Survival after hip fracture

Dietary carotenoid intake and fracture risk based on NHANES 2013-2018 data: a propensity score matching

INTRODUCTION

Several epidemiological studies have reported inconsistent findings on the association between carotenoid intake and fracture risk. This study aimed to determine the association between individual carotenoid intake and fracture risk.

METHODS

A cross-sectional study based on data from the National Health and Nutrition Examination Survey (NHANES), 2013-2018. This study identified elderly individuals with valid and complete data on carotenoid intake and fracture risk. The average dietary intakes of α-carotene, β-carotene, β-cryptoxanthin, lycopene, and lutein + zeaxanthin was taken based on the two 24-hour recall interviews. Matching was done based on age, sex, and body mass index (BMI). Logistic regression models were used to test the associations between carotenoids and fracture risk. All analyses were performed by using R (version 3.4.3; R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

A total of 5491 (1140 cases and 4351 control) subjects were included in this study. The average age of the subjects was 55.62 ± 14.84 years old. In the adjusted model, the risk of osteoporotic fracture was decreased by 6.2% (odd ratio (OR): 0.938; 95% confidence interval (CI): 0.699 to 0.989) and 1.4% (OR 0.986; 95% CI: 0.975 to 0.997) for dietary intake of beta-carotene and lycopene, respectively.

CONCLUSIONS

Dietary intakes of beta-carotene and lycopene have significantly reduced the risk of osteoporotic fracture among the elderly population in the United States of America.

Cost-Effectiveness of Artificial Intelligence-Based Opportunistic Compression Fracture Screening of Existing Radiographs

PURPOSE

Osteoporotic vertebral compression fractures (OVCFs) are a highly prevalent source of morbidity and mortality, and preventive treatment has been demonstrated to be both effective and cost effective. To take advantage of the information available on existing chest and abdominal radiographs, the authors' study group has developed software to access these radiographs for OVCFs with high sensitivity and specificity using an established artificial intelligence deep learning algorithm. The aim of this analysis was to assess the potential cost-effectiveness of implementing this software.

METHODS

A deterministic expected-value cost-utility model was created, combining a tree model and a Markov model, to compare the strategies of opportunistic screening for OVCFs against usual care. Total costs and total quality-adjusted life-years were calculated for each strategy. Screening and treatment costs were considered from a limited societal perspective, at 2022 prices.

RESULTS

In the base case, assuming a cost of software implantation of $10 per patient screened, the screening strategy dominated the nonscreening strategy: it resulted in lower cost and increased quality-adjusted life-years. The lower cost was due primarily to the decreased costs associated with fracture treatment and decreased probability of requiring long-term care in patients who received preventive treatment. The screening strategy was dominant up to a cost of $46 per patient screened.

CONCLUSIONS

Artificial intelligence-based opportunistic screening for OVCFs on existing radiographs can be cost effective from a societal perspective.

Predictors of mortality over time in geriatric patients with hip fracture

Objectives

The aim of this study was to determine the variations in effect for predictors of mortality over time and risk of in-hospital complications in geriatric patients with a hip fracture. Many studies have investigated risk factors of short-term and long-term mortality separately. In current literature, little is known about the variations in effect of risk factors over time and no comparison with the general population is made.

Methods

All patients with a hip fracture aged 70 years or older admitted to our hospital between January 1, 2016, and May 1, 2018, were included in this retrospective study. Patients who had undergone total hip arthroplasty (THA) were not included. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications. Kaplan-Meier (KM) curves for risk factors were generated to visualize survival over time. Data were compared with data extracted from the national health records.

Results

A total of 685 geriatric patients with hip fractures were included with a 1-year mortality of 27%. The adjusted odds ratios (AOR) found differed over time. Five risk factors for mortality were investigated in this study using KM curves: age, prefracture living situation, dementia, sex, and ASA classification.

Conclusions

Over time, the variation of 5 risk factors for mortality were visualized in geriatric patients with a hip fracture: age, prefracture living situation, dementia, sex, and ASA classification. An elevated risk of mortality was discovered compared with the general population. The variation in effect observed in risk factors plays a vital role in prognosis. This insight will help guide accurate medical decision-making for a tailored treatment plan for geriatric patients with a hip fracture.

Matters We Metric Vs. Metrics that Matter

Introduction

Geriatric fracture is a pressing global health issue, marked by elevated mortality and morbidity rates and escalating health care costs. The evolving health care system from fee-for-service to quality-based reimbursement has led to externally driven reward and reimbursement systems that may not account for the complexity of caring for older adults with fracture.

Significance

The aim of this review is to highlight the need for a shift towards meaningful metrics that impact geriatric fracture care and to issue a call to action for all medical societies to advocate for national reimbursement and ranking systems that focus on metrics that truly matter.

Results

Traditional metrics, while easier to capture, may not necessarily represent high quality care and may even have unintentional adverse consequences. For example, the focus on reducing length of stay may lead to older patients being discharged too early, without adequately addressing pain, constipation, or delirium. In addition, a focus on mortality may miss the opportunity to deliver compassionate end-of-life care. Existing geriatric fracture care metrics have expanded beyond traditional metrics to include assessment by geriatricians, fracture prevention, and delirium assessments. However, there is a need to further consider and develop patient-focused metrics. The Age-Friendly Health Initiative (4 Ms), which includes Mobility, Medication, Mentation, and what Matters is an evidence-based framework for assessing and acting on critical issues in the care of older adults. Additional metrics that should be considered include an assessment of nutrition and secondary fracture prevention.

Conclusion

In the realm of geriatric fracture care, the metrics currently employed often revolve around adherence to established guidelines and are heavily influenced by financial considerations. It is crucial to shift the paradigm towards metrics that truly matter for geriatric fracture patients, recognizing the multifaceted nature of their care and the profound impact these fractures have on their lives.

