Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival

Elevated 1-Year Mortality Rate in Males Sustaining Low-Energy Proximal Femur Fractures and Subgroup Analysis Utilizing Age-Adjusted Charlson Comorbidity Index

INTRODUCTION

Low-energy proximal femur fractures are common in the aging population and the ability to identify patients at increased mortality risk provides surgeons information to improve informed decision-making with patients and families. We evaluated for gender differences in 1-year mortality after sustaining low-energy proximal femur fractures with subgroup analysis to identify the impact of fracture location, age, and comorbidities on mortality.

MATERIALS AND METHODS

Patients ≥40 years of age sustaining a low-energy proximal femur fracture identified at our institution between January 1, 2014, and December 31, 2017. International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes were used to identify comorbidities for calculation of the age-adjusted Charlson comorbidity index (ACCI). The county clerk database was searched to identify mortality within 1 year of injury. One-year mortality rates were calculated and multiple comparisons were made between genders controlling for age, fracture location, and/or ACCI.

RESULTS

Women presented with low-energy proximal femur fractures at a rate of almost 3:1 to men at our institution (P = .001). Men demonstrated a significantly increased ACCI at presentation (5.35 ± 2.55 vs 4.86 ± 1.77, P = .03). Men had an increased 1-year mortality rate for all (31.3% vs 21.5%, P = .004) and intertrochanteric (IT) fractures (36.2% vs 22.9%, P = .008). Controlling for ACCI, gender, and fracture location, men demonstrated increased mortality rate with IT fractures (P = .002) and trended toward but did not reach significance with femoral neck fractures (P = .07).

DISCUSSION

Men presenting with low-energy femur fractures are at an increased mortality risk compared to women. On average, men present with an overall worse health status as identified by ACCI, which could predispose these patients not only to fractures themselves but also impair their ability to recover from injury.

CONCLUSION

Men are at an increased 1-year mortality risk after sustaining proximal femur fractures.

Pre-fracture medication use as a predictor of 30-day mortality in hip fracture patients: an analysis of 141,201 patients

PURPOSE

To evaluate the predictive value of pre-fracture medication usage on 30-day mortality following a hip fracture.

METHODS

Information on age, sex, fracture type, time of death and Charlson co-morbidity index (CCI) was collected from the Danish National Patient Registry on all patients above 60 years, sustaining a hip fracture during the period January 1995 to December 2013. Information on drug usage was obtained from the Danish National Prescription Database. Hazard ratios were calculated with 30-day mortality as the outcome. A univariate and 3 multivariate analyses were conducted with increasing adjustments, starting with age, sex and fracture type, adding co-morbidity and dose in the latter.

RESULTS

141,201 patients were included and a total of 12 drugs/drug groups were identified for analysis. Increased mortality was evident in all analyses for antiarrhythmics, beta blockers, proton pump inhibitors, loop diuretics, opioids, acetaminophen and for psycholeptics. For ACE-inhibitors, increased mortality was found in all analyses, except after adjustment for co-morbidity and dose. For thiazide diuretics, a significantly reduced mortality was evident in all but the univariate analyses while NSAIDs and statins were associated with a significantly reduced mortality in all analyses. For calcium channel blockers, an insignificant decrease was found after adjustment for dose. Further analysis showed a dose-response relationship for all drugs except ACE-inhibitors and calcium channel blockers.

CONCLUSION

The study shows a correlation between pre-fracture usage of certain drugs and 30 day mortality after a hip fracture.

Osteoporosis Therapeutics 2020

Numerous safe and efficient drug therapies are currently available to decrease risk of low trauma fractures in patients with osteoporosis including postmenopausal, male, and secondary osteoporosis. In this chapter, we give first an overview of the most important outcomes regarding fracture risk reduction, change in bone mineral density (BMD by DXA) and/or bone markers of the phase III clinical studies of well-established therapies (such as Bisphosphonates, Denosumab or Teriparatide) and also novel therapies (such as Romosozumab or Abaloparatide) and highlight their mechanisms of action at bone tissue/material level. The latter understanding is not only essential for the choice of drug, duration and discontinuation of treatment but also for the interpretation of the clinical outcomes (in particular of eventual changes in BMD) after drug administration. In the second part of this chapter, we focus on the management of different forms of osteoporosis and give a review of the respective current guidelines for treatment. Adverse effects of treatment such as atypical femoral fractures, osteonecrosis of the jaw or influence of fracture healing are considered also in this context.

Osteocalcin and its forms across the lifespan in adult men

PURPOSE

Osteocalcin (OC), an osteoblast-specific secreted protein expressed by mature osteoblasts, is used in clinical practice and in research as a marker of bone turnover. The carboxylated (cOC) and undercarboxylated (ucOC) forms may have a different biological function but age-specific reference ranges for these components are not established. Given the different physiological roles, development of reference ranges may help to identify people at risk for bone disease.

METHODS

Blood was collected in the morning after an overnight fast from 236 adult men (18 to 92 years old) free of diabetes, antiresorptive, warfarin or glucocorticoid use. Serum was analyzed for total osteocalcin (tOC) and the ucOC fraction using the hydroxyapatite binding method. cOC, ucOC/tOC and cOC/tOC ratios were calculated. Reference intervals were established by polynomial quantile regression analysis.

RESULTS

The normal ranges for young men (≤30 years) were: tOC 17.9-56.8 ng/mL, ucOC 7.1-22.0 ng/mL, cOC 8.51-40.3 ng/mL (2.5th to 97.5th quantiles). Aging was associated with a "U" shaped pattern for tOC, cOC and ucOC levels. ucOC/tOC ratio was higher, while cOC/tOC ratio was lower in men of advanced age. Age explained ∼31%, while body mass index explained ∼4%, of the variance in the ratios.

CONCLUSIONS

We have defined normal reference ranges for the OC forms in Australian men and demonstrated that the OC ratios may be better measures, than the absolute values, to identify the age-related changes on OC in men. These ratios may be incorporated into future research and clinical trials, and their associations with prediction of events, such as fracture or diabetes risk, should be determined.

Nationwide in-hospital mortality following major fractures among hemodialysis patients and the general population: An observational cohort study

BACKGROUNDS

End-stage kidney disease (ESKD) is associated with increased risk of fracture and subsequent morbidity and mortality. However, fracture site-specific mortality in ESKD patients have yet to be elucidated in comparison with the general population.

METHODS

In this population-based cohort derived from the Diagnosis Procedure Combination database of Japan from 2012 to 2014, we included 9320 ESKD patients undergoing hemodialysis and 547,726 patients without ESKD who were hospitalized for five major fractures, including hip (proximal femur), spine, forearm, upper arm, and leg (distal femur and proximal tibia). Overall and site-specific risks of in-hospital death were determined by logistic regression models.

RESULTS

The age- and sex-adjusted mortality rates were 4.91% (95% confidence interval [CI], 4.46-5.37) and 1.02% (95% CI, 0.99-1.06) in the hemodialysis and general population groups, respectively. The multivariate odds ratio (OR) of death in hemodialysis patients versus the general population was 2.48 (95% CI, 2.25-2.74) for overall fractures, and was particularly high for a subgroup of upper arm fracture (OR 4.82, 95% CI, 3.19-7.28). The site-specific odds of death (95% CI) among hip, spine, forearm, upper arm, and leg (reference) fractures were 1.77 (0.98-3.18), 1.48 (0.79-2.75), 0.19 (0.04-0.86), and 2.01 (1.01-4.01) in hemodialysis patients, and 1.28 (1.13-1.45), 1.00 (0.88-1.14), 0.13 (0.10-0.17), and 0.83 (0.70-0.97) in the general population, respectively.

CONCLUSION

Hemodialysis patients experienced a 4.8-fold higher mortality rate after fractures than the general population. Mortality after upper arm fracture was specifically high in patients on hemodialysis, likely due to the involvement of vascular access located on the fractured arm.

EVALUATION OF PREDICTIVE FACTORS OF IN HOSPITAL MORTALITY IN PATIENTS WITH PROXIMAL FEMORAL FRACTURE

OBJECTIVE

To investigate the existence of a causal association between orthopedic treatment and the occurrence of in hospital death.

METHODS

338 patients with proximal femoral fracture were evaluated, of whom 27 faced in hospital death. Patients who faced in hospital death (case group) were compared to patients who did not (control group) regarding exposure to risk factors prior to injury and factors related to orthopedic treatment.

RESULTS

The factors related to higher in hospital mortality rate were: male sex (case group: 52%, control: 26%; p = 0.005), lower Parker's score (case group: 5.0 points, control: 6.2; p = 0.048), delirium on admission (case group: 26%, control: 10%; p = 0.011); delirium developed during hospitalization (case group: 77%, control: 35%; p <0.001), and time until surgery (13.3 days, 9.1; p = 0.049).

CONCLUSION

The in hospital mortality rate of patients with proximal femoral fracture was 8%, and the main associated risk factors were male sex, reduced Parker's score, delirium diagnosed on hospital admission or developed during hospitalization, and time until surgery. Level of Evidence III, Case control study.

The impact of care process development and comorbidity on time to surgery, mortality rate and functional outcome for hip fracture patients: a retrospective analysis over 19 years with data from the Swedish National Registry for hip fracture patients, RIKSHÖFT

Abstract

For a long time the attention given to the hip fracture patient group was minor and without any certain consideration to their frailty. To improve the care for these patients Skane University Hospital in Lund has during the past 19 years worked actively with developing the care. This paper aims to describe what impact the care process development has had on functional outcome and mortality, as well as to analyze the impact of comorbidity and fracture type.

