fall from 
a height, either one floor or higher (at least 4.5 meters high). 
Confusion referred to disorientation in time, place or person; wound infection meant all 
wound erythema lasting longer than 24 hours. 
The early outcome was outcome within 3 months of definitive surgical intervention while 
early complications were complications occurring within three months post-operatively.  
Chronic pain syndrome meant pain lasting longer than three months from the initial 
noxious stimuli and not responding to commonly used analgesics. 
Skeletal maturity was confirmed on plain radiography as fusion of the proximal femoral 
capital epiphyses. 
 
 
 
 
 
 
 
 
 
 

 
 
19
ELIGIBILITY CRITERIA 
Inclusion criteria 
All patients 18 years of age and above (and skeletally mature) who underwent operative 
treatment for displaced fracture neck of femur at Kenyatta National Hospital and Kikuyu 
Mission Hospital during the study period were included. 
 
Exclusion criteria 
1.     All patients with any of the following were excluded from the study: 
• Un-displaced or bilateral FNF. 
• Concomitant pelvic or lower limb fracture/ dislocation. 
• Multiple injuries.  
• Confusion. 
• Previous ipsilateral FNF or FNF surgery. 
• Operative treatment done outside the study setting. 
• Malignant pathological fractures or peri-prosthetic fractures. 
2. 
Patients who were non-ambulatory prior to injury. 
3. 
Chronic pain syndrome and/ or chronic opioid use. 
4. 
Patients who declined to give written informed consent. 
 
 
 
 
 

 
 
20
STUDY SAMPLE  
The sample size was derived from the formula provided for by Lwanga and Lemesha69; 
 n =z2pq/d2  
Where “p” is the expected proportion of patients undergoing operative treatment for 
displaced fracture neck of femur in KNH and KMH;  
“d” the confidence limit; 
“q” = (1-p) % and; 
“z” is the standard deviation of the 95th percentile (1.96). 
A confidence limit of 0.05 is used. 
Therefore; 
n 
= 
(1.96)2 x 0.041 (1 – 0.041) / (0.05) 2 = 60.419. 
The calculated sample size was 60 patients.  
The “p” value has been derived from the proportion of patients with displaced FNF (who 
underwent operative intervention) from patients admitted with fractures in KNH and 
KMH orthopedic/trauma wards during the months of January to August 2008, which was 
4.1 %. During this period, there were about 2700 fracture patients admitted with 112 
undergoing operative treatment for displaced FNF. There is no published literature on 
local prevalence of FNF or on the proportion of patients undergoing operative treatment. 
 
 
 
 
 
 

 
 
21
DATA COLLECTION 
Sixty consecutive patients were enrolled over a six months period. Recruitment involved 
consecutive enrolment of patients who satisfied the set eligibility criteria. Enrollment was 
done at admission to the hospital or within three months of admission. A pre-tested 
questionnaire was administered face to face by the investigator or trained assistants and 
patients’ records examined to verify details. Skeletal maturity was confirmed on initial 
pelvic radiographs at admission. 
Functional assessment was conducted at enrollment into the study for the pre-injury 
functional status and at three months post-operatively for the post-operative functional 
status. The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) 
was used to assess function. The outcome measures included pain, stiffness and activities 
of daily living (ADL).  The functional outcome correlates assessed included the patients’ 
demographic features, pre-injury functional status, type of operation and surgical 
approach, patients’ co-morbidities and complications. The timing for wound assessment 
was arbitrarily fixed by the investigator to fit in the discharge and clinic attendance 
routines of the two hospitals. The ASA score was used to assess the patients’ peri-
operative morbidity and risk of complications. No randomization was done and patients 
remained in their study groups according to the intention-to-treat principle.  
 
 
 
 
 
 

 
 
22
DATA ANALYSIS  
Data collected from the questionnaires were entered into a coded data sheet and analyzed 
by a statistician using the Statistical Package of Social Sciences (SPSS), Inc., for 
windows version 15, Chicago, Illinois, U.S.A; to derive descriptive statistics and 
frequency distributions 70.  
In this study, those above 50 years of age were regarded as elderly and this informed the 
basis for the age stratification used in data analysis. This was based on the life expectancy 
at birth in Kenya currently estimated at 53 years of age18 and also the retirement age of 
55 years for most civil servants (though recently revised upwards). Narayan et al, in their 
study also used the life expectancy at birth (in India) to guide their exclusion criteria61. 
The WOMAC scores for each subscale (pain, stiffness and ADL) were normalized into a 
scale of 0-100 (zero indicating extreme symptoms and 100 no symptoms). Each subscale 
was evaluated independently. The scores were either categorized or analyzed as means. 
The categories included; 90-100 for excellent results, 80-89 for good results, 70-79 fair, 
60-69 poor, and below 60 a failed result.  
Categorical data were expressed in terms of proportions while comparison between 
variables was performed by cross tabulation and Pearson’s Chi-squared test. Continuous 
variables were expressed as means, and standard deviations. The Student’s t-test was 
used to compare the differences for significance. For comparable data, a p value less than 
0.05 was considered statistically significant.  
Results are presented as tables, graphs, bar charts and pie charts. 
 
 
 

 
 
23
STUDY LIMITATIONS 
• Follow-up period was not long enough to identify further morbidity and survival. 
• Concomitant academic interests leading to constraints on the investigator in 
patient follow-up since he is a post graduate student with other academic 
engagements. 
• The practice of discharging patients to the nearest health facilities made it difficult 
to follow-up some patients. 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
24
RESULTS 
This chapter presents the results of the study on early functional outcome of 
operative treatment of displaced femoral neck fractures in two Kenyan orthopedic 
centers (Kenyatta National Hospital and Kikuyu Mission Hospital) conducted 
between 12th November, 2008 and 11th May, 2009.  
 
A total of sixty patients were enrolled. All the patients were skeletally mature. The 
patients remained in their study groups according to the intention-to-treat principle and 
there was no conversion from one treatment modality to another. All the patients were 
discharged to residential homes and none to a nursing home. 
 
 
DEMOGRAPHIC CHARACTERISTICS  
 
Most of the patients were males (41 patients, 68%). The mean age of the patients was 
51.6 years (±18.2) with a range of 18 to 96. Seventy five percent of the patients had 
received formal education while sixty five percent were on employment (Table 1).  
All the co-morbidities involving the cardiovascular system resulted from hypertension (9 
patients, 40.9%) while the neuropsychiatric co-morbidities included two cases of epilepsy 
and one case each of Parkinson’s disease and cerebro-vascular accident. Three patients 
had upper respiratory tract infection while one patient had lobar pneumonia. Only one 
patient had pre-operative anaemia with a hemoglobin level of 8.9g/dl. This was corrected 
before surgery by blood transfusion. The malignancies were uterine cervical carcinoma 
and invasive ductal carcinoma of the breast, both of which were treated successfully with 
at least 5 years disease free period (Figure 3). Most patients classified as ASA II were 
due to age and not co-morbidity (Table 1). 

 
 
25
Table 1: Demographic characteristics 
 
Factor 
 
Frequency (n) 
Percentage (%) 
Sex 
Male 
41 
68.0 
 
Female 
19 
32.0 
 
 
 
 
Age groups (in years) 
18-30 
07 
11.6 
 
31-50 
22 
36.7 
 
51-70 
21 
35.0 
 
>70 
10 
16.7 
 
 
 
 
Level of formal education 
None 
15 
25.0 
 
Primary 
16 
26.7 
 
Secondary 
17 
28.3 
 
Tertiary 
12 
20.0 
 
 
 
 
Employment status 
Not employed 
20 
33.3 
 
Self employed 
15 
25.0 
 
Employed by other 
24 
40.0 
 
Retired 
01 
1.7 
 
 
 
 
ASA  class (pre-operative) 
I 
30 
50.0 
 
II 
26 
43.0 
 
III 
04 
7.0 
 
 
N/B: The male patients who were ≤ 50 yrs of age were 25 (61%) while females were 4 (21%) 
 
 
Figure 3: Patients’ co-morbidities (n = 22) 
 
40.9%
18.2%
18.2%
9.1%
9.1%
4.5%
Cardiovascular
Respiratory
Neuropsychiatric
Malignancy
Musculoskeletal
Hematologic
 
N/B: Thirty eight patients (63.3%) had no co-morbidity.       
         All the musculoskeletal conditions were osteoarthritis of the hip. 

 
 
26
INJURY CHARACTERISTICS 
Injuries sustained from minor trauma accounted for a similar proportion (50%) as those 
sustained from severe trauma (Table 2). Severe trauma was either following a fall from a 
height (10 patients, 16.7%), RTI (19 patients, 31.7%) or assault with direct trauma to the 
hip (one patient, 1.7%). Falls accounted for 66.7% of the injuries.  RTI mainly occurred 
in those of 50 years of age and below while fall with mild trauma, mainly in those above 
50 years (Figure 4). Sixty two percent of the fractures were Garden’s IV (Table 2). 
 