Cementless Hemiarthroplasty for a Femoral Neck Fracture in a 93-Year-Old Female Patient: A Case Report

Displaced femoral neck fractures are prevalent in the elderly, necessitating surgical intervention to restore function and mobility. Hemiarthroplasty, available in both cemented and cementless forms, is a common treatment. While cemented hemiarthroplasty is traditionally preferred, cementless options are gaining attention for their potential advantages, including reduced operative time, decreased blood loss, and preservation of bone stock for future revisions. This case report details the successful application of cementless hemiarthroplasty in a 93-year-old female with a displaced femoral neck fracture, underscoring its feasibility and potential benefits in the very elderly. The patient, with multiple comorbidities including hypertension, cerebrovascular accident, osteoarthritis, dementia, chronic kidney disease, diabetes mellitus, osteoporosis, and limited mobility, presented with left hip pain following a fall. Radiographs confirmed a displaced femoral neck fracture. Cementless hemiarthroplasty was performed using the lateral Harding approach, achieving stable fixation without cement. Postoperative care involves standard pain management, early mobilization, and monitoring for complications. This case highlights the potential benefits of cementless hemiarthroplasty, such as reduced operative time and decreased risk of cement-related complications, particularly in elderly patients with good bone quality. The successful outcome, characterized by stable fixation and absence of intraoperative or early postoperative complications, emphasizes the importance of individualized patient assessment and tailored surgical approaches. Further research is needed to refine guidelines and expand the evidence base for the use of cementless techniques in this demographic.

Morphological human bone features and demography controlling damage accumulation and fracture: a finite element study

Prediction of bone fracture risk is clinically challenging. Computational modeling plays a vital role in understanding bone structure and diagnosing bone diseases, leading to novel therapies. The research objectives were to demonstrate the anisotropic structure of the bone at the micro-level taking into consideration the density and subject demography, such as age, gender, body mass index (BMI), height, weight, and their roles in damage accumulation. Out of 438 developed 3D bone models at the micro-level, 46.12% were female. The age distribution ranged from 23 to 95 years. The research unfolds in two phases: micro-morphological features examination and stress distribution investigation. Models were developed using Mimics 22.0 and SolidWorks. The anisotropic material properties were defined before importing into Ansys for simulation. Computational simulations further uncovered variations in maximum von-Misses stress, highlighting that young Black males experienced the highest stress at 127.852 ± 10.035 MPa, while elderly Caucasian females exhibited the least stress at 97.224 ± 14.504 MPa. Furthermore, age-related variations in stress levels for both normal and osteoporotic bone micro models were elucidated, emphasizing the intricate interplay of demographic factors in bone biomechanics. Additionally, a prediction equation for bone density incorporating demographic variables was proposed, offering a personalized modeling approach. In general, this study, which carefully examines the complexities of how bones behave at the micro-level, emphasizes the need for an enhanced approach in orthopedics. We suggest taking individual characteristics into account to make therapeutic interventions more precise and effective.

Impact of vision impairment on discharge destination for patients with hip fracture

Introduction

Vision impairment (VI) due to low vision or blindness is a major sensory health problem affecting quality of life and contributing to increased risk of falls and hip fractures (HF). Up to 60% of patients with hip fracture have VI, and VI increases further susceptibility to falls due to mobility challenges after HF. We sought to determine if VI affects discharge destination for patients with HF.

Materials and methods

Cross-sectional analysis of 2015 Inpatient Medicare claims was performed and VI, blindness/low vision), HF and HF surgery were identified using ICD-9, and ICD-10 codes. Patients who sustained a HF with a diagnosis of VI were categorized as HF + VI. The outcome measure was discharge destination of home, skilled nursing facility (SNF), long-term care facility (LTCF) or other.

Results

During the one-year ascertainment of inpatient claims, there were 10,336 total HF patients, 66.82% female, 91.21% non-Hispanic white with mean (standard deviation) age 82.3 (8.2) years. There was an age-related increase in diagnosis of VI with 1.49% (29/1941) of patients aged 65-74, 1.76% (63/3574) of patients aged 75-84, and 2.07% (100/4821) of patients aged 85 and older. The prevalence of VI increased with age, representing 1.5% (29/1941) of adults aged 65-74, 1.8% (63/3574) of adults aged 75-84, and 2.1% (100/4821) of adults aged 85 and older. The age-related increase in VI was not significant (P = 0.235). Patients with HF were most commonly discharged to a SNF (64.46%), followed by 'Other' (25.70%), home (7.15%), and LTCF (2.67%). VI was not associated with discharge destination. Male gender, Black race, systemic complications, and late postoperative discharge significantly predicted discharge to LTCF with odds ratios (95%CI) 1.42 (1.07-1.89), 1.90 (1.13-3.18), 2.27 (1.66-3.10), and 1.73 (1.25-2.39) respectively.

Conclusions

The co-morbid presence of VI was not associated with altered discharge destinations to home, skilled nursing facility, LTCF or other setting.

The Impact of Endogenous Estrogen Exposure Duration on Fracture Incidence: a Longitudinal Cohort Study

CONTEXT

Although it is well documented that estrogen hormone is positively associated with bone mineral density and lower risk of fracture, there are limited studies on the association between duration of endogenous estrogen exposure (EEE) and fracture, especially by longitudinal design.

OBJECTIVE

This study aimed to investigate the relationship between EEE with fracture incidence by longitudinal design in a community-based study.

METHODS

A total of 5269 eligible postmenarcheal women, including 2411 premenopausal and 2858 menopausal women, were recruited from among the Tehran Lipid and Glucose Study. Cox proportional hazards regression model with adjustment of potential confounders was performed to assess the relationship between duration of EEE and incident of any hospitalized fractures.