Methods

Patients older than 50 years with non-pathological cervical and trochanteric hip fracture admitted between Jan 1st 1999 and Dec 31st 2017 were included and data was retrieved from the National Quality Register for hip fracture patients, RIKSHÖFT. Variables regarding patient characteristics, fracture type, operation method, lead-times and outcome were analyzed. For comparison Fischer’s exact test and Spearman’s rank correlation coefficient was used for the categorical data and Pearson correlation coefficient for the continuous. To further analyze the effect over time a linear regression model was used.

Results

A total of 7827 patients were included. A significant shift in the overall morbidity was seen, with an increase in patients of higher ASA grade. No correlation was seen between outcome and the care process development. The mortality rate for the group as a whole the mortality rate had decreased over time. The total length of stay had decreased significantly over time. There was no statistically significant change in mortality rate over time when relating it to time-to-surgery.

Conclusions

Although the patients display a higher morbidity over time, the mortality rate has not changed significantly, which might indicate an effect of the care process development.

The care process development does not seem to impact on outcome as much as other factors.

This study supports the possibility to create a more specific algorithm for hip fracture patients, taking specific subgroups into consideration.

Preoperative Ascorbic Acid Levels in Proximal Femur Fracture Patients Have No Postoperative Clinical Impact, While Ascorbic Acid Levels upon Discharge Have a Major Effect on Postoperative Outcome

Proximal femur fractures show a high prevalence in elderly patients and are associated with an elevated risk of multimorbidity and early mortality. Recovery is impaired by malnutrition and oxidative stress, which is affected by antioxidants such as ascorbic acid (AA). This study monitored AA levels during hospitalization of patients with a proximal femur to investigate the influence of AA status to the clinical outcome. AA levels of 25 elderly patients with a proximal femur fracture were measured during hospitalization using high performance liquid chromatography. Plasma samples were collected preoperatively, on the first day after surgery, on the third day after surgery and on the day of discharge. Nutritional Risk Screening 2002 (NRS) and Mini Nutritional Assessment (MNA) were assessed to evaluate the nutritional status. In patients with proximal femoral fractures, preoperative AA concentrations were significantly lower compared to elderly patients without an acute fracture. A significant decrease of 33.8% in AA plasma level was measured on the day after surgery with a significant recovery up to the time of discharge. The preoperative AA status did not have any significant effect on clinical outcome. However, inadequate AA levels (<50 µmol/L) upon discharge significantly increased the incidence and the severity of postoperative complications. These results indicate that the AA status upon discharge has a greater impact on clinical outcome than assumed, and therefore, AA supplementation during hospitalization should be considered.

Biochemical markers of inflammation are associated with increased mortality in hip fracture patients: the Bispebjerg Hip Fracture Biobank

PURPOSE

The purpose of this study was to examine the possible association between mortality following a hip fracture and known biochemical markers of inflammation.

METHODS

The study population was identified using two local databases from Bispebjerg Hospital (Copenhagen, Denmark): the Hip Fracture Database containing all patients admitted to the hospital with a fractured hip from 1996 to 2012 and the Hip Fracture Biobank, containing whole blood, serum and plasma taken in relation to admission on a subgroup of patients from the Hip Fracture Database, consecutively collected over a period of 2.5 years from 2008 to 2011. The following biochemical markers of inflammation were included: C-reactive protein (CRP), the soluble urokinase plasminogen activating receptor (suPAR), ferritin and transferrin. The association between the blood markers and mortality was examined using Cox proportional hazards models. Hazard ratios (HR) were expressed per quartile increase in the biochemical markers.

RESULTS

A total of 698 patients were included, 69 (9.9%) died within 30 days after sustaining a hip fracture. The HR for 30-day mortality was significantly increased with increasing quartiles of suPAR, CRP and ferritin and with decreasing quartiles of transferrin.

CONCLUSION

This study shows that 30-day mortality after a hip fracture is associated with elevated levels of suPAR, CRP and ferritin as well as with lower levels of transferrin. This excess inflammatory response is likely caused by muscle damage associated with the hip fracture. However, this needs to be further clarified.

Viewpoint on the role of tissue maintenance in ageing: focus on biomarkers of bone, cartilage, muscle, and brain tissue maintenance

Specific hallmarks are thought to underlie the ageing process and age-related functional decline. In this viewpoint, we put forward the hypothesis that disturbances in the process of tissue maintenance are an important common denominator that may lie in between specific hallmarks of ageing (i.e. damage and responses to damage) and their ultimate (patho)physiological consequences (i.e. functional decline and age-related disease). As a first step towards verifying or falsifying this hypothesis, it will be important to measure biomarkers of tissue maintenance in future studies in different study populations. The main aim of the current paper is to discuss potential biomarkers of tissue maintenance that could be used in such future studies. Among the many tissues that could have been chosen to explore our hypothesis, to keep the paper manageable, we chose to focus on a selected number of tissues, namely bone, cartilage, muscle, and the brain, which are important for mobility and cognition and affected in several common age-related diseases, including osteoporosis, osteoarthritis, sarcopenia, and neurodegenerative diseases. Furthermore, we discuss the advantages and limitations of potential biomarkers for use in (pre)clinical studies. The proposed biomarkers should be validated in future research, for example by measuring these in humans with different rates of ageing.

Detection and localisation of hip fractures on anteroposterior radiographs with artificial intelligence: proof of concept

AIM

To investigate the feasibility of applying a deep convolutional neural network (CNN) for detection/localisation of acute proximal femoral fractures (APFFs) on hip radiographs.

MATERIALS AND METHODS

This study had institutional review board approval. Radiographs of 307 patients with APFFs and 310 normal patients were identified. A split ratio of 3/1/1 was used to create training, validation, and test datasets. To test the validity of the proposed model, a 20-fold cross-validation was performed. The anonymised images from the test cohort were shown to two groups of radiologists: musculoskeletal radiologists and diagnostic radiology residents. Each reader was asked to assess if there was a fracture and localise it if one was detected. The area under the receiver operator characteristics curve (AUC), sensitivity, and specificity were calculated for the CNN and readers.

RESULTS

The mean AUC was 0.9944 with a standard deviation of 0.0036. Mean sensitivity and specificity for fracture detection was 97.1% (81.5/84) and 96.7% (118/122), respectively. There was good concordance with saliency maps for lesion identification, but sensitivity was lower for characterising location (subcapital/transcervical, 84.1%; basicervical/intertrochanteric, 77%; subtrochanteric, 20%). Musculoskeletal radiologists showed a sensitivity and specificity for fracture detection of 100% and 100% respectively, while residents showed 100% and 96.8%, respectively. For fracture localisation, the performance decreased slightly for human readers.

CONCLUSION

The proposed CNN algorithm showed high accuracy for detection of APFFs, but the performance was lower for fracture localisation. Overall performance of the CNN was lower than that of radiologists, especially in localizing fracture location.

Hospitalized fracture rates amongst patients with chronic kidney disease in Australia using data linkage

BACKGROUND

Renal osteodystrophy leading to fractures in chronic kidney disease (CKD) is associated with significant hospitalization, morbidity, mortality and health care costs. There is a paucity of data on fractures in the CKD population in Australia.

AIM

To describe the trends and impact of hospitalized fractures in an Australian population of non-dialysis CKD patients.

METHODS

Retrospective observational data derived using data linkage. Fracture rates, trends in hospital admissions, comorbidity burden and mortality were analysed in a non-dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales. Hospitalized patients with CKD and fractures were compared with CKD patients without fracture.

RESULTS

A total of 149 839 hospitalized patients with CKD were included, of whom 9898 (6.6%) experienced one or more fractures. Patients with fracture were older, more likely to be female with a higher comorbidity burden than those without. Hospital admissions involving fracture were longer than non-fracture admissions (14.3 vs 5.9 days, P < .0001) and patients were less likely to be discharged home (28.3% vs 80.9%, P < .0001). The 12-month mortality rate was high at 41%.

CONCLUSION

Australian non-dialysis CKD patients with hospitalized fractures were older, had a greater burden of disease, and have similar rates of fracture and associated mortality compared to international CKD cohorts. Implications of fracture requiring hospitalization are considerable, with longer admissions, greater healthcare costs, lower likelihood of discharge home and significant mortality. As fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk.

Thyroid-stimulating hormone (TSH) is associated with 30-day mortality in hip fracture patients

PURPOSE

The aim of this study is to assess the possible association between thyroid-stimulating hormone (TSH) and mortality in hip fracture patients.

PATIENTS AND METHODS

The study is based on a hip fracture database from Bispebjerg University Hospital (Copenhagen, Denmark). This database includes all hip fracture patients (ICD-10 codes DS720 (femoral neck), DS721 (pertrochanteric), and DS722 (subtrochanteric)) admitted to Bispebjerg Hospital from 1996 to 2012. From this database, we identified all surgically treated hip fracture patients aged > 60 years with available plasma TSH-measurements at admission.