Table 2: Injury characteristics  
 
Factor 
 
Frequency (n) 
Percentage (%) 
Mechanism of injury 
Fall/mild trauma 
30 
50.0 
 
Fall/severe trauma 
10 
16.7 
 
RTI 
19 
31.7 
 
Others 
01 
1.7 
 
 
 
 
Side affected 
Right 
29 
48.0 
 
Left 
31 
52.0 
 
 
 
 
Garden’s class 
III 
23 
38.0 
 
IV 
37 
62.0 
 
 
 
Figure 4: Mechanism of injury according to age (n = 60) 
 
0
2
4
6
8
10
12
14
16
18
18-30
31-50
51-70
>70
0
3
17
10
1
8
1
0
5
11
3
0
1
0
0
0
Number of patients
Age in years
Fall/mild trauma
Fall/severe trauma
RTI
Assault
 

 
 
27
TREATMENT CHARACTERISTICS 
 
Osteosynthesis was used in the treatment of majority of the fractures (24 patients, 40%); 
with 20 patients being treated using multiple screws and four by Dynamic Hip Screws. 
This was mainly amongst those aged 50 years and below. Twenty patients (33.3%) 
underwent HA and 16 patients (26.7%), THA (Table 3 and figure 5). Twelve patients 
underwent cemented HA and 8, uncemented HA.  Amongst the THA group, only two had 
uncemented THA (Figure 6). There were no patients below 31 years of age who 
underwent HA or THA and there were only two patients above 50 years of age who 
underwent OS. The lateral surgical approach was used in all the patients treated by OS 
(Table 3 and figure 5). 
 
 
Table 3: Treatment characteristics  
 
Factor 
 
Frequency (n) 
Percentage (%) 
Treatment modality 
OS 
24 
40.0 
 
HA 
20 
33.3 
 
THA 
16 
26.7 
 
 
 
 
Surgical approach 
Lateral 
31 
52.0 
 
Antero-lateral 
29 
48.0 
 
 
 
 
Type of anaesthesia 
General 
18 
30.0 
 
Spinal 
42 
70.0 
 
 
 
 
Transfusion pattern 
Transfused 
36 
60.0 
 
Not transfused 
24 
40.0 
 
 
 
 
Prophylaxis against VTE 
Heparin 
21 
35.0 
 
Enoxaparin 
39 
65.0 
 
 
 
 
Antibiotic prophylaxis 
Ceftriaxone 
27 
45.0 
 
Cefuroxime 
13 
21.7 
 
Cloxacillin 
11 
18.3 
 
Others 
09 
15.0 
 
 
N/B: Type of anaesthesia used was chosen by individual anesthetists. 
         Sixty percent of the patients had blood transfusion. 
 

 
 
28
Figure 5: Modalities of treatment according to age (n = 60) 
 
 
 
 
 
Figure 6: Cemented versus uncemented arthroplasty (n = 36) 
 
33%
22%
39%
6%
Cemented HA
Uncemented HA
Cemented THA
Uncemented THA
 
 
N/B: Four of the un-cemented HA and both the un-cemented THA patients were ≤50 years of age.  
 
 
 
 
 

 
 
29
EARLY POST-OPERATIVE COMPLICATIONS 
 
Most of the patients had no early post-operative complication (90%). The commonest 
complication was anaemia affecting 4 patients (Figure 7). Fifty-six patients (93.3%) had 
wound healing within seven days post-operatively. Only one patient (1.7%) took between 
15-21 days to heal (Figure 8). 
 
Figure 7: Early post-operative complications (n = 60) 
 
90%
3%
7%
None
Wound sepsis/ 
dehiscence
Anaemia
 
 
 
Figure 8: Duration of wound healing in days (n = 60) 
 
 
N/B: All wounds had healed by 21 days post-operatively. 
 

 
 
30
 DURATION FROM INJURY TO DISCHARGE FROM HOSPITAL 
 
The duration of stay to surgery was between1 to 140 days with a median of 7 days. The 
delay to surgery was mainly during the period between hospital admission and operative 
intervention. The duration from injury to surgery had a median of 26 days.  
The total length of hospital stay was between 4 to 163 days with a median of 14 days 
(Table 4). Majority of the patients were operated between one to fourteen days after 
injury and there was no patient operated on within one day of injury (Figure 9).  
Thirty-five (58.7%) patients stayed in the hospital for a period of 1-14 days with only 4 
patients (6.7%) staying beyond sixty days from admission to discharge (Figure 10).  
 
 
 
Table 4: Duration from injury to discharge from hospital (n = 60) 
 
Duration (days) 
Mean (SD) 
Median 
Minimum 
Maximum 
Injury to hospital admission  
31.9 (60.0) 
5.0 
1.0 
268 
Admission to surgery 
17.4 (28.2) 
7.0 
1.0 
140 
Injury to surgery 
49.3 (61.5) 
26.0 
4.0 
269 
Surgery to hospital discharge 
8.2 (5.9) 
6.5 
2.0 
42 
Length of hospital stay (LOS) 
25.6 (32.4) 
14.0 
4.0 
163 
 
 
 
N/B: Most of the parameters show a standard deviation (SD) more than the mean; hence the median values    
are used in the analysis. 
 
 
 
 
 
 
 
 

 
 
31
Figure 9: Duration from injury to surgery (n = 60) 
 
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
1-14
15-28
29-60
61-120
>120
36.7
18.3
20.0
10.0
15.0
Percent(%)
Days
 
 
 
 
 
Figure 10: Length of hospital stay in days (n = 60) 
 
0.0
10.0
20.0
30.0
40.0
50.0
60.0
1-14
15-28
29-60
>60
58.3
18.3
16.7
6.7
Percent(%)
Days
 
 
 
 
 
 

 
 
32
PRE-INJURY 
VERSUS 
EARLY 
POST-OPERATIVE 
WOMAC 
SCORES 
 
The ADL scores showed a negative outcome in all the patients while majority of the 
patients had a negative score for pain (81.6%) and stiffness (83.3%) outcome when the 
pre-injury and post-operative WOMAC scores were compared  for each patient (Figure 
11). Thus 88.3% of the patients had not recovered their pre-injury WOMAC scores by 
three months post-operatively (Figure 11). There was a significant reduction in WOMAC 
scores when the pre-injury and post-operative mean scores are compared for pain (p 
value 0.003), Stiffness (p value 0.043) and ADL (p value 0.034) (Table 5). When the 
population was stratified by age, there was still a significant reduction in mean post-
operative WOMAC scores in both age groups when compared to the pre-injury scores 
(Tables 6 and 7). The difference in the pre-injury WOMAC scores amongst the study 
population was not statistically significant. 
 
Figure 11: Changes between pre-injury and post-operative WOMAC scores (n = 60) 
 
0
10
20
30
40
50
60
70
80
90
100
Positive
No change
Negative
1.7
16.7
81.6
1.7
15
83.3
0
0
100
Percent(%)
Changes in mean WOMAC score
Pain
Stiffness
ADL
 
  N/B: Zero percent, 16.7% & 18.4% of the patients had not fully recovered their pre-injury level of   
function at 3 months as measured by ADL, stiffness and pain scores respectively. 

 
 
33
Table 5: Mean pre-injury versus postoperative WOMAC scores (n= 60) 
 
 
 
Mean(SD) 
Minimum 
Maximum 
p value 
Pain 
Before 
99.3(1.95) 
90 
100 
0.003* 
After 
83.2(13.50) 
35 
100 
 
Stiffness 
Before 
97.5(6.78) 
75 
100 
0.043* 
After 
79.2(14.30) 
25 
100 
 
ADL 
Before 
98.5(4.01) 
79.4 
100 
0.034* 
After 
80.3(9.24) 
57.4 
94.1 
*Significant p value < 0.05 
 
 
 
Table 6: Mean pre-injury versus postoperative WOMAC scores in patients aged ≤ 
50 years (n = 29) 
 
 
 
Mean(SD) 
Minimum 
Maximum 
p value 
Pain 
Before 
99.5(1.6) 
95 
100 
<0.001* 
After 
78.3(14.6) 
35 
100 
 
Stiffness 
Before 
97.4(7.7) 
75 
100 
<0.001* 
After 
86.1(8.1) 
35 
100 
 
ADL 
Before 
98.9(3.0) 
89.7 
100 
<0.001* 
After 
80.1(8.1) 
69 
94 
*Significant p value < 0.05 
 
 
 
Table7: Mean pre-injury versus postoperative WOMAC scores in patients aged > 50 
years (n = 31) 
 
 
 
Mean(SD) 
Minimum 
Maximum 
p value 
Pain 
Before 
99.2(2.3) 
90 
100 
<0.001* 
After 
87.7(10.7) 
70 
100 
 
Stiffness 
Before 
97.7(5.9) 
75 
100 
<0.001* 
After 
72.8(15.9) 
25 
100 
 
ADL 
Before 
98.2(4.8) 
79.4 
100 
<0.001* 
After 
80.4(10.4) 
57.4 
94.1 
*Significant p value < 0.05 
 
 
 

 
 
34
DIFFERENCE IN MEAN PAIN OUTCOME SCORES 
 
There was a statistically significant difference in mean pain score at three months post-
surgery based on age (p value 0.006) with those above 50 years of age having a better 
mean score for pain (less pain) compared to those aged 50 years and below (Table 8). 
Though there was no statistically significant difference in early post-operative mean pain 
scores based on presence or absence of co-morbidity and presence or absence of 
complication, the presence of co-morbidity or complication was associated with a poorer 
outcome (Tables 8, 9 & 10). When the study population was stratified by age (Tables 9 
and 10), there was a statistically significant effect of treatment modality on pain for those 
of 50 years of age and below (p value 0.031) with those who underwent OS scoring 
poorly compared to those treated by HA. 
 