RESULTS

A total of 26.7% (1409/5269) women were menopausal at the baseline, and 2858 of the remaining participants reached menopause at the end of follow-up. Results of the unadjusted model demonstrated that the EEE z-score was negatively associated with fracture incidence [unadjusted hazard ratio (HR) 0.81, 95% CI 0.68-0.96] in postmenarchal women, indicating that per 1-SD increase of EEE z-score, the hazard of fracture reduced by 19%. Results remained statistically unchanged after adjustment for potential confounders (adjusted HR 0.70, 95% CI 0.58-0.86).

CONCLUSION

The findings of this cohort study suggest that a longer duration of EEE has a protective effect on fracture incidence; a point that needs to be considered in fracture risk assessment.

Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function Is Associated with Increased Mortality

BACKGROUND

Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion.

QUESTIONS/PURPOSES

(1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections?

METHODS

Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD6-9], 10-19 [MELD10-19], and 20-40 [MELD20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test.

RESULTS

Patients in the MELD20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD20-40 group compared with the other two MELD classifications (13% for MELD20-40 and 0% for both MELD6-9 and MELD10-19; p = 0.02).

CONCLUSION

The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Risk factors for postoperative mortality at 30 days in elderly Chinese patients with hip fractures

Arrhythmia, pneumonia, cardiac insufficiency, a high leukocyte count, and low albumin concentrations were associated with increased 30-day mortality in elderly hip fracture patients after surgery. It is important to improve short-term survival rates by optimizing the respiratory and cardiac function of geriatric patients before they undergo surgery.

INTRODUCTION

This study aims to investigate the 30-day mortality and related risk factors for elderly patients following surgery for hip fractures.

METHODS

This retrospective study examined chart reviews for evaluating associations of gender, age, fracture site, biochemical indicators, pre-surgery comorbidities, number of pre-surgery comorbidities, time to surgery and anesthesia and surgery methods with postoperative 30-day mortality in elderly hip fracture surgery patients.

RESULTS

A total of 1,004 patients were included in the study and 43 (4.3%) patients died within 30 days after surgery. Univariate analysis showed that patients in the non-survival group had a higher mean age, higher leukocyte counts, lower hemoglobin and albumin levels, a higher proportion of arrhythmias, pneumoniae and cardiac insufficiency and number of presurgical comorbidities than the survival group (all P-values < 0.05). Multivariate logistic analysis further confirmed that arrhythmia (OR = 2.033, P = 0.038), pneumonia (OR = 2.246, P = 0.041), cardiac insufficiency (OR = 2.833, P = 0.029), high leukocyte count (OR = 1.139, P = 0.009), and low albumin (OR = 0.925, P = 0.041) were all significant risk factors for mortality 30 days after surgery.

CONCLUSIONS

This study demonstrates that arrhythmia, pneumonia, cardiac insufficiency, a high leukocyte count, and low albumin concentrations were associated with increased 30-day mortality in elderly hip fracture patients after surgery.

Effect of body mass index on vertebral and hip fractures in older people and differences according to sex: a retrospective Japanese cohort study

OBJECTIVES

The purpose of this study was to investigate the incidence of vertebral and hip fractures in the older people and to clarify the relationship between these fractures and body mass index (BMI) along with the impact of sex differences.DesignThis was a retrospective cohort study.SettingWe used administrative claims data between April 2010 and March 2018.

PARTICIPANTS

Older people aged ≥75 years who underwent health examinations in 2010 and were living in the Fukuoka Prefecture, Japan were included in the study. A total of 24 691 participants were included; the mean age was 79.4±4.3 years, 10 853 males and 13 838 females, and an the mean duration of observation was 6.9±1.6 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the incidence of vertebral and hip fractures by BMI category (underweight: <18.5 kg/m², normal weight: 18.5-24.9 kg/m², overweight and obese: ≥25.0 kg/m²) using a Kaplan-Meier curve in males and females and determined fracture risk by sex using Cox proportional hazards regression analyses.

RESULTS

The incidence of vertebral and hip fractures was 16.8% and 6.5%, respectively. The cumulative incidence of vertebral and hip fracture at the last observation (8 years) in each BMI groups (underweight/normal weight/overweight and obese) estimated using the Kaplan-Meier curve was 14.7%/10.4%/9.0% in males and 24.9%/23.0%/21.9% in females, and 6.3%/2.9%/2.4% in males and 14.1%/9.0%/8.1% in females, respectively, and both fractures were significantly higher in underweight groups regardless of sex. Multivariable Cox proportional hazards models showed that underweight was a significant risk factor only in males for vertebral fractures and in both males and females for hip fractures.

CONCLUSION

Underweight was associated with fractures in the ageing population, but there was a sex difference in the effect for vertebral fractures.

The Effect of Frailty on Walking Recovery After Hip Fracture: A Secondary Analysis of the Community Ambulation Project

BACKGROUND

The impact of frailty on walking recovery after hip fracture has not been reported. We describe the prevalence of frailty approximately 3 months after hip fracture, and identify the impact of baseline frailty on ambulation recovery.

METHODS

Data from the Community Ambulation Project, that examined the effects of 2 multicomponent home exercise programs on 6-minute walk test in participants post hip fracture, were used to reconstruct the 5-item frailty phenotype. We detailed the prevalence of frailty by subgroup and assessed the comparability between frailty groups for the categorical variable of achieving 300 m in 6-minute walk test (community ambulation threshold), and the continuous variable of total distance in 6-minute walk test before and after 16 weeks of intervention.

RESULTS

Of the 210 participants, 9% were nonfrail, 59% were prefrail, and 32% were frail. The odds of a nonfrail participant achieving the 300-m threshold were 14.4 (95% CI: 2.4-87.6) times the odds of a frail participant, while a prefrail participant's odds were 6.1 (95% CI: 1.3-28.4) times after controlling for treatment group and baseline walking distance. The nonfrail participants had an increase of 92.1 m from baseline to 16 weeks, the prefrail had a 50.8 m increase, and the frail group had the smallest increase of 36.6 m (p < .001 for all).