RESULTS

Of the 914 included patients (24% men and 76% women), 10.5% died within 30 days. At inclusion, 161 (17.6%) of the patients were hyperthyroid (TSH < 0.65 mIU/L), 58 (6.4%) were hypothyroid (TSH > 4.8 mIU/L), while 695 (76.0%) were euthyroid (0.65 < TSH < 4.80 mIU/L), p = 0.03. Mortality was significantly higher in the two higher quartiles of TSH [Q3 (13.0%) and Q4 (15.4%)] compared to the two lower quartiles [Q1 (7.4%) and Q2 (6.2%), p = 0.0003. After adjustment for age, sex and Charlson Comorbidity Index (CCI) in a Cox proportional hazard model, the risk of 30-day mortality continued to be increased in patients with TSH above the median as compared to patients with TSH below the median (HR 2.1 (1.4-3.3), p = 0.0006].

CONCLUSION

The study demonstrates increased 30-day mortality in surgically treated hip fracture patients with plasma TSH levels above the median (1.41 mIU/L) at admission, even after adjusting for age, sex and CCI.

Impact of Frailty on 30-Day Morbidity and Mortality of Patients With Intertrochanteric Femur Fractures

The aim of this study was to evaluate the association between frailty and 30-day morbidity and mortality in patients with intertrochanteric femur fractures. Furthermore, the authors sought to identify a specific frailty index score that would help identify high-risk patients. This retrospective study evaluated 229 consecutive patients 50 years or older who presented to a single level I trauma center for surgical fixation of an intertrochanteric femur fracture. Frailty was determined using a previously validated 11-point modified frailty index (mFI) scale. Primary outcome variables included 30-day morbidity and mortality. Of the 229 patients included in this study, 82 (36%) had a postoperative complication and there were 10 (4%) mortalities. The most common complications were delirium (n=40; 17%) and acute kidney injury (n=25; 11%). Mean mFI score for those who developed a postoperative complication was 0.24 compared with 0.14 for those who did not (P<.001). The mortality rate increased from 0% for mFI of 0 to 11% for mFI of 0.27 or more. Patients with an mFI of 0.27 or more were more than 9 times as likely to have a mortality compared with patients with an mFI of less than 0.27 (P=.006). This study demonstrates that the mFI is associated with 30-day morbidity and mortality in patients aged 50 years or older with intertrochanteric femur fractures. The authors identified an mFI score of 0.27 or more as the most robust predictor of increased 30-day morbidity and mortality following surgical fixation of intertrochanteric femur fractures. [Orthopedics. 2019; 42(6):344-348.].

Effect of Kidney Disease on Hemiarthroplasty Outcomes After Femoral Neck Fractures

OBJECTIVE

To compare the outcomes of patients with predialysis chronic kidney disease (CKD) or end-stage renal disease (ESRD) with the outcomes of patients with no kidney disease after hemiarthroplasty (HA) for femoral neck fractures (FNF).

DESIGN

Retrospective review utilizing the Nationwide Readmissions Database.

SETTING

National database incorporating inpatient data from 22 states.

PATIENTS

Using the Nationwide Readmissions Database, 214,399 patients who underwent HA after FNF between 2010 and 2014 were identified and divided into 3 groups using ICD-9 diagnosis codes: no kidney disease (n = 176,300, 82%), predialysis CKD (n = 34,400, 16%), and ESRD (n = 3,698, 2%).

INTERVENTION

HA for FNF.

MAIN OUTCOME MEASUREMENT

Mortality, blood transfusion, and postoperative complications during index hospitalization. Hospital readmission, postoperative dislocation, periprosthetic fracture, and revision surgery within 90 days of surgery.

RESULTS

Compared to patients with no kidney disease, ESRD patients had an increased risk of mortality [odds ratio (OR) = 3.76, 95% confidence interval (CI), 2.95-4.78], blood transfusion (OR = 2.35, 95% CI, 2.08-2.64), and postoperative complications (OR = 1.64, 95% CI, 1.45-1.86) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 3.09, 95% CI, 2.72-3.50). Interestingly, even patients with predialysis CKD had an increased risk of mortality (OR = 1.80, 95% CI, 1.59-2.05), blood transfusion (OR = 1.66, 95% CI, 1.59-1.75), and postoperative complications (OR = 2.37, 95% CI, 2.25-2.50) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 1.43, 95% CI, 1.37-1.51).

CONCLUSIONS

This retrospective cohort study demonstrates that both ESRD and CKD patients have worse outcomes compared to patients with no kidney disease after HA for FNF.

LEVEL OF EVIDENCE

Prognostic Level III. See instructions for authors for a complete description of levels of evidence.

Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study

Background

We investigated the association of anti-osteoporosis medication with mortality risk in older adults with hip fractures and evaluated the influence of medication adherence on mortality.

Methods

We conducted a population-based cohort study and identified a total of 13,123 patients aged 65 years or older with hip fracture from the Taiwan National Health Insurance Database during the period 2001–2010. Individuals with (n = 2092) and without (n = 2092) receiving anti-osteoporosis medication were matched using propensity score matching (1:1 ratio). The 1-, 3- and 5-year survival rates after the index fracture were compared between patients with and without treatment. In the treated group, survival rate was compared between those with good and non-adherence. Good adherence was defined as the medication possession ratio of ≥80% and non-adherence as a ratio < 80%.

Results

The 1-, 3- and 5-year mortality rates were significantly lower in the treated vs. the non-treated group (all p < 0.0001). In the treated group, the estimated 1-, 3- and 5-year survival rates were higher in those with good adherence than in those with non-adherence (all p < 0.0001). Regarding all-cause mortality, the adjusted hazard ratio in the treated vs. the non-treated group was 0.63 (95% confidence interval 0.58–0.68, p < 0.0001). The good adherence subgroup showed a significantly lower mortality risk than that in the non-adherence subgroup (hazard ratio 0.41, 95% confidence interval 0.32–0.51, p < 0.0001).

Conclusions

The 1-, 3- and 5-year survival rates were significantly higher in patients receiving anti-osteoporosis medication than in the untreated group. All-cause mortality rates were lower in patients with good adherence to anti-osteoporosis medication.

Postoperative mortality after a hip fracture over a 15-year period in Denmark: a national register study

Background and purpose - In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods - The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results - 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8-25) to 8 (IQR 5-11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation - Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.

Effects of postoperative osteoporosis treatment on subsequent fracture and the 5-year survival rates after hemiarthroplasty for hip fracture

According to the literature, only 20-30% of patients are screened for osteoporosis after a hip fracture. Osteoporosis treatment may have a potential protective effect on the 5-year mortality rate. Our results demonstrated that 5-year survival is higher in patients who received osteoporosis treatment after hemiarthroplasty for hip fracture compared with those who did not.

PURPOSE

This study aims to investigate the status of osteoporosis treatment in patients who underwent hemiarthroplasty for an osteoporotic hip fracture and to compare subsequent fractures and the 5-year survival rates of these patients with those who did not receive the osteoporosis treatment.

METHODS

Patients > 65 years of age who underwent hemiarthroplasty for an osteoporotic hip fracture were included in this retrospective multicenter study. Patients who died within 12 months postoperative, who were lost to follow-up, and those with malignancy and secondary osteoporosis were excluded. Group I comprised patients who had no postoperative osteoporosis screening and treatment, and Group II comprised those who received the screening and treatment.

RESULTS

A total of 460 of 562 patients (82%) did not receive osteoporosis treatment after hip fracture. No significant difference was observed between the groups in terms of subsequent fracture numbers and fracture sites (p = 0.296 and 0.240, respectively). Mean 5-year survival rate was significantly higher in Group II (p = 0.002).

CONCLUSIONS

According to our results, elderly patients who underwent hemiarthroplasty for an osteoporotic hip fracture were not commonly screened or treated for osteoporosis. Our results demonstrated no significant difference between the groups in terms of subsequent fracture. However, we observed a significant high 5-year survival rate among patients who received the osteoporosis treatment.

Promoting mobility and healthy aging in men: a narrative review

Maintaining mobility is an important aspect of health and well-being in older men. This literature review describes several modifiable and nonmodifiable risk factors impacting bone, muscle, and joint health. Exercise and nutritional interventions may help to prevent the progressive deterioration in bones, muscles, and joints impacting mobility in later life. Limitations in mobility are increasingly recognized as a major public health problem due to an aging population and growing number of older individuals affected by disabling comorbidities. Despite increasing numbers and debilitating consequences, there are no guidelines providing recommendations on strategies to maintain mobility for healthy aging among older men. This narrative review aims to fill this literature gap. PubMed, Scopus, and Google Scholar databases were searched using predefined search terms. Primary studies, exploratory analyses, cross-sectional surveys, meta-analyses, evidence-based clinical reviews, and guidelines from nationally recognized societies focusing on mobility in older men and key elements including bone, muscle and joint health, and balance were selected. Several modifiable and nonmodifiable risk factors have been reported in the literature that impact bone, muscle, and joint health and predispose older men to falls and fractures. The most common conditions impacting bones, muscles, and joints are osteoporosis, sarcopenia, and osteoarthritis, respectively. In addition to being key contributors to disability in the elderly, these conditions are all associated with a higher mortality risk. Although more studies are required, current evidence supports the use of various nonpharmacological (mainly exercise and nutrition) and/or pharmacological treatment modalities to help prevent and/or reverse these conditions. Incorporating lifestyle interventions involving exercise and nutrition at a younger age can help prevent the age-related, progressive deterioration in bones, muscles, and joints that can reduce mobility in later life. Established barriers to physical activities (e.g., poor health, social isolation) in men are important to consider for optimizing outcomes.

History of cardiovascular disease and cardiovascular biomarkers are associated with 30-day mortality in patients with hip fracture

Hip fractures are associated with increased mortality and it is important to identify risk factors. This study demonstrates that preexisting cardiovascular disease as well as cardiovascular biomarkers that are associated with increased 30-day mortality. These findings can be used to identify high-risk patients who might benefit from specialized care.