Table 8: Difference in mean pain outcome scores according to age, sex, co-
morbidity, treatment modality, surgical approach, type of anaesthesia and 
complication(s) 
 
Factor 
Pain score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Age in years 
          ≤ 50  
           51+ 
 
29 
31 
 
78.3(14.6) 
87.7(10.7) 
 
35 
70 
 
100 
100 
 
0.006* 
Sex 
         Male 
         Female 
 
41 
19 
 
81.7(14.8) 
86.3(9.7) 
 
35 
70 
 
100 
100 
 
0.222 
Co-morbidity 
         Yes 
         No 
 
22 
38 
 
78.6(17.5) 
85.8(9.8) 
 
35 
70 
 
100 
100 
 
0.089 
Treatment modality 
        HA 
        THA  
        OS 
 
20 
16 
24 
 
83.0(20.3) 
89.1(9.5) 
79.4(5.4) 
 
35 
70 
70 
 
100 
100 
90 
 
0.082 
Surgical approach 
         Lateral 
         Anterolateral 
 
31 
29 
 
82.3(8.74) 
84.1(17.30) 
 
70 
35 
 
100 
100 
 
0.602 
Type of anaesthesia 
         General 
         Spinal 
 
18 
42 
 
82.5(10.18) 
83.5(14.8) 
 
55 
35 
 
100 
100 
 
0.094 
Complication (s) 
         Yes 
         No 
 
06 
54 
 
80.0(12.2) 
83.5(13.7) 
 
70 
35 
 
100 
100 
 
0.961 
*Significant p value < 0.05 

 
 
35
Table 9: Difference in mean pain outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged ≤ 50 
years  
 
Factor 
Pain score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
25 
4 
 
77.4(15.3) 
83.8(8.5) 
 
35 
75 
 
100 
95 
 
0.429 
Co-morbidity 
         Yes 
         No 
 
7 
22 
 
65.0(21.4) 
82.5(8.7) 
 
35 
70 
 
85 
100 
 
0.075 
Treatment modality β 
        HA 
         OS 
 
5 
22 
 
87.8(12.6)  
79.6(5.1) 
 
76 
70 
 
100 
90 
 
0.031* 
Surgical approach 
         Lateral 
         Anterolateral 
 
24 
5 
 
81.9(7.5) 
61.0(26.8) 
 
70 
35 
 
100 
100 
 
0.157 
Type of anaesthesia 
         General 
         Spinal 
 
14 
15 
 
81.8(9.9) 
75.0(17.6) 
 
55 
35 
 
100 
100 
 
0.330 
*Significant p value < 0.05. 
 β Only 2 patients in this age bracket underwent THA and so were not analyzed. 
 
 
 
Table 10: Difference in mean pain outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged >50 
years   
 
Factor 
Pain score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
16 
15 
 
88.4(11.5) 
87.0(10.1) 
 
70 
70 
 
100 
100 
 
0.716 
Co-morbidity 
         Yes 
         No 
 
15 
16 
 
85.0(11.3) 
90.3(9.7) 
 
70 
70 
 
100 
100 
 
0.172 
Treatment modality α 
        HA 
        THA 
         
 
15 
14 
 
 
89.0(11.7) 
87.9(9.6) 
 
70 
70 
 
100 
100 
 
0.776 
Surgical approach 
         Lateral 
         Anterolateral 
 
7 
24 
 
83.57(12.8) 
88.96(10.0) 
 
70 
70 
 
100 
100 
 
0.445 
Type of anaesthesia 
         General 
         Spinal 
 
4 
27 
 
85.0(12.2) 
88.2(10.7) 
 
70 
70 
 
100 
100 
 
0.562 
α Only 2 patients in this age bracket underwent OS and so were not analyzed. 
 
 
 

 
 
36
DIFFERENCE IN MEAN STIFFNESS OUTCOME SCORES 
 
There was a statistically significant difference in mean stiffness score at three months 
post-operatively based on age (p value <0.0001), with better score for those 50 years of 
age and below; and based on sex (p value 0.027), with better score amongst the male 
population. When stratified by age (Table 12 and 13), there was no statistically 
significant difference in mean stiffness outcome score based on sex. There was no 
statistically significant difference in mean stiffness outcome scores at three months post-
operatively based on comorbidity and presence or absence of complications though those 
with either co-morbidities or complications had a poorer score (Table 11).  
 
Table 11: Difference in mean stiffness outcome scores according to age, sex, co-
morbidity, treatment modality, surgical approach, type of anaesthesia and 
complication(s)  
 
Factor 
Stiffness score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Age in years 
          ≤ 50  
           51+ 
 
29 
31 
 
86.1(8.1) 
72.8(15.9) 
 
75 
25 
 
100 
100 
 
<0.0001* 
Sex 
         Male 
         Female 
 
41 
19 
 
82.0(12.9) 
80.9(8.4) 
 
50 
25 
 
100 
100 
 
0.027* 
Co-morbidity 
         Yes 
         No 
 
22 
38 
 
75.3(10.2) 
81.5(15.9) 
 
63 
25 
 
88 
100 
 
0.109 
Treatment modality 
        HA 
        THA  
        OS 
 
20 
16 
24 
 
74.6(17.9) 
80.7(14.3) 
82.1(9.9) 
 
25 
63 
50 
 
100 
100 
88 
 
0.195 
Surgical approach 
         Lateral 
         Anterolateral 
 
31 
29 
 
82.2(12.03) 
76.0(16.0) 
 
50 
25 
 
100 
100 
 
0.707 
Type of anaesthesia 
         General 
         Spinal 
 
18 
42 
 
80.8(13.1) 
78.5(14.9) 
 
50 
25 
 
100 
100 
 
0.747 
Complication (s) 
         Yes 
         No 
 
06 
54 
 
75.3(11.2) 
79.7(14.6) 
 
63 
25 
 
88 
100 
 
0.426 
*Significant p value < 0.05 

 
 
37
Table 12: Difference in mean stiffness outcome scores according to sex, co-
morbidity, treatment modality, surgical approach and type of anaesthesia in 
patients aged ≤ 50 years 
 
Factor 
Stiffness score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
25 
4 
 
85.8(7.9) 
87.8(10.2) 
 
75 
75 
 
100 
100 
 
0.662 
Co-morbidity 
         Yes 
         No 
 
7 
22 
 
82.4(6.9) 
87.2(8.2) 
 
75 
75 
 
88 
100 
 
0.175 
Treatment modality β 
        HA 
        OS 
 
5 
22 
 
87.6(12.5) 
84.5(5.9) 
 
75 
75 
 
100 
88 
 
0.389 
Surgical approach 
         Lateral 
         Anterolateral 
 
24 
5 
 
86.3(7.7) 
85.2(10.5) 
 
75 
75 
 
100 
100 
 
0.328 
Type of anaesthesia 
         General 
         Spinal 
 
14 
15 
 
85.1(8.8) 
87.0(7.5) 
 
75 
75 
 
100 
100 
 
0.224 
β Only 2 patients in the age bracket underwent THA and so were not analyzed. 
 
 
Table 13: Difference in mean stiffness outcome scores according to sex, co-
morbidity, treatment modality, surgical approach and type of anaesthesia in 
patients aged >50 years 
 
Factor 
Stiffness score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
16 
15 
 
76.0(16.7) 
69.4(14.9) 
 
50 
25 
 
100 
88 
 
0.256 
Co-morbidity 
         Yes 
         No 
 
15 
16 
 
72.0(9.9) 
73.6(20.4) 
 
63 
25 
 
88 
100 
 
0.790 
Treatment modality α 
        HA 
        THA 
 
15 
14 
 
70.2(17.6) 
77.9(13.0) 
 
25 
63 
 
100 
100 
 
0.187 
Surgical approach 
         Lateral 
         Anterolateral 
 
7 
24 
 
68.3(14.3) 
74.13(16.4) 
 
50 
25 
 
88 
100 
 
0.915 
Type of anaesthesia 
         General 
         Spinal 
 
4 
27 
 
66.0(15.9) 
73.8(16.0) 
 
50 
25 
 
88 
100 
 
0.998 
α Only 2 patients in this age bracket underwent OS and so were not analyzed. 
 
 
 

 
 
38
DIFFERENCE IN MEAN ADL OUTCOME SCORES 
There was a statistically significant difference in ADL status at 3 months post-surgery 
based on treatment modality (p value 0.002) with OS group having the lowest mean score 
of 75.2 (SD 6.7). Though there was no statistically significant difference in mean ADL 
outcome scores based on age, the presence or absence of co-morbidity (or complication), 
the presence of co-morbidity or complication was associated with a poorer mean ADL 
score at three months post-operatively (Table 14).  
 