CONCLUSIONS

Prefrailty and frailty were highly prevalent in this sample of community-dwelling survivors of a recent hip fracture. Gains in walking distance and attaining a level of community ambulation were affected significantly by the level of baseline frailty.

Life expectancy of older people living in aged care facilities after a hip fracture

To the authors’ knowledge, no study has been conducted on life expectancy for aged care facility residents with hip fracture. We assessed life expectancy of 240 residents of aged care facilities in Australia who experienced recent hip fracture treated with surgery. 149 deaths occurred over a mean follow-up of 1.2 years. Being female and having better cognition were associated with longer life expectancy. Increased age was associated with shorter life expectancy. The cumulative mortality rate within three months after hip fracture was 25.0% while the cumulative mortality rate for the whole study period was 62.1%. Life expectancy was 8.2 years, 4.8 years and 2.8 years for 70, 80 and 90-years old female patients. Life expectancy was 3.8 years, 2.2 years and 1.3 years for 70, 80 and 90 years old male patients, respectively. In conclusion, age, gender and cognition level were associated with life expectancy of hip fracture patients living in aged care facilities and their life expectancy was much shorter than that of the general Australian population.

Fall Patterns Predict Mortality After Hip Fracture in Older Adults, Independent of Age, Sex, and Comorbidities

Falls are the most frequent cause of hip fracture. We aimed to investigate whether specific fall patterns have predictive value for mortality after hip fracture. In this cohort study, data of individuals presented to the Severance Hospital, Seoul, Korea, between 2005 and 2019 due to fragility hip fracture (n = 1986) were analyzed. Fall patterns were defined as causes, activities leading to falls, and a combination of both, based on electronic medical records using pre-specified classification from a prior study on video-captured falls. Mean age of study subjects were 77 years (71% women) and 211 patients (10.6%) died during follow-up (median 544 days). Indoor falls at home had a higher mortality than outdoor falls (11.9 vs. 8.0%, p = 0.009). Among 16 fall patterns, incorrect weight shift while sitting down (adjusted hazard ratio [aHR] 4.03) or getting up (aHR 2.01), collapse during low-risk activity (aHR 2.39), and slipping while walking (aHR 2.90, p < 0.01 for all) were associated with increased mortality compared to outdoor falls, after adjustment for age, sex, and Charlson comorbidity index (CCI), constituting a high-risk pattern. High-risk fall patterns were associated with a higher risk of mortality (aHR 2.56, p < 0.001) than low-risk patterns (aHR 1.37, p = 0.080) and outdoor falls (referent; log rank p < 0.001), which improved mortality prediction when added to a base model including age, sex, and CCI (integrative area under receiver-operating characteristics curve 0.675 to 0.698, p < 0.001). Specific fall patterns were associated with higher mortality in older adults with hip fracture, independent of age, sex, and comorbidities.

Causes of death among 93.637 hip fracture patients- data based on the Danish National Registry of causes of death

PURPOSE

Excess mortality among hip fracture patients is well documented. Less is known, however, about the causes of death in this group of patients, although existing literature suggests that bronchopneumonia and cardiovascular diseases constitute the leading causes of death. In this study, we investigated the causes of death in Danish hip fracture patients, who died within 30-days after sustaining a hip fracture, with a focus on differences in causes of death between men and women and between different age groups. Furthermore, the frequency of potentially preventable causes of death such as pneumonia, urinary tract infections and thromboembolic events was examined.

METHODS

All Danish patients aged 18 or more suffering from a hip fracture in the period 2002-2012 were examined for inclusion into the study. Data were collected from the Danish National Patient registry. The last month of 2012 being December was left out since we were looking at 30-days mortality. Logistic regression analysis was used to test the association between 30-day mortality with each of the causes of death adjusted for age, sex and CCI in multivariable models with results presented as odds ratios (OR) with 95% confidence intervals.

RESULTS

During this period, 93,637 patients sustained a hip fracture. Of these, 9504 patients died within 30-days and were included in the study. For patients dead within 30-days after sustaining a hip fracture, the two leading medical causes of death were cardiovascular disease (21.1%) and pneumonia (10.5%) when looking at both genders. A frequent cause of death especially in the younger age group of women less than 50 years old were infections (other than pneumonia) (18.2%) especially urinary tract infections. Pulmonary embolism accounted for 3.9% of causes of deaths in hip fracture patients.

CONCLUSION

In this study, cardiovascular disease and pneumonia were overall the leading medical causes of death in patients dead within 30-days after sustaining a hip fracture. Apart from pneumonia, another potentially preventable infection in younger female hip fracture patients was urinary tract infections. Pulmonary embolism, another potentially preventable cause of death might be underreported in Danish death certificates.

Mortality incidence and its determinants after fragility hip fractures: a prospective cohort study from an Egyptian level one trauma center

BACKGROUND

Fragility hip fracture is a common condition with serious consequences. Most outcomes data come from Western and Asian populations. There are few data from African and Middle Eastern countries.

OBJECTIVE

The primary objective was to describe mortality rates after fragility hip fracture in a Level-1 trauma centre in Egypt. The secondary objective was to study the causes of re-admissions, complications, and mortality.

METHODS

A prospective cohort study of 301 patients, aged > 65 years, with fragility hip fractures. Data collected included sociodemographic, co-morbidities, timing of admission, and intraoperative,ostoperative, and post-discharge data as mortality, complications, hospital stay, reoperation, and re-admission. Cox regression analysis was conducted to investigate factors associated with 1-year mortality.

RESULTS

In-hospital mortality was 8.3% (25 patients) which increased to 52.8% (159 patients) after one year; 58.5% of the deaths occurred in the first 3-months. One-year mortality was independently associated with increasing age, ASA 3-4, cardiac or hepatic co-morbidities, trochanteric fractures, total hospital stay, and postoperative ifection and metal failure.