INTRODUCTION

This study investigates the association between cardiovascular disease (CVD), cardiovascular biomarkers, and 30-day mortality following a hip fracture.

METHODS

The Danish National Patient Registry was used to investigate the association between CVD and mortality following hip fracture in a nationwide population-based cohort study. In a subset of the included patients (n = 355), blood samples were available from a local biobank. These samples were used for analyzing the association between specific biochemical markers and mortality. The primary outcome was 30-day mortality.

RESULTS

A total of 113,211 patients were included in the population-based cohort study. Among these, heart failure was present in 9.4%, ischemic heart disease in 15.9%, and ischemic stroke in 12.0%. Within 30 days after the hip fracture, 11,488 patients died, resulting in an overall 30-day mortality of 10.1%. The 30-day mortality was significantly increased in individuals with preexisting CVD with multivariably adjusted odds ratios of 1.69 (95% confidence interval, 1.60-1.78) for heart failure, 1.23 (1.17-1.29) for ischemic heart disease, and 1.06 (1.00-1.12) for ischemic stroke. In the local database including 355 patients, 41 (11.5%) died within 30 days. The multivariably adjusted odds ratio for 30-day mortality increased with increasing NT-proBNP (2.36 [1.53-3.64] per quartile) and decreased with increasing HDL cholesterol (0.58 [0.41-0.82] per quartile). On this basis, we established a model for predicting the probability of death based on the biochemical markers.

CONCLUSION

Preexisting CVD was associated with increased 30-day mortality after a hip fracture. Furthermore, high levels of NT-proBNP and low levels of HDL cholesterol were associated with increased 30-day mortality.

Patient and Perioperative Factors Influencing the Functional Outcomes and Mortality in Elderly Hip Fractures

This study aimed to evaluate the functional outcomes and mortality following hip fracture surgery in elderly patients, and to identify the associated risk factors. Between January 2016 and December 2017, 480 consecutive patients were finally included for data analyses. The Harris score and Barthel index were used to evaluate the hip function and ability to perform activities of daily living (ADL). Univariate and multivariate logistics regression analyses were performed to determine the independent risk factors for mortality, poor hip function or poor ability to perform ADL. The mortality rate was 15.6% (75/480). In the survivors, poor outcome developed in 133 (32.8%) patients and poor ADL was in 72 (17.8%) patients. The independent factors that influenced mortality were advanced age (p = 0.033), male gender (0.031), living in rural area (p < 0.001), self-reported diabetes (p = 0.005), tumor (p = 0.024), preoperative delay >7 days (p = 0.020), postoperative drainage use (p = 0.034), WBC > 10 × 10⁹/L (p = 0.005), reduced RBC (p = 0.011), PLT < 100 × 10⁹/L (p < 0.001), ALB < 35 g/L (p < 0.001) and CK > 200 U/L (p = 0.003). The independent factors that influenced the hip function were male gender (p = 0.009), WBC > 10 × 10⁹/L (p < 0.001), lower HBG (p = 0.005), and ALB < 35 g/L (p < 0.001). The independent factors that influenced the ability to perform ADL were diagnosis of trochanteric fracture (p = 0.048), preoperative delay > 7 days (p = 0.027), postoperative drainage use (p = 0.010), elevated WBC (p = 0.020), lower HGB (p < 0.001), PLT < 100 × 10⁹/L (p = 0.002), and ALB < 35 g/L (p < 0.001). Although most of risk factors were not modifiable, they aid in patient individual risk evaluation, risk stratification, and counseling patients or relatives.

Does Routine Anti-Osteoporosis Medication Lower the Risk of Fractures in Male Subjects? An Updated Systematic Review With Meta-Analysis of Clinical Trials

Background: Several epidemiological articles have reported the correlations between anti-osteoporosis medication and the risks of fractures in male and female subjects, but the specific efficacy of anti-osteoporosis medication for male subjects remains largely unexplored. Objective: The aim of this study was to evaluate the correlation between anti-osteoporosis medication and the risk of fracture in relation to low bone mass [including outcomes of osteoporosis, fracture, and bone mineral density (BMD) loss] in male subjects analyzed in studies within the updated literature. Methods: Randomized controlled trials (RCTs) that analyzed the effectiveness of a treating prescription for male subjects with osteoporosis (or low BMD) and that focused on the outcomes of fracture were included. Relevant studies from Embase, Web of Science, PubMed, and Chinese database of CNKI were retrieved from inception to January 30th, 2019. Two staff members carried out the eligibility assessment and data extraction. The discrepancies were settled by consultation with another researcher. We calculated the pooled relative risks (RRs) based on 95% confidence intervals (CIs). Results: Twenty-seven documents (28 studies) with 5,678 subjects were identified. For the category of bisphosphonates, significant results were observed in pooled analyses for decreased risk of the vertebral fracture domain (RR, 0.44 [95% CI, 0.31-0.62]), nonvertebral fracture domain (RR, 0.63 [95% CI, 0.46-0.87]), and clinical fracture domain (RR, 0.59 [95% CI, 0.48-0.72]) compared with those of controls. Participants with bisphosphonates had a 56% (95% CI = 38-69%) lower risk of vertebral fractures, 37% (95% CI = 13-54%) lower risk of nonvertebral fractures, and 41% (95% CI = 28-52%) lower risk of clinical fractures. Furthermore, meta-analyses also demonstrated a decreased risk of the vertebral fracture domain via treatment with risedronate (RR, 0.45 [95% CI, 0.28-0.72]) and alendronate (RR, 0.41 [95% CI, 0.23-0.74]), but not with calcitriol, calcitonin, denosumab, ibandronate, monofluorophosphate, strontium ranelate, teriparatide, or zoledronic acid, compared with that of controls. Conclusions: This systematic review confirms that bisphosphonates were connected with a decreased risk of vertebral fractures, nonvertebral fractures, and clinical fractures for male subjects with osteoporosis. Future research is needed to further elucidate the role of nonbisphosphonates in treating fractures of osteoporosis subjects.

Mortality after osteoporotic hip fracture: incidence, trends, and associated factors

BACKGROUND

It is known that mortality after hip fracture increases compared to the general population; the trend in mortality is a controversial issue. The objective of this study is to examine incidence, trends, and factors associated with mortality in patients with osteoporotic hip fractures.

METHODS

This is a retrospective cohort study that uses the Registry for Hospital Discharges of the National Health System of our hospital. Patients older than 45 having an osteoporotic hip fracture between 1999 and 2015 were identified. Demographic data and comorbidities were obtained. A survival analysis was performed (Cox regression and Kaplan-Meier). Incidence rate, standardized death rate (SDR), trend (Poisson regression), and risk (hazard ratio) were calculated.

RESULTS

During 1999-2015, in our hospital, there were a total of 3992 patients admitted due to osteoporotic hip fracture. Out of these 3992 patients, 3109 patients (77.9%) were women with an average age of 84.47 years (SD 8.45) and 803 (22.1%) were men with an average age of 81.64 years (SD 10.08). The cumulative incidence of mortality was 69.38%. The cumulative mortality rate for 12 months was 33%. The annual mortality was 144.9/1000 patients/year. The 1-year mortality rate increased significantly by 2% per year (IRR 1.020, CI95% 1.008-1.033). The median overall survival was 886 days (CI95% 836-951). The probability of mortality density for a period of 10 years following a hip fracture was 16% for women and 25% for men (first 90 days). The SDR was 8.3 (CI95% 7.98-8.59). Variables that showed statistically significant association with mortality were aged over 75, masculine, institutionalization, mild to severe liver disease, chronic kidney disease, COPD, dementia, heart failure, diabetes, the Charlson Index > 2 , presence of vision disorders and hearing impairment, incontinence, and Downton scale.

CONCLUSIONS

For the last 17 years, an increase of mortality for patients with hip fracture and a higher mortality rate in men than in women were observed. Institutionalization combined with comorbidities is associated with a higher mortality.

Analysis of the Morbidimortality of Patients with Peritrochanteric Fractures Surgically Treated with Proximal Femoral Intramedullary Rod

Objective  To analyze the morbimortality of patients with peritrochanteric fractures treated with intramedullary rod and its relationship to the length of hospital stay, the time until surgery and the comorbidities of the patients. Methods  An observational, analytical and retrospective study was carried out through the evaluation of the medical records of 74 patients who underwent surgical treatment of peritrochanteric fractures with intramedullary proximal femoral rods from 2011 to 2014 in a hospital unit. Results  The mean age at the moment of the fracture was 79.7 years, and the mean total hospitalization time was 16.7 days, with an average of 11.3 days until surgery and 5.4 days from surgery to discharge. The incidence of complications during hospitalization in the group aged ≥ 78.5 years was of 47.6%, while in the younger group it was of 19.4% ( p  = 0.013). The incidence of hospitalization complications in the group that underwent surgery more than 6 days after the fracture was significantly higher: 42.9% ( p  = 0.019). It was also observed that the incidence of complications during hospitalization was significantly associated with a surgical risk index ≥ 3 ( p  = 0.001) and diabetes mellitus ( p  = 0.001). Conclusion  Complications related to peritrochanteric fractures are significantly related with a high surgical risk index (grades 3 and 4), diabetes mellitus, age (> 78.5 years), and prolonged preoperative hospitalization (> 6 days).