Table 14: Difference in mean ADL outcome scores according to age, sex, co-
morbidity treatment modality, surgical approach, type of anaesthesia and 
complication(s)  
 
Factor 
ADL score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Age in years 
          ≤ 50  
           51+ 
 
29 
31 
 
80.1(8.1) 
80.4(10.4) 
 
69.2 
57.4 
 
94.1 
94.1 
 
0.906 
Sex 
         Male 
         Female 
 
41 
19 
 
80.0(9.7) 
80.8(8.4) 
 
57.4 
58.8 
 
94.1 
94.1 
 
0.730 
Co-morbidity 
         Yes 
         No 
 
22 
38 
 
78.1(9.6) 
81.5(8.9) 
 
57.4 
61.8 
 
89.7 
94.1 
 
0.164 
Treatment modality 
        HA 
        THA  
        OS 
 
20 
16 
24 
 
83.4(9.4) 
83.9(9.3) 
75.2(6.7) 
 
58.8 
57.4 
60.3 
 
94.1 
94.1 
88.2 
 
0.002* 
Surgical approach 
         Lateral 
         Anterolateral 
 
31 
29 
 
76.1(9.3) 
84.7(6.9) 
 
57.4 
72.1 
 
94.12 
94.12 
 
0.295 
Type of anaesthesia 
         General 
         Spinal 
 
18 
42 
 
76.8(9.2) 
81.8(9.0) 
 
60.3 
57.4 
 
94.12 
94.12 
 
0.659 
Complication (s) 
         Yes 
         No 
 
06 
54 
 
71.6(8.1) 
81.2(8.9) 
 
57 
59 
 
82 
94 
 
0.257 
*Significant p value < 0.05 
 
 
 
 

 
 
39
When the study population was stratified by age, there was still a statistically significant 
difference in mean ADL outcome scores for those of 50 years of age and below based on 
treatment modality (p value <0.0001) with those treated by OS scoring poorly compared 
to the HA group (Table 15). There was also a statistically significant difference in mean 
ADL outcome score for those more than 50 years of age based on presence or absence of 
co-morbidity (p value 0.016) and type of surgical approach (p value 0.007). Those with 
co-morbidity scored poorly compared to those without comorbidity (means of 75.9 and 
84.7 respectively) while those who underwent surgery via the lateral approach scored 
poorly compared to those operated via the anterolateral approach (means of 68.1 and 84.0 
respectively). There was no statistically significant difference in ADL outcome between 
the HA and THA groups (Table 16).  
 
Table 15: Difference in mean ADL outcome scores according to sex, co-morbidity, 
treatment modality, surgical approach and type of anaesthesia in patients aged ≤ 50 
years 
 
Factor 
ADL  score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
25 
4 
 
79.9(8.1) 
81.3(9.1) 
 
69.1 
73.5 
 
94.1 
91.2 
 
0.769 
Co-morbidity 
         Yes 
         No 
 
7 
22 
 
79.3(8.2) 
82.8(7.6) 
 
69.1 
70.6 
 
 
94.1 
89.7 
 
 
0.326 
Treatment modality β 
        HA 
         OS 
 
5 
22 
 
90.3(2.5) 
76.5(5.3) 
 
88.2 
69.1 
 
94.1 
88.2 
 
<0.0001* 
Surgical approach 
         Lateral 
         Anterolateral 
 
24 
5 
 
78.5(7.6) 
87.9(5.3) 
 
69.1 
79.4 
 
94.1 
94.1 
 
0.169 
Type of anaesthesia 
         General 
         Spinal 
 
14 
15 
 
78.9(8.1) 
81.3(8.1) 
 
69.1 
70.6 
 
94.1 
94.1 
 
0.959 
*Significant p value < 0.05 
β Only 2 patients in the age bracket underwent THA and so were not analyzed. 
 
 

 
 
40
Table 16: Difference in mean ADL outcome scores with sex, co-morbidity, treatment 
modality, surgical approach and type of anaesthesia in patients aged >50 years 
 
Factor 
ADL  score after operation 
P value 
n 
Mean(SD) 
Minimum 
Maximum 
Sex 
         Male 
         Female 
 
16 
15 
 
80.1(12.1) 
80.1(8.6) 
 
57.4 
58.8 
 
94.1 
94.1 
 
0.849 
Co-morbidity 
         Yes 
         No 
 
15 
16 
 
75.9(9.9) 
84.7(9.1) 
 
57.4 
61.8 
 
86.8 
94.1 
 
0.016* 
Treatment modality α 
        HA 
        THA 
        
 
15 
14 
 
81.1(9.8) 
82.5(9.0) 
 
58.8 
57.4 
 
94.1 
94.1 
 
0.692 
Surgical approach 
         Lateral 
         Anterolateral 
 
7 
24 
 
68.1(10.8) 
84.0(7.1) 
 
57.4 
72.1 
 
82.4 
94.1 
 
0.007* 
Type of anaesthesia 
         General 
         Spinal 
 
4 
27 
 
69.5(9.8) 
82.0(9.6) 
 
60.3 
57.4 
 
77.9 
94.1 
 
0.694 
*Significant p value < 0.05 
α Only 2 patients in this age bracket underwent OS and so were not analyzed. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
41
EFFECT OF DURATION TO SURGERY ON EARLY FUNCTIONAL 
OUTCOME 
 
The mean outcome scores for pain, stiffness and ADL at three months post-operatively 
had no statistically significant correlation with duration from fracture to surgery (p values 
0.514, 0.941 and 0.603 respectively). 
 
Figure 12: Difference in mean WOMAC outcome scores according to duration from 
fracture to surgery  
 
 
 
 
 
 
 
 
 
 
 
 

 
 
42
EFFECT OF LENGTH OF STAY ON EARLY FUNCTIONAL 
OUTCOME 
The mean outcome scores for ADL at three months post-operatively had a statistically 
significant correlation with LOS (p value 0.020). The mean outcome scores for pain and 
stiffness had no statistically significant correlation with LOS (p values 0.677 and 0.473 
respectively), though the mean pain outcome scores are poorer with prolonged LOS 
(Figure 13). 
 
 
Figure 13: Difference in mean WOMAC outcome scores according to length of 
hospital stay 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
43
DISCUSSION 
How well patients are able to regain their pre-injury level of function and 
independence is a measure of the success or failure of a treatment regime41. To date 
there are still controversies in the choice of appropriate treatment for displaced 
femoral neck fractures and the problem is whether to reduce the fracture and use 
internal fixation or perform partial or total hip replacement arthroplasty5, 6. 
Locally, the choice of treatment modality was noted to be guided by both the 
principles applicable internationally6, 9, 46, 51, 56-59, 61- 64 and also the affordability of 
the necessary implants on the part of the patient. 
 
There was a male preponderance noted in the study and majority of the patients were 
relatively young (mean age, 51.6 ± 18.2 years). This was consistent with findings 
reported in other local series2, 13. Studies from the USA and western European countries 
however, indicate a female preponderance with a relatively elderly population (mean ages 
above 70 years) 17, 19.  Nyarango2 and Ochiel13 in separate local studies found that these 
fractures are commoner in the younger age group (mean ages of 45 and 53 years 
respectively), though Ochiel13 further noted that the male population was younger than 
the females; findings corroborated by this study. The younger population noted in the 
local studies compared to the western series, could probably be due to the relatively 
shorter life expectancy in the local setting compared to the western countries18.  
Nyarango2 found that RTI was the commonest etiologic factor (84.5%), while Ochiel13 
found that a fall with minor injury predominate (48%). The latter is also the commonest 
finding in western series17, 19. This study, found that severe trauma resulted in equal 
proportions of FNF (50% each) just as minor trauma, possibly due to the almost equal 

 
 
44
distribution of the study population (mean 51.6 years and median 51 years) and the 
improving life expectancy locally18 with a more elderly population than before. A fall, 
either with mild or severe trauma, was the commonest etiologic factor (66.7%) though 
RTI resulted in a significant proportion of the injuries (31.7%). RTI was the main 
etiologic factor in those of 50 years and below while fall with minor trauma was the 
dominant etiologic factor in those above 50 years of age. The increased predisposition to 
a fall and the increased rate of osteoporosis with advancing age makes falling, especially 
with minor trauma the commonest etiologic factor in the elderly population21, 22, 25.  
It is worth noting that this study only looked at skeletally mature patients who underwent 
operative treatment for displaced FNF. Nyarango’s study2, undertaken more than twenty 
years ago, looked at those who underwent operative treatment for FNF irrespective of age 
or Garden’s class. Many changes have occurred especially in the demographics, which 
are likely to affect not only the etiologic patterns but also the subsequent treatment 
outcome. Ochiel’s study13 looked at all cases of FNF irrespective of age, Garden’s class 
or treatment modality.  
 