CONCLUSION

Our in-hospital mortality rate resembles developed countries reports, reflecting good initial geriatric healthcare. However, our 3- and 12-months mortality rates are unexpectedly high. The implementation of orthogeriatric care after discharge is mandatory to decrease mortality rates.

Adherence to Anti-Osteoporotic Treatment and Clinical Implications after Hip Fracture: A Systematic Review

The role of anti-osteoporotic treatment as part of the secondary prevention after hip fracture in terms of mortality and re-fracture risk has been studied, and the results are promising. Decreased treatment adherence and compliance is a problem that needs to be addressed by healthcare professionals. A systematic review of the literature was performed using the PubMed database with terms that included hip fracture, mortality, second fracture, and specific anti-osteoporotic treatment. We included 28 articles, 21 regarding mortality and 20 re-fracture rates in hip fracture patients. All studies showed lower mortality after hip fracture associated with anti-osteoporotic treatment, mostly bisphosphonate agents. The re-fracture risk is still debatable, since conflicting data were found. Although most of the studies showed notable effects on mortality and re-fracture rates associated with anti-osteoporotic treatment, we still need more data to validate the actual results.

Low Heart Rate Variability Predicts Stroke and Other Complications in the First Six Postoperative Months After a Hip Fracture Operation

Background: One-year mortality after hip fractures is underestimated and is reported as 25%. An improved risk stratifying could contribute to a better follow up of these patients. Heart Rate Variability (HRV) is an easy point-of-care investigation and is been used in cardiology, endocrinology, and perioperative care. This observational study intended to explore relevant associations between HRV parameters and 6-months mortality and morbidity after a hip fracture. Methods: One hundred and sixty-five patients admitted to two hospitals were included, and short-time HRV measurements (5 min, and 10 min at the two hospitals, respectively) were obtained. Mortality data were gathered by means of the Norwegian central address register. Patients, close relatives of patients, and in some cases their general physicians or nursery home physicians were interviewed 6 months postoperatively regarding the incidence of pneumonia, cardiac events, or stroke. Results: One and hundred fifty-seven (95.2%) patients were followed up after 6 months post-surgery. Twenty-one (13%) died during this period. Twenty patients (13%) developed pneumonia, eight (5 %) stroke, and four (2%) myocardial infarction. No HRV parameter was associated with 6-month general mortality. However, patients who developed stroke had significantly lower High Frequency Power (HF, p < 0.001) and lower Very Low Frequency Power (VLF, p = 0.003) at inclusion compared to patients without complications. Patients who developed pneumonia had at the inclusion lower root mean square of successive differences (RMSSD, p = 0.044). Patients with a history of coronary heart disease (n = 41) showed a mortality of 7%. Mortality in this group was associated with standard deviation of beat-to-beat intervals (SDNN, p = 0.006), Total Power (TP, p = 0.009), HF (p = 0.026), and Low Frequency Power (LF, p = 0.012). Beta-blocker intake was associated with lower heart rate, but not with differences in HRV parameters. Conclusion: In this exploratory study, we present for the first-time significant associations between different preoperative HRV parameters and stroke, myocardial infarction, and pneumonia during a 6-month period after hip fracture. HRV might be a simple and effective tool to identify patients at risk that would warrant better follow-up.

Palliative care and aggressive interventions after falling: A Nationwide Inpatient Sample analysis

OBJECTIVE

The purpose of this study is to identify whether there is an opportunity for improvement to provide palliative care services after a serious fall. We hypothesized that (1) palliative care services would be utilized in less than 10% of patients over the age of 65 who fall and (2) more than 20% of patients would receive aggressive life-sustaining treatments (LSTs) prior to death.

METHODS

Using the 2017 Nationwide Inpatient Sample, we identified patients who were admitted to the hospital with a fall (ICD-10 W00-W19) and were hospitalized at least two days with valid discharge data. Palliative care services (Z51.5) or LSTs (cardiopulmonary resuscitation, ventilation, reintubation, tracheostomy, feeding tube placement, vasopressors, transfusion, total parenteral nutrition, and hemodialysis) were identified with ICD-10 codes. We examined the use of palliative care or LSTs by discharge destination (home, facility, and death). Logistic regression was used to identify factors associated with palliative care.

RESULTS

In total, 155,241 patients were identified (median 82 years old, interquartile range 74-88); 2.5% died in hospital, and 69.4% were transferred to a facility. Palliative care occurred in 4.5% of patients, and LST occurred in 15.1%. Patients who died were significantly more likely to have had palliative care (50.1% vs. 3.4% of home or facility discharges) and were more likely to have an LST [53.0% vs. 9.8% (home) vs. 15.9% (facility)]. Palliative care was associated with both death [adjusted odds ratio (AOR) 19.84, 95% confidence interval (CI) 18.39-21.41, p < 0.001] and LST (AOR 1.36, 95% CI 1.27-1.46, p < 0.001).

SIGNIFICANCE OF RESULTS

Palliative care is associated with both death and LST, suggesting that physicians use palliative care as a last resort after aggressive measures have been exhausted. Patients who fall would likely benefit from the early use of palliative care to align future goals of care.

Sparing effect of peritoneal dialysis vs hemodialysis on BMD changes and its impact on mortality

INTRODUCTION

Bone loss in end stage renal disease (ESRD) patients associates with fractures, vascular calcification, cardiovascular disease (CVD) and increased mortality. We investigated factors associated with changes of bone mineral density (ΔBMD) during the initial year on dialysis therapy and associations of ΔBMD with subsequent mortality in ESRD patients initiating dialysis.

MATERIALS AND METHODS

In 242 ESRD patients (median age 55 years, 61% men) starting dialysis with peritoneal dialysis (PD; n = 138) or hemodialysis (HD; n = 104), whole-body dual-energy X-ray absorptiometry (DXA), body composition, nutritional status and circulating biomarkers were assessed at baseline and 1 year after dialysis start. We used multivariate linear regression analysis to determine factors associated with ΔBMD, and fine and gray competing risk analysis to determine associations of ΔBMD with subsequent mortality risk.