Excess mortality following hip fracture in patients with diabetes according to age: a nationwide population-based cohort study of 154,047 hip fracture patients

OBJECTIVE

to test the hypothesis that excess mortality conferred by diabetes following hip fracture decreases with advancing age.

METHODS

a nationwide population-based cohort study including 154,047 patients who were admitted with a hip fracture in Denmark from 1996 to 2012. Information on hip fracture diagnosis, diabetes, other comorbidities, and the primary outcome all-cause mortality was collected using the national Danish health registries. The association between diabetes and all-cause mortality according to age was assessed using Cox proportional hazards regression in the age categories: <50, 50-59, 60-69, 70-79, 80-89 and ≥90 years.

RESULTS

during a median follow-up of 3 years (interquartile range: 1-6 years, 603,091 person-years) 114,990 died from any cause. In total, 8% (n = 12,158) of the patients had diabetes at baseline and had unadjusted, and age, sex and Charlson Comorbidity Index adjusted hazard ratios for all-cause mortality of 1.19 (95% confidence interval: 1.16-1.21) and 1.14 (1.12-1.17) as compared to patients without diabetes. The sex and Charlson Comorbidity Index adjusted hazard ratios according to age were 1.64 (1.34-2.02) for patients <50 years, 1.26 (1.12-1.40) for patients 50-59 years, 1.21 (1.13-1.29) for patients 60-69 years, 1.11 (1.07-1.16) for patients 70-79 years, 1.10 (1.07-1.14) for patients 80-89 years and 1.09 (1.02-1.16) for patients ≥90 years. There was a statistically significant interaction between diabetes and age (P < 0.001).

CONCLUSIONS

diabetes is associated with excess mortality following hip fracture across all ages, but the excess mortality decreases with advancing age.

Prognostic Role of Serum Albumin, Total Lymphocyte Count, and Mini Nutritional Assessment on Outcomes After Geriatric Hip Fracture Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Hip fracture is a significant health risk for older adults and malnutrition indicates hip fracture risk.

METHODS

We evaluated whether nutrition status could predict clinical outcomes and mortality after hip fracture surgery in older adults. MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched for studies published until July 1, 2018, in patients with serum albumin or total lymphocyte count (TLC) at admission, nutritional status by Mini Nutritional Assessment (MNA), and in-hospital follow-up. Data extracted were analyzed using random-effects or fixed-effects models.

RESULTS

Nineteen studies with 34,363 adults aged 74-85 years receiving hip fracture surgery were eligible for inclusion. Among these studies, 13 were screened for low albumin, 4 were evaluated for TLC, and 4 for nutritional status by MNA. Hypoalbuminemia was significantly associated with higher total mortality and higher risk of in-hospital death (both P < .001). Low TLC and MNA results "at risk of malnutrition" (hazard ratio, 1.67; 95% confidence interval = 1.28-2.18) and "malnourished" nutritional status (hazard ratio, 2.65; 95% CI = 1.81-3.88) also were significantly associated with higher total mortality (all P < .001).

CONCLUSION

Low serum albumin level is a sole indicator for increased risk of in-hospital death, postoperative complications, and total mortality after hip fracture surgery in older adults. Low TLC and malnutrition classified by MNA predict increased mortality. These indicators provide valuable prognostic information and routine use may be prudent.

Sex-related differences in patients undergoing surgery for shoulder instability: a Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort study

HYPOTHESIS AND BACKGROUND

Male sex has been identified as a risk factor for both primary shoulder dislocation and recurrent instability, and male patients more often undergo surgery for instability. Despite published discrepancies between sexes regarding the incidence and surgical rates of shoulder instability, there is little detail on the differences in presentation, mechanism of injury, and intraoperative findings. The purpose of this study was to explore these differences.

METHODS

Prospective baseline data from 1010 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed for sex-related differences using demographic characteristics, patient-reported outcomes, radiographic findings, intraoperative findings, and surgical procedures performed. Two-tailed t tests and χ² tests were used to compare the continuous and categorical data, respectively. Patients were categorized using the Frequency, Etiology, Direction, Severity (FEDS) classification system.

RESULTS

Male patients comprised 81.3% of the cohort. Male patients had a significantly higher rate of traumatic instability and rate of initial instability while playing sports, as well as significantly higher activity scores. Female patients had significantly lower preoperative American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability Index, 36-Item Health Survey, and Single Assessment Numeric Evaluation scores. No difference in the number of dislocations was found between male and female patients. Intraoperatively, male patients had higher rates of labral pathology and bone loss whereas female patients had higher rates of capsular laxity. These differences resulted in more Latarjet procedures for male patients and more soft-tissue procedures for female patients.

CONCLUSION

There are differences between male and female patients in the etiology of their instability, baseline patient-reported outcomes, and associated shoulder pathology, likely reflecting intrinsic and activity-related variation. These differences may influence clinical decision making and patient outcomes.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies

BACKGROUND

Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings.

OBJECTIVES

To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission.

MEASUREMENTS

Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy.

RESULTS

Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001).

CONCLUSIONS

This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

Chronic Kidney Disease Worsens Health Outcomes in Diabetic Patients After Hip Fracture Surgery: An Asian Nationwide Population-Based Cohort Study

There is an increased tendency for hip fractures in patients with chronic kidney disease (CKD). Although surgery is the mainstay of treatment for hip fractures, there is scant information on outcomes after hip fracture surgery in diabetic patients at different stages of CKD. In this population-based cohort study, we compared the surgical outcome, readmission, and mortality rates after osteosynthesis of hip fractures in diabetic patients with different stages of renal function. Diabetic patients who received primary osteosynthesis for hip fracture between January 1997 and December 2013 were enrolled. The primary outcomes were surgical outcomes, including infection and revision surgery. The secondary outcomes were all-cause readmission and mortality. This study included 44,065 patients; 11,954 had CKD (diabetic CKD group), 1662 patients were receiving dialysis (diabetic dialysis group), and 30,449 patients had no CKD (diabetic non-CKD group). We found that the diabetic dialysis group had a significantly higher risk of infection and revision surgery compared with diabetic non-CKD patients (HR = 1.52, 95% CI, 1.24 to 1.87; HR = 1.62, 95% CI, 1.33 to 1.97, respectively, both P < 0.001) and diabetic CKD patients (HR = 1.62, 95% CI, 1.32 to 1.99; HR = 1.48, 95% CI, 1.22 to 1.80, respectively, both P < 0.001). Diabetic CKD patients had a comparable risk of surgical complications including infection and revision as diabetic non-CKD patients. For readmission and mortality, the diabetic dialysis group had the highest risk among the three groups at all time-points (3 months after surgery, 1 year, and the last follow-up, all P < 0.001). Compared with the diabetic non-CKD group, the diabetic CKD group had an elevated risk of readmission and mortality at all time-points (all P < 0.001). In conclusion, CKD was associated with worse outcomes after hip fracture fixation surgery. Although at significantly higher risk of readmission and mortality, CKD patients still had a comparable risk of infection and revision to non-CKD patients. © 2019 American Society for Bone and Mineral Research.

In vitro injection of osteoporotic cadaveric femurs with a triphasic calcium-based implant confers immediate biomechanical integrity

Current pharmaceutical therapies can reduce hip fractures by up to 50%, but compliance to treatment is low and therapies take up to 18 months to reduce risk. Thus, alternative or complementary approaches to reduce the risk of hip fracture are needed. The AGN1 local osteo-enhancement procedure (LOEP) is one such alternative approach, as it is designed to locally replace bone lost due to osteoporosis and provide immediate biomechanical benefit. This in vitro study evaluated the initial biomechanical impact of this treatment on human cadaveric femurs. We obtained 45 pairs of cadaveric femurs from women aged 77.8 ± 8.8 years. One femur of each pair was treated, while the contralateral femur served as an untreated control. Treatment included debridement, irrigation/suction, and injection of a triphasic calcium-based implant (AGN1). Mechanical testing of the femora was performed in a sideways fall configuration 24 h after treatment. Of the 45 pairs, 4 had normal, 16 osteopenic, and 25 osteoporotic BMD T-scores. Altogether, treatment increased failure load on average by 20.5% (p < 0.0001). In the subset of osteoporotic femurs, treatment increased failure load by 26% and work to failure by 45% (p < 0.01 for both). Treatment did not significantly affect stiffness in any group. These findings provide evidence that local delivery of the triphasic calcium-based implant in the proximal femur is technically feasible and provides immediate biomechanical benefit. Our results provide strong rationale for additional studies investigating the utility of this approach for reducing the risk of hip fracture. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society.

Estonian hip fracture data from 2009 to 2017: high rates of non-operative management and high 1-year mortality

Background and purpose - There are no national guidelines for treatment of hip fractures in Estonia and no studies on management. We assessed treatment methods and mortality rates for hip fracture patients in Estonia. Patients and methods - We studied a population-based retrospective cohort using validated data from the Estonian Health Insurance Fund's database. The cohort included patients aged 50 and over with an index hip fracture diagnosis between January 1, 2009 and September 30, 2017. The study generated descriptive statistics of hip fracture management methods and calculated in-hospital, 1-, 3, 6-, and 12-month unadjusted all-cause mortality rates. [CrossRef] Results - 91% (number of hips: 11,628/12,731) of the original data were included after data validation. Median patient age was 81 years, 83 years for women and 74 years for men. 28% were men. Treatment methods were: total hip arthroplasty 7%; hemiarthroplasty 25%; screws 6%; sliding hip screw 25%; intramedullary nail 27%; and nonoperative management 10%. Unadjusted all-cause mortality rates for in-hospital, 1, 3, 6, and 12 months were: 3%, 9%, 18%, 24%, and 31% respectively. The 12-month mortality rate for nonoperative management was 58%. [CrossRef] Interpretation - High rates of nonoperative management and overall high 1-year mortality rates after an index hip fracture indicate the need to review exclusion criteria for surgery and subacute care in Estonia.