Pre-injury functional status versus early post-operative functional outcome 
At three months postoperatively, most patients had not fully recovered their pre-injury 
level of function and independence. All the patients had not fully recovered there pre-
injury ADL function and only 18.4%  and 16.7% respectively had recovered their pre-
injury function as measured by pain and stiffness score. 
Koot et al7 in a study looking at patients aged 55-102 years who underwent OS and HA, 
found that at 4 months, only 36% of the patients had fully recovered their mobility while 
the overral functional recovery was 29%. Though this population was more elderly, the 

 
 
45
functional results seem to be better than the local findings. This probably could be due to 
better rehabilitation facilities, still lacking in our set-up. 
 
 Effect of age on early post-operative functional outcome 
Those older than 50 years had a better functional outcome for pain (p value 0.006) but a 
poorer outcome for stiffness (p value <0.0001) than those of 50 years and below. Age had 
no significant effect on ADL. However, majority of those above 50 years of age in this 
study underwent treatment by arthroplasty while those of 50 years and below were 
mainly treated using OS. This can explain the poorer outcome for pain in the younger 
group since OS is associated with a poorer outcome compared to arthroplasty as found in 
this study and other series6, 9, 56-58. Age has been shown in many studies to influence 
functional outcome6, 7, 10, with advancing age generally being associated with a poor 
outcome. Warrakah12 however, found no significant effect of age on functional 
performance though his study population was slightly elderly (average age of 62 years).  
 
Effect of sex on early post-operative functional outcome 
Sex had no significant effect on early post-operative pain and ADL outcome. There was a 
statistically significant effect on stiffness outcome (p value 0.027), with better outcome 
amongst the male population, though when corrected for age, the difference was not 
significant.  
Sex has been shown to have no influence on functional outcome in other series12, 44. 
Merchant et al44 found that sex has no influence on the post-operative functional outcome 
though they found high rates of complication in females than males.  
 

 
 
46
Effect of co-morbidity on early post-operative functional outcome 
Co-morbidity has been found to be associated with a negative impact on functional 
outcome in many studies6, 7, 37. This study found that the presence of co-morbidity was 
associated with a poor functional outcome though this was not statistically significant. 
However, when stratified by age, there was a statistically significant difference in ADL 
outcome for those above 50 years of age with those having co-morbidity scoring poorly 
than those without co-morbidity (p value 0.016).  
 
Effect of treatment modality on early post-operative functional outcome 
There are controversies in the choice of the best treatment modality for displaced FNF 
especially in the middle age groups. In an attempt to circumvent this challenge, several 
studies have compared outcome following the use of these modalities6, 9, 46, 51, 56-59, 61- 64. 
In this study, it was noted that arthroplasty was mainly used amongst patients older than 
30 years while OS was popular in those younger than 50 years. This was consistent with 
the understanding of the pattern of blood supply to the hip and healing of FNFs and also 
other treatment choice determinants already alluded to earlier in this dissertation4, 8, 9, 37. 
The study found that the HA group had a better outcome for pain (p value 0.031) and 
ADL (p value <0.0001) compared to OS. Both THA and HA groups had a better outcome 
for ADL compared to OS (p value 0.002). There was no statistically significant 
difference in stiffness outcome between the THA/HA group and OS group. Many studies 
have found better pain relief and mobility following HA compared to OS6, 9, 46, 64. Lu-Yao 
et al6 in a meta-analysis of 106 published reports, found better pain relief and better 
mobility in the arthroplasty group (HA or THA) compared to the OS group. The 
difference for mobility in this study however, was not statistically significant (p value 

 
 
47
0.48). Other studies comparing THA and OS have found better function and less 
pronounced decline in the health-related quality of life following THA than OS39, 56-58. 
However, Bhandari et al51 in a meta-analysis of 14 randomized controlled trials found no 
significant difference in functional outcome between arthroplasty and OS (relative risk, 
1.12 for pain relief and 0.99 for function). Söreide et al59 reported similar findings.  
Most studies comparing HA and THA have only looked at the long-term functional 
outcome at periods ranging from 12 months to 13 years with varying results. This study 
found no difference in functional outcome between the HA and THA groups. Squires et 
al60 found poorer functional outcome following HA compared to THA while Narayan et 
al61 found no statistically significant difference in functional outcome. Smrke et al62 
found, HA to give a better range of motion compared to THA but the total Harris hip 
score showed no statistically significant difference. Ravikumar et al63, found that both 
OS and HA resulted in the poorest functional outcome compared to THA. 
 
Effect of duration from fracture to surgery on early post-operative functional 
outcome 
The in-hospital delay to surgery had a median of 7 days while the duration from injury to 
surgery had a median of 26 days. Nyarango6 had previously reported that the in-hospital 
delay can take up to 20 weeks, mainly worse amongst the cases referred from other 
institutions to KNH. This study found no significant effect of the duration from injury to 
surgery on functional outcome, findings corroborated by other studies 49, 50. Delay to 
surgery could have been due to the delay by the patients or their families in raising funds 
to meet the cost of the necessary implants despite a good socio-economic standing (65% 
on employment and 75% literacy level). Most of the patients were not economically 
productive during this period.  

 
 
48
Effect of length of in-hospital stay (LOS) on early post-operative functional outcome 
The LOS was mainly contributed to by the duration from hospital admission to operative 
intervention (median 7 days). Prolonged in-hospital stay was associated with a poor ADL 
outcome at three months post-operatively (p value 0.020) while pain and stiffness 
outcome were not affected by the length of in-hospital stay.  
Warrakah12 found poor function with prolonged post-operative in-hospital stay.  
 
Effect of surgical approach on early post-operative functional outcome 
The lateral approach was the preferred method of access to the hip especially for OS. 
These findings were consistent with a previous report by Warrakah12 who found that the 
lateral approach was more popular locally being used in 84% of the patients who 
underwent Austin Moore HA.  
The antero-lateral approach was associated with a better ADL outcome amongst patients 
above 50 years of age when compared to the lateral approach (p value 0.007), though 
there was no statistically significant difference in postoperative pain and stiffness 
outcome between these two groups. 
Amongst the patients undergoing Austin Moore HA, Warrakah12 found that the lateral 
approach was associated with a better functional outcome compared to the antero-lateral 
approach. In this study, 82% of the patients who underwent treatment by the lateral 
approach had satisfactory results compared to 66% for antero-lateral approach and 50% 
for anterior approach. Most other studies however, compared anterior and posterior 
approaches, none of which was used amongst the study population46, 64. These studies 
have shown that a posterior approach is associated with a better functional outcome but 
more complications when compared to the anterior approach46, 64. 

 
 
49
Effect of type of anaesthesia on early post-operative functional outcome 
Spinal anaesthesia was used in the majority of the patients (70%) in this study. There was 
no significant difference in outcome between those treated under general anaesthesia and 
the spinal anaesthesia group. Few published studies have looked at the difference in 
outcome following either regional or general anaesthesia. In a meta-analysis of 15 
randomized trials, Urwin et al47 found fewer incidences of mortality and deep vein 
thrombosis in the regional anaesthesia group compared to general anaesthesia. These 
studies however, did not assess functional outcome.  
 
Effect of early post-operative complication on early post-operative functional 
outcome 
Most of the patients had no post-operative complication (90%). Anaemia was the 
commonest complication affecting 4 patients (7%) while two patients (3%) had wound 
sepsis/dehiscence. Nyarango2 and Warrakah12 separately found that wound sepsis was the 
commonest post-operative complication. Nyarango2 found an infection rate of 8.5% in 
his study. The low rate of wound sepsis currently reported could be due to the widespread 
use of prophylactic antibiotics noted in the current study. 
The study found that the presence of complication(s) was associated with a poor early 
post-operative functional outcome though this was not statistically significant. Anaemia 
has been shown to independently impact negatively on mobility45. Other postoperative 
complications are also associated with poor functional outcome6, 7, 9, 23, 24, 37, 41, 44.  
Some other studies however, found no effect of post-operative complication(s) on 
functional outcome8, 51. Bhandari et al51 in a meta-analysis of 14 published reports, found 
no effect of post-operative complication(s) on functional outcome.   
 

 
 
50
CONCLUSIONS: 
This study reveals that: 
1. Majority of the patients who undergo operative treatment of displaced fracture 
neck of femur at KNH and KMH are males (male: female ratio, 2.15: 1). 
2. The most affected age class (31-50 years) comprises people in the economic 
prime age.  
3. The commonest etiologic factor is a fall either with low energy trauma or severe 
trauma, though Road Traffic Injuries (RTI) still contributes to a significant 
proportion of the fractures. 
4. The delay to surgery is mainly from admission to operative intervention (within 
the hospital) and not the period from injury to hospital admission. 
5. Hypertension is the commonest co-morbid condition amongst patients undergoing 
operative treatment for displaced FNF at the KNH and KMH. 
6. The commonly used treatment modality is OS with THA being the least used 
modality of treatment, though OS is mainly used in those below 51 years of age. 
7. At three months post-operatively, majority of the patients have not fully recovered 
their pre-injury level of function and independence. 
8. There is a significant effect of age on early functional outcome with those above 
50 years of age having less pain and more stiffness compared to those of 50 years 
and below though age has no significant effect on ADL outcome. 
9. Sex has no significant effect on early functional outcome for pain, stiffness and 
ADL. 