RESULTS

BMD decreased significantly in HD patients (significant reductions of BMD_total and BMD_{leg, trunk, rib, pelvis and spine}) but not in PD patients. HD compared to PD therapy associated with negative changes in BMD_{total (β=- 0.15)}, BMD_{head (β=- 0.14)}, BMD_{leg (β=- 0.18)} and BMD_{trunk (β=- 0.16)}. Better preservation of BMD associated with significantly lower all-cause mortality for ΔBMD_total (sub-hazard ratio, sHR, 0.91), ΔBMD_head (sHR 0.91) and ΔBMD_leg (sHR 0.92), while only ΔBMD_head (sHR 0.92) had a beneficial effect on CVD-mortality.

CONCLUSIONS

PD had beneficial effect compared with HD on BMD changes during first year of dialysis therapy. Better preservation of BMD, especially in bone sites rich in cortical bone, associated with lower subsequent mortality. BMD in cortical bone may have stronger association with clinical outcome than BMD in trabecular bone.

30-day mortality after hip fracture surgery: Influence of postoperative factors

Purpose

The 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. The aim of this work is to analyse preoperative and postoperative factors potentially related to early 30-day mortality in patients over 65 undergoing hip fracture surgery.

Methods

Prospective cohort study including all consecutive primary hip fracture patients over 65 admitted to Trauma and Orthopaedics department from January 1, 2018 to December 31, 2019. Bed-ridden, non- surgically treated patients, and high energy trauma or tumoral aetiology fractures were excluded. A total of 943 patients were eligible (attrition rate: 2.1%). Follow-up included 30-days after discharge. We noted the 30-day mortality after hip fracture surgery, analysing 130 potentially related variables including biodemographic, fracture-related, preoperative, and postoperative clinical factors. Qualitative variables were assessed by χ², and quantitative variables by non-parametric tests. Odds ratio determined by binary logistic regression. We selected preventable candidate variables for multivariate risk assessment by logistic regression.

Results

A total of 923 patients were enrolled (mean age 86.22±6.8, 72.9% women). The 30-day mortality rate was 6.0%. We noted significant increased mortality on men (OR = 2.381[1.371–4.136], p = 0.002), ageing patients (OR_year = 1.073[1.025–1.122], p = 0.002), and longer time to surgery (OR_day = 1.183[1.039–1146], p<0.001), on other 20 preoperative clinical variables, like lymphopenia (lymphocyte count <10³/μl, OR = 1.842[1.063–3.191], p = 0.029), hypoalbuminemia (≤3.5g/dl, OR = 2.474[1.316–4.643], p = 0.005), and oral anticoagulant intake (OR = 2.499[1.415–4.415], p = 0.002), and on 25 postoperative clinical variables, like arrhythmia (OR = 13.937[6.263–31.017], p<0.001), respiratory insufficiency (OR = 7.002[3.947–12.419], p<0.001), hyperkalaemia (OR = 10.378[3.909–27.555], p<0.001), nutritional supply requirement (OR = 3.576[1.894–6.752], p = 0.021), or early arthroplasty dislocation (OR = 6.557[1.206–35.640], p = 0.029). We developed a predictive model for early mortality after hip fracture surgery based on postoperative factors with 96.0% sensitivity and 60.7% specificity (AUC = 0.863).

Conclusion

We revealed that not only preoperative, but also postoperative factors have a great impact after hip fracture surgery. The influence of post-operative factors on 30-day mortality has a logical basis, albeit so far they have not been identified or quantified before. Our results provide an advantageous picture of the 30-day mortality after hip fracture surgery.

One-year mortality rates and factors affecting mortality after surgery for fracture neck of femur in the elderly

Context:

Fractures around hip in elderly are associated with significant morbidity and mortality.

Aim:

This sudy aims to investigate 1-year mortality rates and risk factors associated with this mortality. Effect of delay in surgery on mortality rates will also be studied. Our null-hypothesis was that there is no association between common comorbid conditions or delay in surgery on 1-year mortality rates.

Study Settings and Design:

Patients 60-years and above who underwent operative treatment for fracture of neck of femur between January 2018 and February 2019 were included in this retrospective study.

Materials and Methods:

Demographic and clinical data were collected from hospital information system and inpatient case records. Patients were followed up with quality of life (QoL) assessment with short form-12 (SF-12) at 1 year. Mortality during this period was also evaluated.

Statistical Analysis:

Continuous factors were expressed as means, standard deviations. Different risk factors between the patients alive and dead were studied using Fisher's exact test.

Results:

Nineteen out of 95 patients died at the end of 1 year. Smoking, hypertension, diabetes, low hemoglobin, raised total leukocyte count, low serum albumin, delay in surgery (>1 week), higher American Society of Anesthesiologist grade, and postoperative blood transfusion were significantly associated with higher mortality rates. Mean SF-12 QoL scores at 1 year was 35.6 ± 6.3.

Conclusion:

Hip fractures in elderly are associated with higher mortality rates. Results of this study indicate that patients at a higher risk of mortality may be identified and help in preoperative optimization with the aim to reduce mortality. However, these findings need to be verified by further studies with a relatively larger sample size and longer follow-up period.

Fractures and their sequelae in non-dialysis-dependent chronic kidney disease: the Stockholm CREAtinine Measurement project

Introduction

People undergoing maintenance dialysis are at high risk for fractures, but less is known about fracture incidence and associated outcomes in earlier stages of chronic kidney disease (CKD).

Methods

We conducted an observational analysis from the Stockholm Creatinine Measurement project, a Swedish health care utilization cohort during 2006–11. We identified all adults with confirmed CKD Stages 3–5 and no documented history of fractures and extracted information on comorbid history, ongoing medication, cardiovascular events and death. We studied incidence rates of fractures (overall and by location), with the estimated glomerular filtration rate (eGFR) as time-dependent exposure. We then studied hazard ratios [HRs and 95% confidence intervals (CIs)] for the events of death and major adverse cardiac events (MACE) using Cox regression with fracture as time-varying exposure.