Comorbidity and mortality after hip fracture in nineteen thousand six hundred and eighty two patients aged eighteen to sixty five years in Denmark from 1996 to 2012

PURPOSE

This nationwide study assessed associations between comorbidity and mortality after hip fracture in young and middle-aged patients.

METHODS

Data on 19,682 patients aged 18 to 65 years were extracted from Danish registries out of 154,047 patients who experienced a hip fracture between 1996 and 2012. Mortality and comorbidity were assessed using information on vital status, hospital admissions, and prescriptions.

RESULTS

Of the 19,682 patients 17,722 (90.0%) were middle-aged (40-65 years) and 1960 (10.0%) were young (18-39 years). The 30-day mortality rates were 3.2% (n = 570) and 1.6% (n = 32), respectively. Indicators of multi-trauma (hazard ratio (HR), 3.5 95% confidence interval (CI) [1.6-7.8], n = 2056) and having diabetes (HR, 4.4 [1.2-11.3], n = 59) and heart disease (HR, 4.4[1.3-14.8], n = 57) increased 30-day mortality in the young patients, while having cancer (HR, 5.0 [4.2-5.9], n = 1958) increased 30-day mortality in the middle-aged patients.

CONCLUSION

Heart disease and diabetes were associated with high mortality in the young patients while having cancer was associated with high mortality in the middle-aged patients.

Adults with polio are at risk of hip fracture from middle age: A nationwide population-based cohort study

BACKGROUND

Having motor impairment since childhood and being at risk of osteoporosis and falls, adults with polio would be more likely to suffer a hip fracture (HF) and may experience different epidemiological characteristics from the general population.

OBJECTIVE

To estimate the risk and incidence of HF in adults with polio.

DESIGN

Using a national database, we conducted a population-based cohort study. We identified patients with polio using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 138. For each patient with polio, we randomly selected five age- and sex-matched control subjects. Those subjects aged <40 years were excluded. We analyzed participants aged 40˜64 years (middle-aged) and subjects aged ≥65 years (elderly) separately and recognized subjects who had an HF (ICD-9-CM code, 820) only when they received hospitalization to care for the illness from January 1, 2003 to December 31, 2008.

RESULTS

We identified 403 adults with polio (mean age ± standard deviation, 47.2 ± 8.6 years). Compared to the controls, patients with polio had a higher incidence of HF (all, 4.1 vs. 1.1/1000 person-years, p = 0.002; middle-aged, 2.3 vs. 0.3/1000 person-years, p < 0.001; male, 6.2 vs. 0.9/1000 person-years, p < 0.001); had a younger mean age (±standard deviation) of fracturing a hip (61.0±14.9 vs. 74.4±9.3 years, p = 0.015); had a lower cumulative HF-free probability (±standard error) before the age of 65 years (0.970±0.017 vs. 0.988±0.007, p<0.001) and throughout the study duration (0.415 ± 0.296 vs. 0.682 ± 0.158, p<0.001); and had a higher risk of HF, yielding an adjusted hazard ratio (95% confidence interval) of 3.58 (1.45˜8.79, p = 0.006). Patients with polio aged >48.2 years were likely to experience an HF.

CONCLUSIONS

Adults with polio are at risk of HF. A customized HF prevention program is important for people with polio. The program should be started early in middle-age and should include men.

Hip fracture rates and time trends in use of anti-osteoporosis medications in Denmark for the period 2005 to 2015: Missed opportunities in fracture prevention

BACKGROUND

Declining use of bisphosphonates (BP) in the United States and Europe may lead to a widening of the treatment gap for osteoporosis and an increase in fracture rates. However, a shift to non-bisphosphonates and to hospital administered i.v. BPs could lead to overestimation of the treatment gap if analyses are based exclusively on BP prescriptions. When a healthcare system successfully narrows the treatment gap by making appropriate use of anti-osteoporosis drugs, we would expect to see declining rates of osteoporotic fractures with much of the decrease being statistically attributable to medication uptake. We analysed a best-case scenario where all use of BPs, denosumab, raloxifene and PTH analogues - including the oncology area - was contrasted with the trend in hip fracture rates. This scenario also considered users of raloxifene and teriparatide as covered by osteoporosis drugs though the primary RCT for raloxifene showed no risk reduction in nonvertebral fractures and the RCT for teriparatide risk reductions for non-vertebral fractures but not hip fracture specifically. Sensitivity analyses were also done.

METHODS

We used aggregate statistics on hip fracture events and total use of the above medications estimating the number of persons potentially covered. The reduction in hip fracture rates attributable to treatment was estimated using the absolute risk reduction (ARR) found in real-world users of oral alendronate in Denmark with the ARR in the FIT primary prevention arm as an alternative scenario.

RESULTS

A plateau in use of osteoporosis medications occurred in 2014. Between 2005 and 2015, hip fracture rates declined by 30%. However, only up to 20% of the observed reduction in hip fracture rates was statistically attributable to treatment even in a best-case scenario. Sensitivity analyses where raloxifene and teriparatide were excluded did not impact on this finding.

DISCUSSION

Anti-osteoporosis treatment in Denmark reached a plateau in 2014 even in a best-case scenario where all dispensations were assumed to be for osteoporosis. Future studies may be able to distinguish between the oncology area and the osteoporosis indication as well as provide a delineation of age and gender demographics among users of hospital administered osteoporosis medications. About 80% of the decline in hip fracture rates appears to be due to factors other than osteoporosis medication. The plateau in use of osteoporosis treatment at a level that is too low to make a meaningful impact on societal fracture burden is problematic given the predicted increased age-specific hip fracture rates.

Higher Mortality in Men Compared with Women following Distal Radius Fracture in Population Aged 50 Years or Above: Are Common Distal Radius Fracture Classifications Useful in Predicting Mortality?

Introduction

Distal radius fractures (DRF) are one of the most common fractures with growing incidence in developed countries and are a reliable predictor of another osteoporotic fracture. Data concerning DRF mortality are conflicting and vague. Usefulness of common DRF classification systems in predicting mortality is unexplored.

Methods

We identified all patients hospitalized between January 1^st 2008 and May 30^th 2015 with isolated distal radius fracture, aged 50 y/o or above, in a 1^st level trauma center in Poland. Fractures were evaluated according to AO, Frykman, and Fernandez classifications. Mortality ratios and long-term survival analysis with Kaplan-Meier estimator and log-rank tests with univariate and multivariate Cox proportional hazards model were used.

Results

We enrolled 1308 consecutive patients. The average age of the entire cohort was 72.5 ± 12 years. The study group consisted of 256 men (19.6%) with mean age 66 ± 12 y/o and 1052 women (80.4%) with mean age 74 ± 12 y/o. Men were statistically younger at the time of the fracture than women (p<0.0001). After 1-year follow-up the overall study group mortality ratio was 4.5%, being 2.2-fold higher in men compared to women. In long-term survival analysis, excess men mortality remained significant. Factors associated with higher mortality at any point of the study were age (HR: 1.08, 95%CI: 1.07-1.10, p<0.000001), male sex (HR: 1.92, 95%CI: 1.34-2.77; p<0.001), AO type A (HR: 1.64 95%CI 1.19-2.25, p<0.01), and Frykman type I (HR: 2.12 95%CI: 1.36-3.29, p<0.001).

Conclusion

Distal radius fractures are connected with premature mortality. Men have higher mortality compared with women following distal radius fracture in population aged 50 years or above. Simple extra articular fractures classified as AO type A or Frykman type I may be predictors of higher mortality in DRF cohort.

The association of female sex with application of evidence-based practice recommendations for perioperative care in hip fracture surgery

BACKGROUND

Sex and gender inequality is prevalent in health care, and affects receipt of health care services and outcomes. Our objective was to measure the association between sex and receipt of evidence-based perioperative care for hip fracture in Ontario.

METHODS

This was a population-based retrospective cross-sectional analysis. We identified all Ontario residents aged 66 years and older who had hip fracture surgery between 2014 and 2016. After protocol registration, we measured the adjusted association between female sex and perioperative geriatric care (primary outcome), anesthesia consultations, regional analgesia and neuraxial anesthesia (secondary outcomes) using multilevel multivariable adjusted logistic regression. Pre-specified sensitivity analyses were also performed.

RESULTS

We identified 22 661 patients who had hip fracture surgery; 16 162 (71.3%) were women. Women were less likely to receive perioperative geriatric care (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.72 to 0.88) and anesthesia consultations (adjusted OR 0.89, 95% CI 0.80 to 0.98); women were more likely to have timely surgery (adjusted OR 1.26, 95% CI 1.17 to 1.36). Receipt of neuraxial anesthesia (adjusted OR 0.98, 95% CI 0.93 to 1.04) and regional analgesia (adjusted OR 1.00, 95% CI 0.94 to 1.07) were not different between sexes.

INTERPRETATION

More than 2 out of 3 patients who had hip fracture surgery were women; however, women were less likely to receive perioperative geriatric care and anesthesia consultations. Given the effectiveness of these interventions for improving outcomes, population-level hip fracture outcomes may be improved by decreasing sex-based disparities in application of evidence-based recommended perioperative care. Protocol registration: ClinicalTrials.gov, no. NCT03422497.