 
 
51
10. The presence of co-morbidity is associated with a poorer functional outcome for 
pain, stiffness and ADL though this difference is only significant for ADL 
outcome in those above 50 years of age. 
11. There is no significant difference in early post-operative functional outcome for 
pain, stiffness and ADL between those treated using HA and THA. 
12. The early post-operative functional outcome for ADL is better for those patients 
who undergo treatment by HA or THA compared to those treated by OS. 
13. Duration from fracture to surgery (delay to surgery) has no significant effect on 
functional outcome. 
14. The prolonged in-hospital stay (LOS) is mainly pre-operative, and is associated 
with poor ADL outcome but no effect on pain and stiffness outcome. 
15. The antero-lateral surgical approach is associated with a better ADL outcome 
compared to the lateral approach in patients above 50 years of age though there is 
no significant effect on pain and stiffness outcome. 
16. There is no statistically significant difference in early functional outcome between 
spinal anaesthesia and general anaesthesia in the treatment of FNF.  
17. The commonest early post-operative complication is anaemia though early post-
operative complication has no significant effect on early functional outcome. 
 
Finally, it can be stated that: 
 
Most FNF occur in the younger, economically productive age group hence FNF 
has a negative socio-economic impact locally. At three months post-operatively, most 
patients have not fully recovered their pre-injury level of function and independence. 
Both HA and THA are associated with better functional outcome compared to OS.  

 
 
52
RECOMMENDATIONS 
The following recommendations are made: 
 
1. Long term randomized multicenter studies should be undertaken within the 
country to determine the long-term functional outcome following operative 
treatment of FNF in Kenya. 
2. Local studies should be undertaken to look at the other outcome measures 
including complications and mortality both in the short-term and long-term. 
3. A study should be undertaken to look at the socio-economic impact of fracture 
neck of femur and its treatment locally. 
4. A study should be undertaken to find out the main cause of delay to surgery and 
prolonged in-hospital stay by the patients, though anecdotal evidence suggests 
that the in-ability by the patients to buy the necessary implants for operative 
treatment contributes to the delay. 
5. Measures should be instituted to ameliorate the incidence of fracture neck of 
femur such us execution of stringent traffic rules (the “Michuki rules”). RTI is 
one of the commonest and preventable causative factors.  
6. Measures should be instituted to reduce the duration of in-hospital stay by 
ensuring prompt treatment since prolonged hospital stay has been found to be 
associated with poor functional outcome. This prolonged stay is contributed to 
mainly by the pre-operative in-hospital stay. 
 
 

 
 
53
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Kanis J.A. & McCloskey E.V. Evaluation of the risk of hip fracture. Bone 1996; 18: 
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van Staa T.P., Leufkens H.G., Abenhaim L., et al. Oral corticosteroids and fracture 
risk: relationship to daily and cumulative doses. Rheumatology (Oxford) 2000; 39: 
1383–1389. 
23. 
Wejda B., Hintze G., Katschinski B., et al. Hip fractures and the thyroid: a case-
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25. 
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55
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American College of Surgeons Committee on Trauma. Advanced trauma life 
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Surg Br 1964; 46: 630–647. 
37. 
Israr A. Mortality and morbidity in elderly patients with fracture neck of femur 
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Delamarter R. & Moreland J.R. Treatment of acute femoral neck fractures with 
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39. 
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arthroplasty in the treatment of displaced femoral neck fractures: a prospective 
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40. 
Winter W.G. Non-operative treatment of proximal femoral fractures in the 
demented, non-ambulatory patient. Clin Orthop 1987; 97–103. 
41. 
Koval K.J. & Zuckerman J.D. Functional recovery after fracture of the hip. J Bone 
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outcome after total hip arthroplasty, J Bone Joint Surg Am 2007; 89:11-17. 
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44. 
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postoperative complications and outcomes after hip fracture surgery. Ann Acad Med 
Singapore 2005; 34: 163-168. 

 
 
56
45. 
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hip fracture surgery. Age and ageing 2008; 37: 173-178. 
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displaced subcapital fracture of the femur. A prospective randomized study. J Bone 
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Urwin S.C., Parker M.J., Griffiths R. General versus regional anaesthesia for hip 
fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 2000; 84:450-5. 
48. 
Taine W.H. & Armour P.C. Primary total hip replacement for displaced subcapital 
fractures of the femur. J Bone Joint Surg Br 1985; 67: 214–217. 
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Orosz G.M., Magaziner J., Hannan E.L.,  et al. Association of timing of surgery 
for hip fracture and patient outcomes. JAMA 2004; 291(14):1738-1743. 
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Jain R., Koo M., Kreder H.S., et al. Comparison of early and delayed fixation of 
subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am 
2002; 84: 1605–1612. 
51. 
Bhandari M., Devereaux P.J., Swiontkowski M.F., et al. Internal fixation 
compared with arthroplasty for displaced fractures of the femoral neck: A meta-
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52. 
Herngren B., Mörk-Petersen F. & Bauer M. Uppsala screws or Hansson pins for 
internal fixation of femoral neck fractures? A prospective study of 180 cases. Acta 
Orthop Scand 1992; 63: 41–46. 
53. 
Lagerby M., Asplund S. & Ringqvist I. Cannulated screws for fixation of femoral 
neck fractures. No difference between Uppsala screws and Richards screws in a 
randomized prospective study of 268 cases. Acta Orthop Scand 1998; 69: 387–391. 
54. 
Christie J., Howie C.R. & Armour P.C. Fixation of displaced subcapital femoral 
fractures. Compression screw fixation versus double divergent pins. J Bone Joint 
Surg Br 1988; 70: 199–201. 
55. 
Godsiff S.P., Emery R.J., Heywood-Waddington M.B. et al. Cemented versus 
uncemented femoral components in the ring hip prosthesis. J Bone Joint Surg Br 
1992; 74: 822–824. 
56. 
Blomfeldt R., Tornkvist H., Ponzer S., et al. Comparison of internal fixation with 
total hip replacement for displaced femoral neck fractures. Randomized, controlled 
trial performed at four years. J Bone Joint Surg Am 2005; 87: 1680–1688. 
57. 
Keating J.F., Masson G.M., Scott N.M., et al. Randomized comparison of reduction 
and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of 
displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am 
2006; 88: 249–260. 

 
 
57
58. 
Jónsson B., Sernbo I., Carlsson A., et al. Social function after cervical hip fracture. 
A comparison of hook-pins and total hip replacement in 47 patients. Acta Orthop 
Scand 1996; 67: 431–434. 
59. 
Söreide O., Mölster A. & Raugstad T.S. Internal fixation versus primary prosthetic 
replacement in acute femoral neck fractures: a prospective, randomized clinical study. 
Br J Surg 1979; 66: 56–60. 
60. 
Squires B., Bannister G. Displaced intracapsular neck of femur fractures in mobile 
independent patients: total hip replacement or hemiarthroplasty? Injury Int J Care 
Injured 1999; 30: 345-348. 
61. 
Narayan K.K., George T., Functional outcome of fracture neck of femur treated 
with total hip replacement versus bipolar arthroplasty in a South Asian population. 
Arch Orthop Trauma Surg 2006; 126: 545-548. 
62. 
Smrke D., Beden R. & Stankovski V. Bipolar versus total hip endoprosthesis: 
functional results. Arch Orthop Trauma Surg 2000; 120: 259–261. 
63. 
Ravikumar K.J. & Marsh G. Internal fixation versus hemiarthroplasty versus total 
hip arthroplasty for displaced subcapital fractures of femur – 13 year results of a 
prospective randomized study. Injury 2000; 31: 793–797. 
64. 
Montgomery S.P., and Lawson L.R. Primary Thompson prosthesis for acute 
femoral neck fractures. Clin. Orthop. 1978; 137:62-68. 
65. 
Kocher M.S., Zurakowski D. Clinical epidemiology and biostatistics: A primer for 
orthopaedic surgeons. Current concepts review J Bone Joint Surg Am 2004; 86 (3): 
607-620. 
66. 
Young W., Seigne R., Bright S., et al. Audit of morbidity and mortality following 
neck of femur fracture using the POSSUM scoring system. NZMJ 19 May 2006; 119 
(1234):1-8. 
67. 
Wolters U., Wolf T., Stutzer H., et al. ASA classification and perioperative 
variables as predictors of postoperative outcome. Br. J. Anaesth. 1996; 77: 217-222. 
68. 
The World Medical Association. Declaration of Helsinki. World Med J. 2008; 
54:122–5. 
69. 
Lwanga S.K and Lemesha. Sample size Determination in Health Studies. 
Epidemiological and Statistical Methodology Unit, WHO Geneva 1988, 1-5. 
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SPSS Inc. (2006). SPSS Base 15.0 for Windows User’s Guide. SPSS Inc., Chicago 
IL. 
 
 

 
 
58
APPENDICES 
 
Appendix 1 
 
CONSENT BY THE PARTICIPATING PATIENT 
(English)* 
 
 
Study No………………………………….. 
 