Results

We identified 68 764 individuals with confirmed CKD (mean age 79 years, 56% women). During a median follow-up of 2.7 years, 9219 fractures occurred, of which 3105 were hip fractures. A more severe CKD stage was associated with a higher risk of fractures, particularly hip fractures: compared with CKD Stage 3a, the adjusted HR was 1.10 (95% CI 1.02–1.19), 1.32 (1.17–1.49) and 2.47 (1.94–3.15) for CKD Stage 3b, 4 and 5, respectively. Spline curves suggested a linear association with fracture risk with an eGFR <30 mL/min/1.73 m². Compared with non-fracture periods, incident fracture was associated with a 4-fold increased mortality within 90 days [HR 4.21 (95% CI 3.95–4.49)]. The risk remained elevated beyond 90 days [HR 1.47 (95% CI 1.40–1.54)] and was stronger after hip fractures. Post-fracture MACE risk was also highest in the first 90 days [HR 4.02 (95% CI 3.73–4.33)], particularly after hip fractures, and persisted beyond 90 days [HR 1.20 (95% CI 1.10–1.30)].

Conclusion

Our findings highlight the commonness of fractures and the increased risk for subsequent adverse outcomes in CKD patients. These results may inform clinical decisions regarding post-fracture clinical surveillance and fracture prevention strategies.

Effects of β-carotene intake on the risk of fracture: a Bayesian meta-analysis

BACKGROUND

Epidemiological studies examining the association between β-carotene intake and risk of fracture have reported inconsistent findings. We conducted a meta-analysis to investigate the association between β-carotene intake and risk of fracture.

METHODS

We systematically searched PubMed, EMBASE and Cochrane library databases for relevant articles that were published until December 2019. We also identified studies from reference lists of articles identified from the clinical databases. The frequentist and Bayesian random-effects model was used to synthesize data.

RESULTS

Nine studies with a total of 190,545 men and women, with an average age of 59.8 years, were included in this meta-analysis. For β-carotene intake (1.76-14.30 mg/day), the pooled risk ratio (RR) of any fracture was 0.67 (95% Credible Interval (CrI): 0.51-0.82; heterogeneity: P = 0.66, I2 = 0.00%) and 0.63 (95%CrI: 0.44-0. 82) for hip fracture. By study design, the pooled RRs were 0.55 (95% CrI: 0.14-0.96) for case-control studies and 0.82 (95% CrI: 0.58-0.99) for cohort studies. By geographic region, the pooled RRs were 0.58 (95% CrI: 0.28-0.89), 0.86 (95% CrI: 0.35-0.1.37), and 0.91(95% CrI: 0.75-1.00) for studies conducted in China, the United States, and Europe, respectively. By sex, the pooled RRs were 0.88 (95% CrI: 0.73-0.99) for males and 0.76 (95% CrI, 0.44-1.07) for females. There was a 95% probability that β-carotene intake reduces risk of hip fracture and any type of fracture by more than 20%.

CONCLUSIONS

The present meta-analysis suggests that β-carotene intake was inversely associated with fracture risk, which was consistently observed for case-control and cohort studies. Randomized controlled trials are warranted to confirm this relationship.

Mortality Risk Among Older People Who Did Versus Did Not Sustain a Fracture: Baseline Prefracture Strength and Gait Speed as Predictors in a 15-Year Follow-Up

BACKGROUND

Physiological reserve, as indicated by muscle strength and gait speed, may be especially determinant of survival in people who are exposed to a health stressor. We studied whether the association between strength/speed and mortality risk would be stronger in the time period after a fracture compared to other time periods.

METHODS

Participants were population-based sample of 157 men and 325 women aged 75 and 80 years at baseline. Maximal 10-m gait speed and maximal isometric grip and knee extension strength were tested at the baseline before the fracture. Subsequent fracture incidence and mortality were followed up for 15 years. Cox regression analysis was used to estimate fracture time-stratified effects of gait speed and muscle strength on mortality risk in three states: (i) nonfracture state, (ii) the first postfracture year, and (iii) after the first postfracture year until death/end of follow-up.

RESULTS

During the follow-up, 20% of the men and 44% of the women sustained a fracture. In both sexes, lower gait speed and in women lower knee extension strength was associated with increased mortality risk in the nonfracture state. During the first postfracture year, the mortality risk associated with slower gait and lower strength was increased and higher than in the nonfracture state. After the first postfracture year, mortality risk associated with lower gait speed and muscle strength attenuated.

CONCLUSIONS

Lower gait speed and muscle strength were more strongly associated with mortality risk after fracture than during nonfracture time, which may indicate decreased likelihood of recovery.

Living alone vs. living with someone as a predictor of mortality after a bone fracture in older age

Background

Living alone is a risk factor for health decline in old age, especially when facing adverse events increasing vulnerability.

Aim

We examined whether living alone is associated with higher post-fracture mortality risk.

Methods

Participants were 190 men and 409 women aged 75 or 80 years at baseline. Subsequent fracture incidence and mortality were followed up for 15 years. Extended Cox regression analysis was used to compare the associations between living arrangements and mortality risk during the first post-fracture year and during the non-fracture time. All participants contributed to the non-fracture state until a fracture occurred or until death/end of follow-up if they did not sustain a fracture. Participants who sustained a fracture during the follow-up returned to the non-fracture state 1 year after the fracture unless they died or were censored due to end of follow-up.

Results

Altogether, 22% of men and 40% of women sustained a fracture. During the first post-fracture year, mortality risk was over threefold compared to non-fracture time but did not differ by living arrangement. In women, living alone was associated with lower mortality risk during non-fracture time, but the association attenuated after adjustment for self-rated health. In men, living alone was associated with increased mortality risk during non-fracture time, although not significantly.