Multi-state analysis of hemi- and total hip arthroplasty for hip fractures in the Swedish population-Results from a Swedish national database study of 38,912 patients

INTRODUCTION

Hip fractures are a common problem of the elderly population with significant mortality and morbidity. The choice between total hip arthroplasty (THA) and hemiarthroplasty depends on multiple factors including comorbidity. The Swedish Hip Arthroplasty Register (SHAR) provides a unique opportunity to study mortality and revision rates in this population. Linkage with government databases allow for in-depth research into the factors that influence risk of revision surgery and death in the hip fracture patient.

PATIENTS AND METHODS

Data was linked between SHAR, Statistics Sweden and the National Board of Health and Welfare. Data was collected on 38,912 patients who received a fracture-related hip arthroplasty between 2005 and 2012. A multistate analysis was performed and three states were identified: primary hip surgery and alive (state 1), revision after primary hip surgery (state 2) and death (state 3). These were marking points in the longitudinal outcome study.

RESULTS

38,912 patients who received an arthroplasty for an acute hip fracture were included. By the end of the study period 1309 (3.4%) of these patients underwent a revision and 17,365 (45.1%) patients died. Patients with THA had a reduced risk of death from primary operation compared to hemiarthroplasty (HR = 0.49) and a decreased revision risk (HR = 0.69). Female patients had a statistically significant reduced mortality (HR = 0.6) compared to men. There was no statistically significant difference in risk of revision surgery between direct lateral and posterior approach.

CONCLUSION

We identified an influence of type of surgery, sex, age and Elixhauser Comorbidity Index (ECI) on risk of revision and mortality. Males, greater comorbidity burden and older patients had higher mortality risks. The posterior approach did not have a significant influence on revision risk. Further research could include all patients who had reoperation(s) to further strengthen our findings. Patients who had a THA had lower revision rate and mortality. The latter is likely due to selection.

Low predictive power of comorbidity indices identified for mortality after acute arthroplasty surgery undertaken for femoral neck fracture

Aims

Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture.

Patients and Methods

We analyzed data from 42 354 patients from the Swedish Hip Arthroplasty Register between 2005 and 2012. Only the first operated hip was included for patients with bilateral arthroplasty. We obtained comorbidity data by linkage from the Swedish National Patient Register, as well as death dates from the national population register. We used univariable Cox regression models to predict mortality based on the comorbidity indices, as well as multivariable regression with age and gender. Predictive power was evaluated by a concordance index, ranging from 0.5 to 1 (with the higher value being the better predictive power). A concordance index less than 0.7 was considered poor. We used bootstrapping for internal validation of the results.

Results

The predictive power of mortality was poor for both the Elixhauser and Charlson comorbidity indices (concordance indices less than 0.7). The Charlson Comorbidity Index was superior to Elixhauser, and a model with age and gender was superior to both indices.

Conclusion

Preoperative comorbidity from administrative data did not predict mortality for patients with a hip fracture treated by arthroplasty. This was true even if association on group level existed.

Efficacy, cost, and aspects to take into account in the treatment of osteoporosis in the elderly

Age is one of the principal risk factors for development of frailty fractures. Age pyramids show a population that is becoming increasingly more elderly, with an increasing incidence of fractures, and the forecasts for the future are truly alarming. Adequate handling of these patients who are especially at risk, at both the preventive and care levels, with a well-defined orthogeriatric model is necessary to respond to this clinical challenge. The objective of this review is to analyze the efficacy of the different strategies for the handling of geriatric patients with fracture risk.

Charlson Comorbidity Index Predicts 5-Year Survivorship of Surgically Treated Hip Fracture Patients

Introduction:

This study aims to assess the correlation of the age-adjusted Charlson comorbidity index (ACCI) with 5-year mortality in a surgically treated hip fracture population.

Materials and Methods:

A retrospective analysis was performed on 1057 patients aged 60 years and above who underwent surgery for hip fracture with a minimum of 5-year follow-up (92.2% 5-year follow-up rate) in a tertiary hospital. Manual review of patients’ electronic hospital records was performed to record demographic data, comorbidities, and length of stay. Mortality data were extracted from the hospital’s electronic medical records and corroborated with the National Electronic Health Record.

Results:

Of the 1057 patients, 283 (26.8%) were male. The majority of patients were 80 years of age and above (42.5%), with the oldest patient operated on age 102 with a mean age of 77.8 (8.6) years. Four hundred eighteen (39.5%) patients sustained extracapsular intertrochanteric fractures. The mean follow-up duration was 8 years and 3 days with an overall survivorship of 37.2%. A multiple regression model constructed with ACCI, age, gender, and fracture pattern demonstrated satisfactory predictive ability with a concordance statistic of 0.68. Patients with a higher ACCI category (≥6) had an increased 5-year mortality rate (41.8%) with an odds ratio of 13.6 (6.7-31.8, P < .001) compared to those with an ACCI category of 3 and below (89.3%).

Discussion:

The study demonstrates that ACCI correlated with 5-year mortality after surgical treatment of hip fracture. This information is pertinent in the counseling of patients with regard to their midterm survival following hip fracture surgery and may inform policy makers of the varied midterm survival rates in patients with differing ACCI scores and educate the allocation of health-care resources.

Conclusion:

The ACCI correlates with 5-year mortality after surgical treatment of hip fracture.

Fall episodes in elderly patients with asthma and COPD - A pilot study

OBJECTIVE

Evidence of an increased risk of falls in patients with chronic obstructive pulmonary disease (COPD) exists; however, this has not been studied in elderly asthmatic patients. The aim of the study was to determine the incidence of falls in elderly patients who were diagnosed with bronchial asthma compared to subjects with COPD.

METHODS

A 12-month prospective observational study in elderly outpatients with diagnosis of either asthma or COPD was conducted. All of the participants were monitored on the following parameters: falls, comorbidities, drug therapy, and The Berg Balance Scale. The rate of falls was shown as an incidence ratio. Cluster analysis for subgroups with similar features was performed on all patients included in the study. Two clusters of frequent fallers were determined.

RESULTS

The fall incidence rate in falls per person per year was 1.41 (95% CI: 0.86-1.96) in asthmatic patients and 1.49 (95% CI: 1.05-2.11) in the COPD group. Frequent fallers were more prevalent in the COPD group, with 32% in this group compared to 28% in the groups of patients with asthma. In cluster analysis, frequent fallers were grouped into two models characterized by polytherapy, depression symptoms, hospitalizations, coronary disease, dementia, and diagnosis of COPD or asthma.

CONCLUSION

Elderly asthmatic patients presented a high rate of falls, which is comparable to that of patients with COPD.

Association between time to surgery and 90-day mortality after hip fracture: A retrospective cohort study of 1734 cases

BACKGROUND

It remains unclear whether early surgical intervention can reduce mortality after surgery in hip fracture patients. The aim of this study was to investigate the association between time from injury to surgery and mortality rate within 90 days after hip fracture surgery.

METHODS

We retrospectively identified 1827 patients who underwent hip fracture surgery in a tertiary care center in Japan between April 2007 and March 2017. After applying exclusion criteria (patients with spontaneous fracture, multiple fractures, revision surgery, total hip arthroplasty, or a refusal to participate), 1734 patients were included. We extracted data concerning patients' age, race, sex, operative procedure, American Society of Anesthesiologists (ASA) score, days from injury to surgery (injury-surgery days), and days from admission to surgery (admission-surgery days), which could affect 90-day mortality after surgery. Variables associated with 90-day mortality were determined using multivariate logistic regression analysis.

RESULTS

The 90-day postoperative mortality rate was 3.5% (60 of 1734). Multivariable analysis showed that injury-surgery days were not associated with 90-day mortality (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.80 to 1.05; P = 0.19), and that older age (OR, 1.06; 95% CI, 1.02 to 1.10; P = 0.005), male sex (OR, 3.62; 95% CI, 1.86 to 7.03; P < 0.001) and high ASA score (OR, 2.10; 95% CI, 1.06 to 4.18; P = 0.034) significantly increased 90-day mortality. In addition, admission-surgery days were not associated with 90-day mortality (OR, 0.95; 95% CI, 0.83 to 1.09; P = 0.45).

CONCLUSION

Our results demonstrated that time from injury to surgery was not associated with mortality within 90 days after surgery after adjusting for age, sex, operative procedure, and ASA score.

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register

BACKGROUND

Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study.

METHODS

A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register.

RESULTS

A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients' accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h.

CONCLUSION

Safety measures to prevent fall at elderly patient's accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.

Cardiovascular biomarkers and risk of low-energy fractures among middle-aged men and women-A population-based study

BACKGROUND

Low-energy fractures are a growing health challenge as their incidence increases with advancing age. As cardiovascular instability may be associated with higher likelihood of traumatic falls, we aimed to investigate the associations between four cardiovascular biomarkers and the risk of low-energy fractures in a middle-aged population.

METHODS

A total of 5291 individuals from the prospective Malmö Diet and Cancer (MDC) study (mean age, 57 years; 59% women) with data on baseline levels of four cardiovascular biomarkers: mid-regional-fragment of pro-adrenomedullin-peptide (MR-pro-ADM), mid-regional-fragment of pro-atrial-natriuretic-peptide (MR-proANP), N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-terminal-pro-arginine-vasopressin (CT-pro-AVP/Copeptin) were included. The associations between biomarker levels and first incident low-energy fracture were tested in Cox proportional-hazard models, taking potential interactions and traditional risk factors into account.