I have understood the explanation by DR OCHIENG’ SEPHENIA RADUMA who is carrying out a study 
at Kenyatta National Hospital and Kikuyu Mission Hospital on the early functional outcome for the 
operative treatment of fracture neck of femur and hereby give consent to participate in the study. I have 
understood that this is a fracture involving the hip.  
I have also understood that the purpose of this study is to determine the functional outcome of management 
of this fracture including the factors that influence this outcome.  
 
I agree to participate in this study as a patient on my own free will and also accept to do the following: 
• 
Be interviewed concerning my illness and subsequent management and the answers to be 
recorded by DR OCHIENG’. 
• 
Be examined physically.  
 
I have also understood that my participation in this study is voluntary and that I can withdraw my consent 
at any time and failure to participate or withdrawal of the consent will not affect my treatment in any way. 
 
That the information I give will be treated with utmost confidence and my name will not be included in the 
results. 
 
PARTICIPANT’S NAME 
(OR PARENT/GUARDIAN/ CONSULTANT) 
 
…………………………………………….       
          Signature/Thumb Print…………………..… 
 
WITNESS’ NAME 
 
…………………………………………….          
          Signature/thumb Print……….………..….... 
 
INVESTIGATOR 
DR OCHIENG’ SEPHENIA RADUMA 
 
           Signature…………………………………… 
(Cell phone contact: +254-722-652-202) 
 
*There is a Swahili version for those who do not understand English. 
 
 

 
 
59
Appendix 2 
 
FOMU YA MAKUBALIANO KWA MGONJWA ANAYESHIRIKI KATIKA UTAFITI 
(Swahili)* 
 
 
Nambari ya Kushiriki……………….. 
 
Nimeelewa maelezo ambayo nimepatiwa na DAKTARI OCHIENG’ SEPHENIA RADUMA ambaye 
anafanya utafiti katika hospitali kuu ya Kenyatta na hospitali ya misheni ya Kikuyu unaochunguza matokeo 
(hali ya kujitegemea) ya mwanzo/awali baada ya matibabu kwa njia ya upasuaji kufuatia kuvunjika kwa 
mfupa wa paja kwenye kiungo cha nyonga, na nimekubali kuwa mmoja wa wale wagonjwa wanaoshiriki 
katika utafiti huu. 
 
Pia, ninaelewa ya kwamba, utafiti huu unachunguza matokeo (hali ya kujitegemea) baada ya matibabu na 
yale yanayoleta hayo matokeo. 
 
Nimekubali kushiriki katika huu utafiti kama mgonjwa na kwa hiari yangu na pia nimekubali kufanya 
yafuatayo: 
• 
Kuhojiwa juu ya ugonjwa wangu pamoja na matibabu yale nitapata na kwa DAKTARI 
OCHIENG’, kuandika yale nitasema kwa shuguli za huu utafiti. 
• 
Kupimwa kimwili kwa minajili wa huu utafiti. 
 
Pia, nimeelewa ya kwamba, ninashiriki kwa huu utafiti kwa hiari yangu bila kulazimishwa, na ninaweza 
kujiondoa wakati wowote. Pia nimeelewa kwamba kutokubali kushiriki au kujiondoa katika utafiti huu 
hakutaathiri matibabu yangu kwa vyovyote vile haswa kubadilishwa au kukosa matibabu. 
 
 
JINA LA MSHIRIKI (MGONJWA) 
(AU MZAZI/MLINZI/DAKTARI MTAALAMU) 
 
…………………………………………………. 
 
Sahihi/Kidole gumba………………………. 
 
MSHAIDI 
 
…………………………………………………. 
 
Sahihi/Kidole gumba………………………. 
 
 
MTAFITI 
DAKTARI OCHIENG’ SEPHENIA RADUMA 
 
Sahihi………………………………………. 
(Nambari ya simu ya rununu: +254-722-652-202) 
 
*Kunayo fomu iliyotafsiriwa kwa lugha ya kiingereza kwa wale hawaelewi Swahili. 

 
 
60
    Appendix 3 
QUESTIONNAIRE 
 Tick the appropriate bracket for yes or no, present or absent (where applicable). 
A. 
DEMOGRAPHIC DATA: 
Patient’s name…………………………………………………………………………………………………  
 
Age in years (        ) 
                   Address (Permanent Residence)…………………………………...  
IP No …………………………………..; Study Code No…………………...……………………………….. 
Gender: Male ( 1 ); Female (  2 ); 
         Telephone contact………………………………………………… 
 
Date and time of injury....…………….….………...; Date and time of admission......……..….…………..…. 
 
Date and timing of Operation ……….…….….……; Date and time of discharge/death...……..….........…..  
 
 
 
B. 
SOCIO-ECONOMIC STATUS 
a) 
Education level 
1. Illiterate  
 
(      ) 
2. Primary  
 
(      ) 
3. Secondary 
 
(      ) 
4. Tertiary  
 
(      ) 
 
b) 
  Employment status 
1. Not employed 
 
(      ) 
2. Self employed 
 
(      ) 
3. Employed by other 
(      ) 
4. Retired  
 
(      ) 
 
 
C. 
MECHANISM OF INJURY 
1. Fall with mild trauma 
 
(      ) 
2. Fall with severe trauma 
 
(      ) 
3. RTI 
 
 
 
(      ) 
4. Others (specify)…………………………………… 
 
 
 
D. 
CO-MORBIDITIES (Specify if present and any long-term medication)   
1. None......................................................................................... 
2. Respiratory…………………………………………………... 
3. Cardiovascular………………………………………………. 
 
 
  
4. Neuropsychiatric…………………………………………….. 
 
  
5. Metabolic…………………………………………………….    
 
 
6. Haematologic………………………………………………... 
 
 
7. Musculoskeletal……………………………………………... 
8. Malignancy (specify) ………………………………………. 
9. Others (specify)……………………………………………… 
 

 
 
61
E. 
PHYSICAL FINDINGS (on admission) 
a) Glasgow coma score  
 
 
 
(        ) 
b) Blood Pressure 
 
 
 
 
(        ) 
c) Pulse Rate 
 
 
 
 
 
(        ) 
d) Respiratory Rate 
 
 
 
 
(        ) 
 
 
F. 
ASA Class  
I ( 1 ); 
    II ( 2 ); 
 III ( 3 );        IV ( 4 );     
V ( 5 ) 
 
 
 
G. 
The WOMAC score within one week before injury (Annex 1) 
1. Pain pre-operatively (P)    
 
 
 
(          ) 
 
2. Stiffness (S)  
 
 
 
 
(          )  
 
3. ADL score (A) 
 
 
 
 
(          ) 
 
 
H. 
RADIOLOGICAL INVESTIGATIONS  
1. Pre-operative plain Pelvic/Hip X-ray 
 
Side affected 
           
 
  Right (  1  )  
Left (  2   ) 
Garden’s class 
 
  
     III   (  1  )  
   IV (  2   ) 
 
2. Post-operative plain Pelvic/Hip X-ray......................................................................... 
 
3. Others (specify)……………………………………………………………………… 
 
 
I. 
LABORATORY INVESTIGATIONS (Pre-operatively) 
1. TWBC Count………………………………………………………………….................... 
2. Hemoglobin…..…………..........…..……………………………………………………… 
3. Serum Sodium……..……………………………………………………………………… 
4. Serum Potassium………...……...………………………………………………………… 
5. Blood Urea & Creatinine...………………………………………………………………... 
6. ELISA (HIV I & II)………………………………………………………………………... 
7. Others (specify)…………………………………………………………………………….. 
 
 
J. 
TREATMENT MODALITIES 
1. Hemiarthroplasty (HA) 
 
 
(        ) Specify…………………………….... 
 
 
 
2. Total Hip Arthroplasty (THA) 
 
(        ) 
 
 
3. Osteosynthesis (OS) 
 
 
(        ) Specify…………………………….... 
 
 
4. Others (specify)………………………………………………………….………………........ 
 
 
K. 
SURGICAL APPROACH 
1. Anterior 
 
 
(        ) 
 
2. Posterior  
 
(        ) 
 
3. Lateral 
 
 
(        )     
4.   Others (specify)……................................ 
 
 

 
 
62
L. 
TYPE OF ANAESTHESIA 
1. General anaesthesia  
 
 
 
 
(        ) 
 
2. Regional anaesthesia (specify) 
 
 
 
(        )……………………  
 
 
M. 
BLOOD TRANSFUSION 
1. None 
 
 
 
 
 
 
(        ) 
 
2. Transfused 
 
 
 
 
 
(        ) 
 
 
 
If transfused, specify the number of units and time of transfusion………………………..  
 
 
N. 
ANTIBIOTIC PROPHYLAXIS 
a) None 
 (  1  ) 
  
 
b) Yes 
 (  2  ) Cefriaxone; 
 (  3  ) Cefuroxime;  
(  4  ) Flucloxacillin;  
 
 (  5  ) Cloxacillin;  
 (  5  ) Others (specify).......................................... 
 
 
O. 
ANTICOAGULANT PROPHYLAXIS 
a) None 
 
 (  1  ) 
  
 
b) Yes (Specify) 
 (  2  ) Heparin; (  3  ) Clexane; (  4  ) Others (specify)..... ……………... 
 