RESULTS

Participants were followed for a median time of 21.0 years, during which 1002 subjects (19%) experienced at least one low-energy fracture. Subjects with incident fracture were older, more likely to be women, had lower BMI and higher prevalence of previous fractures. Among biomarkers, there was a significant interaction between gender and MR-pro-ADM on the risk of fracture (p = 0.002). MR-pro-ADM predicted fractures in men only (hazard ratio, 1.23; 95% CI 1.09-1.40; p = 0.001), whereas there was no association among women. Levels of MR-pro-ANP, NT-pro-BNP and CT-pro-AVP did not predict fractures.

CONCLUSIONS

Higher circulating levels of MR-pro-ADM predict low-energy fractures among middle-aged-men, whereas levels of MR-pro-ANP, NT-pro-BNP and CT-pro-AVP are not associated with increased fracture risk. Further controlled studies should test the hypothesis whether MR-pro-ADM may improve prediction of bone fractures.

A 10-Year Retrospective Study of 490 Hip Fracture Patients: Reoperations, Direct Medical Costs, and Survival

BACKGROUND AND AIMS

Reoperations after operative treatment of hip fracture patients may be associated with higher costs and inferior survival. We examined the acute hospital costs, long-term reoperation rates, and survival of patients with a new hip fracture.

MATERIALS AND METHODS

A total of 490 consecutive new hip fracture patients treated at a single center between 31 December 2004 and 6 December 2006 were analyzed retrospectively. Fractures were classified according to Garden and AO. All medical records were checked manually. The costs of reoperations were calculated using the diagnosis-related groups (DRG)-based prices. Survival analysis was performed using the life-table method. The follow-up time was 10 years.

RESULTS

In all, 70/490 patients (14.3%) needed reoperations. Of all reoperations, 34.2% were performed during the first month and 72.9% within 1 year after the primary operation. The hemiarthroplasty dislocation rate was 8.5%, and mechanical failures of osteosynthesis occurred in 6.2%. Alcohol abuse was associated with a heightened risk of reoperation. The mean direct costs of primary fracture care were lower than the mean costs of reoperations (€7500 vs €9800). The mortality rate at 10 years was 79.8% among non-reoperated patients and 62.9% among reoperated patients.

CONCLUSIONS

According to our hypothesis, the cost per patient of reoperation in acute care was 31% higher than the corresponding cost of a primary operation. Reoperations increased the overall immediate costs of index fractures by nearly 20%. One-third of all reoperations were performed during the first month and almost 75% within 1 year after the primary operation.

A Phase III Randomized Placebo-Controlled Trial to Evaluate Efficacy and Safety of Romosozumab in Men With Osteoporosis

CONTEXT

Globally, one in five men aged >50 years is predicted to experience an osteoporotic fracture. Because of the treatment gap in osteoporosis and the paucity of bone-forming agents for men, new osteoporosis treatments are needed.

OBJECTIVE

To evaluate the safety and efficacy of romosozumab in men with osteoporosis.

DESIGN

Phase III randomized BRIDGE study (placebo-controlled double-blind study evaluating the efficacy and safety of romosozumab in treating men with osteoporosis; ClinicalTrials.gov identifier, NCT02186171) for 12 months.

SETTING

Thirty-one centers in Europe, Latin America, Japan, and North America.

PATIENTS

Men aged 55 to 90 years with a baseline bone mineral density (BMD) T-score at the lumbar spine (LS), total hip (TH), or femoral neck of ≤-2.5 or ≤-1.5 with a history of a fragility nonvertebral or vertebral fracture.

INTERVENTIONS

The subjects were randomized 2:1 to receive romosozumab 210 mg subcutaneously monthly or placebo for 12 months.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was percentage change from baseline in LS BMD at month 12.

RESULTS

In 245 subjects (163 romosozumab, 82 placebo), at month 12, the mean percentage change from baseline in the LS and TH BMD was significantly greater for the romosozumab group than for the placebo group (LS, 12.1% vs 1.2%; TH, 2.5% vs -0.5%; P < 0.001). Adverse events and serious adverse events were balanced between the two groups, with a numerical imbalance in the positively adjudicated cardiovascular serious adverse events [romosozumab, 8 (4.9%) vs placebo, 2 (2.5%)].

CONCLUSIONS

Treatment with romosozumab for 12 months increased the spine and hip BMD compared with placebo and was well tolerated in men with osteoporosis.

The independent patient factors that affect length of stay following hip fractures

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

Treatment of Osteoporosis: Unmet Needs and Emerging Solutions

Efficient therapies are available for the treatment of osteoporosis, however, there are still unmet needs. Anti-resorptive therapies only increase bone mineral density to a certain extent and reduce the risk of non-vertebral fractures by 20%, only one anabolic option is available in most parts of the world-the effect of which levels off over time, and the evidence for combination therapy targeting both resorption and formation is limited. In addition, identification and treatment of patients with high and imminent fracture risk following a recent fracture and long-term adherence to treatment are 2 other very prominent challenges to the management of osteoporosis. The current review will focus on emerging osteoporosis treatments and optimized use of the existing treatments that may help overcome the currently unmet needs in the management of osteoporosis.

Poor nutritional status but not cognitive or functional impairment per se independently predict 1 year mortality in elderly patients with hip-fracture

BACKGROUND & AIMS

Hip fractures are strongly associated with mortality in the elderly. Studies investigating predisposing factors have suggested a negative impact of poor nutritional, cognitive and functional status on patient survival, however their independent prognostic impact as well as their interactions remain undefined. This study aimed to determine whether poor nutritional status independently predicts 1 year post-fracture mortality after adjusting for cognitive and functional status and for other clinically relevant covariates.

METHODS

1211 surgically treated hip fracture elderly (age ≥ 65) patients consecutively admitted to the Orthopaedic Surgery Unit of the "Azienda Sanitaria Universitaria Integrata Trieste" (ASUITs), Cattinara Hospital, Trieste, Italy and managed by a dedicated orthogeriatric team. Pre-admission nutritional status was evaluated by Mini Nutritional Assessment (MNA) questionnaire, cognitive status by Short Portable Mental Status Questionnaire (SPMSQ) and functional status by Activity of Daily Living (ADL) questionnaire. All other clinical data, including comorbidities, type of surgery, post-operative complications (delirium, deep vein thrombosis, cardiovascular complications, infections, need for blood transfusions) were obtained by hospital clinical records and by mortality registry.

RESULTS

Poor nutritional status (defined as MNA ≤23.5), increased cognitive and functional impairment were all associated with 3-, 6- and 12 month mortality (p < 0.001). Both cognitive and functional impairment were associated with poor nutritional status (p < 0.001). Logistic regression analysis demonstrated that the association between nutritional status and 3-, 6- and 12- month mortality was independent of age, gender, comorbidities, type of surgery and post-operative complications as well as of cognitive and functional impairment (p < 0.001). In contrast, the associations between mortality and cognitive and functional impairment were independent (p < 0.001) of demographic (age, gender) and clinical covariates but not of malnutrition. Kaplan-Meier analysis showed a lower mean survival time (p < 0.001) in patients with poor nutritional status compared with those well-nourished.

CONCLUSIONS

In hip fracture elderly patients, poor nutritional status strongly predicts 1 year mortality, independently of demographic, functional, cognitive and clinical risk factors. The negative prognostic impact of functional and cognitive impairment on mortality is mediated by their association with poor nutritional status.

Death and Postoperative Complications After Hip Fracture Repair: Dialysis Effect

Introduction

It is unknown whether patients receiving dialysis have a higher morbidity and mortality risk after hip fracture repair conferred by their kidney failure or by the high comorbidity burden often present.

Methods

We examined associations of dialysis dependency with postoperative complications, death, and readmission in a matched cohort study of U.S. patients undergoing hip fracture repair, from January 2010 to December 2013, in the American College of Surgeons National Surgical Quality Improvement Program. Matching included sex, age, race, diabetes mellitus, operation year, primary surgery type, and anesthesia technique.

Results

Among 22,621 patients, 377 dialysis-dependent patients were matched to 1508 nondialysis patients. Median age was 78 years (interquartile range = 68−85) years, 56% were men, 70% were white, 43% had diabetes, and 47% underwent fracture fixation under mostly (80%) general anesthesia. Dialysis-dependent patients had higher physical status classification, had more heart failure and hypoalbuminemia, and were less often smokers. After adjustment, a greater risk of prolonged postoperative stays beyond 7 days (odds ratio [OR] = 1.43, 95% confidence interval [CI] = 1.09−1.89), higher in-hospital mortality (OR = 3.13, CI = 1.72−5.7), and 30-day death (OR = 2.29, CI = 1.51−3.48) but not 30-day readmission (P = 0.09) was observed with dialysis dependency. Adjusted analyses in the original cohort (n = 22,621) were similar: the dialysis group had greater risk of prolonged postoperative stay (OR = 1.77, CI = 1.42−2.21), in-hospital mortality (OR = 2.65, CI = 1.74−4.05), and 30-day death (OR = 2.03, CI = 1.48−2.80) and 30-day readmission (OR = 1.62, CI = 1.66−2.26).

Conclusion

Dialysis dependency is associated with an increased risk of death and postoperative complications after hip fracture repair. These findings have implications for case-mix adjustment and quality metrics.