 
P. 
EARLY COMPLICATIONS 
a) None 
 
 
 
 
 
 
(  1  ) 
 
b) Local:   
i. 
Wound sepsis/dehiscence  
 
 
(  2  ) 
ii. 
Hip Dislocation  
 
 
 
(  3  ) 
iii. 
Deep Joint Infection 
 
 
 
(  4 ) 
iv. 
Haemarthrosis 
 
 
 
 
(  5  ) 
v. 
Sciatic Nerve Palsy 
 
 
 
(  6  ) 
vi. 
AVN of Femoral Head 
 
 
 
(  7  ) 
vii. 
Others (specify)…………………………….................( 8  ) 
 
c) Systemic (specify for each): 
i. 
Cardiac  
 
 
 
 
(   9  )…………………… 
ii. 
Pulmonary 
 
 
 
 
(  10 )…………………… 
iii. 
Neuropsychiatric  
 
 
 
(  11 )…………………… 
iv. 
Anemia (specify Hemoglobin level) 
 
(  12 )…………………… 
v. 
Septicemia 
 
 
 
 
(  13 )…………………… 
vi. 
Others   
 
 
 
 
(  14 )…………………… 
 
 
 
Q. 
DURATION TAKEN FOR INCISION WOUND TO HEAL 
1. By day 7  
 
 
 
 
(      ) 
 
2. 8 to 14 days 
 
 
 
 
(      ) 
 
3. 15 to 21 days 
 
 
 
 
(      ) 
 
4. > 21 days  
 
 
 
 
(      ) 

 
 
63
R. 
The WOMAC score  at three months post-operatively (± one week; annex 2) 
1. Pain post-operatively (P)     
 
 
(            ) 
 
2. Stiffness (S) 
 
 
 
 
(            ) 
 
 
3. ADL score (A) 
 
 
 
 
(            ) 
 
 
 
S. 
DISCHARGE DESTINATION 
1. Residential home  
 
 
(      ) 
 
2. Nursing home 
 
 
 
(      ) 
 
3. Others (specify)............................................................................................ 
 
 
T. 
REVISION SURGERY 
1. None 
 
 
 
 
 
(      ) 
 
2. Yes 
 
 
 
 
 
(      ) 
 
If undertaken, specify reason, type and when …………………………….. 
 
 
U. 
REMARKS 
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………… 
 
PRINCIPAL INVESTIGATOR’S SIGNATURE……………………………………………………….. 
 
 
 
 
 
 
      DR OCHIENG’ SEPHENIA RADUMA  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
64
Annex 1 to appendix 3 
 
Western Ontario and McMaster Universities Osteoarthritis Index, English version LK 3.0 
 
 
THE WOMAC SCORE 
(pre-injury functional status evaluation) 
Study No. 
Patient’s Initials: 
Study Hip: Left (   );     Right (   )  
Date of operation (DD/MM/YY)                                                      
Assessment Date (DD/MM/YY):           /           /     
 
 
INSTRUCTIONS:  
This survey asks for your view about your hip. This information will help us evaluate how you felt about 
your hip and how well you were able to do your usual activities within the last one week prior to injury. 
Answer every question by ticking the appropriate box before the response (only one box for each question). 
If you are uncertain about how to answer a question, please give the best answer you can. 
 
P(a)-Pain: 
What amount of hip pain were you experiencing in the last week prior to injury during the following 
activities? 
P1(a). Walking on a flat surface 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P2(a). Going up or down stairs or a slope 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P3(a). At night while in bed 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P4(a). Sitting or lying 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P5(a). Standing upright 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 
S(a) - Stiffness:  
The following questions concern the amount of joint stiffness you were experiencing during the last week 
prior to injury in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you 
move your hip joint. 
S1(a). How severe was your hip joint stiffness after first wakening in the morning? 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
S2(a). How severe was your hip stiffness after sitting, lying or resting later in the day? 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A(a)-Physical function, (activities of daily living): 
The following questions concern your physical function. By this we mean your ability to move around and 
to look after yourself. For each of the following activities please indicate the degree of difficulty you were 
experiencing in the last week prior to injury due to your hip. 
 
A1(a). Descending stairs/ walking down a slope 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 

 
 
65
 
A2(a). Ascending stairs/ walking up a slope 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A3(a). Rising from sitting 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A4(a). Standing 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
For each of the following activities please indicate the degree of difficulty you were experiencing in the last 
week prior to injury due to your hip. 
A5(a). Bending to the floor/pick up an object 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A6(a). Walking on a flat surface 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A7(a). Getting in/out of car or a public service vehicle 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A8(a). Going shopping or to the market 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A9(a). Putting on socks/stockings or shoes 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A10(a). Rising from bed 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A11(a). Taking off socks/stockings or shoes 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A12(a). Lying in bed (turning over, maintaining hip position) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A13(a). Getting in/out of bath 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A14(a). Sitting 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A15(a). Getting on/off toilet 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A16(a). Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 

 
 
66
A17(a). Light domestic duties (cooking, dusting, sweeping the compound, etc) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 
 
 
 
SECTION TO BE USED BY THE INVESTIGATOR: 
 
NORMALIZED PRE-INJURY SCORES (a): 
 
1. PAIN:  
 
 
100 - Total score P1-P5 x 100  = 100 -______ = ______  
                                                 
 
 
  20          
     20  
 
2. STIFFNESS:  
 
100 - Total score S1-S2 x 100  = 100 -______ = ______ 
8 
                8  
 
3. ADL:  
 
 
100 - Total score A1-A17 x 100  = 100 -______ = ______ 
    68  
         68  
 
 
PRINCIPAL INVESTIGATOR 
 
 
           
..…………………………………………………….. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DR OCHIENG’ SEPHENIA RADUMA  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
67
Annex 2 to appendix 3 
 
Western Ontario and McMaster Universities Osteoarthritis Index, English version LK 3.0 
 
 
THE WOMAC SCORE 
(post-operative functional status evaluation) 
Study No. 
Patient’s Initials: 
Study Hip: Left (   );     Right (   )  
Date of operation (DD/MM/YY)                                                      
Assessment Date (DD/MM/YY):           /           /     
 
 
INSTRUCTIONS:  
This survey asks for your view about your hip. This information will help us evaluate how you feel about 
your hip and how well you are able to do your usual activities. Answer every question by ticking the 
appropriate box before the response (only one box for each question). If you are uncertain about how to 
answer a question, please give the best answer you can. 
 
P(b)-Pain: 
P1(b). Walking on a flat surface 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P2(b). Going up or down stairs 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P3(b). At night while in bed 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P4(b). Sitting or lying 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
P5(b). Standing upright 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 
S(b)-Stiffness:  
The following questions concern the amount of joint stiffness you have experienced during the last week in 
your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint. 
S1(b). How severe was your hip joint stiffness after first wakening in the morning? 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
S2(b). How severe was your hip stiffness after sitting, lying or resting later in the day? 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 
A(b)-Physical function, (activities of daily living): 
The following questions concern your physical function. By this we mean your ability to move around and 
to look after yourself. For each of the following activities please indicate the degree of difficulty you have 
experienced in the last week due to your hip. 
 
A1(b). Descending stairs/ walking down a slope 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 

 
 
68
A2(b). Ascending stairs/ walking up a slope 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A3(b). Rising from sitting 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A4(b). Standing 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
For each of the following activities please indicate the degree of difficulty you have experienced in the last 
week due to your hip. 
A5(b). Bending to the floor/pick up an object 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A6(b). Walking on a flat surface 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A7(b). Getting in/out of car or a public service vehicle 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A8(b). Going shopping or to the market 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A9(b). Putting on socks/stockings or shoes 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A10(b). Rising from bed 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A11(b). Taking off socks/stockings or shoes 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A12(b). Lying in bed (turning over, maintaining hip position) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A13(b). Getting in/out of bath 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A14(b). Sitting 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A15(b). Getting on/off toilet 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
A16(b). Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 

 
 
69
A17(b). Light domestic duties (cooking, dusting, sweeping the compound, etc) 
􀀁 None  
􀀁 Mild  
 
􀀁 Moderate  􀀁 Severe  
􀀁 Extreme 
 
 
 
Thank you very much for completing all the questions in this questionnaire. 
 
 
 
 
 
 
SECTION TO BE USED BY THE INVESTIGATOR: 
 
NORMALIZED POST-OPERATIVE SCORES (b): 
 
1. PAIN:  
 
 
100 - Total score P1-P5 x 100  = 100 -______ = ______  
                                                 
 
 
  20          
     20  
 
2. STIFFNESS:  
 
100 - Total score S1-S2 x 100  = 100 -______ = ______ 
8 
                8  
 
3. ADL:  
 
 
100 - Total score A1-A17 x 100  = 100 -______ = ______ 
    68  
         68  
 
 
PRINCIPAL INVESTIGATOR 
 
 
           
..…………………………………………………….. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DR OCHIENG’ SEPHENIA RADUMA  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
70
Appendix 4 
 
 
 
 

 
 
71
 Appendix 5 
 
 
 
 

 
 
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Appendix 6