Conclusion

The results suggest that living alone is not associated with pronounced mortality risk after a fracture compared to living with someone.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01511-5) contains supplementary material, which is available to authorized users.

Magnesium oxide and hip fracture in the elderly: a population-based retrospective cohort analysis

Using national insurance claims of Taiwan, we found that magnesium oxide (MgO) use is associated with an increased risk of hip fracture in the elderly. Further studies are warranted to explore the mechanisms associated with MgO use that lead to hip fracture.

PURPOSE

The purpose of this study was to investigate the association between MgO use and hip fracture risk in the elderly (age > 65 years).

METHODS

This nationwide population-based retrospective study was conducted from 1996 to 2013. Individuals with (n = 26,069) and without (n = 26,069) MgO use were enrolled after propensity score matching. Primary outcome was a hip fracture. After adjusting for age, sex, comorbidities, and medications, multivariate Cox proportional hazards regression models were used to calculate incidences and risk of hip fracture [hazard ratio (HR)].

RESULTS

During the mean follow-up duration of 4.8 years in the MgO cohort and 5.7 years in the non-MgO cohort, respectively 1547 and 1107 cases developed a hip fracture. MgO use was identified as a risk factor for hip fracture in both univariate [crude HR, 1.68; 95% confidence interval (CI), 1.55-1.81; p < 0.001] and multivariate [adjusted HR (aHR), 1.66; 95% CI, 1.54-1.80; p < 0.001] Cox proportional hazards regression models. The cumulative incidence of hip fracture was significantly higher in the MgO cohort than in the non-MgO cohort (1.23 per 100 person-years vs. 0.74 per 100 person-years, logrank test, p < 0.001).

CONCLUSION

MgO use is an independent risk factor for hip fracture in the elderly.

Advance Care Planning Prior to Death in Older Adults with Hip Fracture

BACKGROUND

Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown.

OBJECTIVE

To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP.

DESIGN

Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data.

PARTICIPANTS

Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey.

MAIN MEASURES

Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP.

KEY RESULTS

Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06-0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35-0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26-0.72). No clinical factors were found to be associated with ACP completion prior to death.

CONCLUSIONS

A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.

Prospective assessment of trochanteric fracture managed by intramedullary nailing with controlled and limited blade back-out

INTRODUCTION

The main objective of the present prospective study was to assess mechanical complications associated with an original intramedullary nail with limited and controlled blade back-out in the treatment of trochanteric fracture.

MATERIAL AND METHOD

All patients treated for trochanteric fracture in a single orthopedic/traumatologic surgery department over a 2-year period were included. Minimum follow-up was 6 months. Fracture stability was assessed on the AO criteria. The TFP® intramedullary nail has a monobloc helicoid blade. Its main feature is the controlled and limited blade back-out, optimizing fracture site compression in weight-bearing, without the drawback of excessive back-out. The main endpoint was onset of mechanical complications: cut-out, intra-articular protrusion, non-union, and pain. Baumgaertner's Tip-Apex Distance (TAD), blade centering within the femoral head and fracture reduction were also assessed.

RESULTS

One hundred thirty-eight patients (mean age, 83 years) were operated on, and 118 followed up. There were 9 mechanical complications (7.6%): 4 cut-outs (3.4%), 3 intra-articular protrusions (2.5%), 1 non-union (0.8%) and 1 case of pain (0.8%). TAD length was not associated with complications rate. Poor reduction was significantly associated with more complications (p=0.02), as was blade malpositioning. Mean back-out was 3.3mm, affecting 22 nails (19%). There were no complications in case of back-out, versus a 9.4% rate in absence of back-out, although this difference was not significant (p=0.21). There were no postoperative infections.

CONCLUSION

The TFP® nail is useful for fixation of trochanteric fracture, whether stable or unstable, due to its low rate of mechanical complications compared to the literature.

Major fractures after initiation of dialysis: Incidence, predictors and association with mortality

BACKGROUND

Major fractures (MF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MF occurring after initiation of dialysis (MF_first).

METHODS

In Swedish Renal Registry of 9714 incident (2005-2016) dialysis patients (age 68 years, 67% men), we identified all MF_first in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MF_first, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MF_first.

RESULTS

During median follow-up of 2.2 years, the crude incidence rate of MFfirst (n = 835) was 23.7/1000 patient-years and that of hip fractures (n = 470) 13.3/1000 patient-years. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, comorbidity, and previous history of MF (MF_previous) were associated with increased risk for MF_first, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased risk. The adjusted fracture incidence rate of MF_first during the first 90 days following dialysis initiation was higher in patients with MF_previous than in those without MF_previous. MF_first independently predicted increased all-cause (sub-distribution hazard ratio, SHR, 1.67(95%CI 1.47-1.91)) and CVD (SHR 1.49 (95%CI 1.22-1.84)) mortality. Adjusted mortality rate following hip fractures was higher than for other types of MF. Spline curves showed that mortality following MF_first was highest during the first 6 months of follow-up.

CONCLUSIONS

MF are common and associated with increased mortality in incident dialysis patients.

Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients

Older people with hip fractures are often malnourished at the time of fracture, which can have substantial influence on mortality and clinical outcomes, as well as functional outcome and quality of life. A close relationship between protein intake and muscle maintenance has been demonstrated. Skeletal muscle weakness is an independent risk factor for falls and fall-related injuries in the elderly and is an independent marker of prognosis. However, the effect of perioperative nutritional interventions on outcomes in elderly hip-fracture patients remains controversial. In this narrative review, an overview is presented of the existing literature on nutritional status and sarcopenia in elderly hip-fracture patients, clinical outcomes, and the effects of nutritional intervention on outcome and rehabilitation in this patient group.

Menopause and risk of hip fracture in middle-aged Chinese women: a 10-year follow-up of China Kadoorie Biobank

OBJECTIVE

Bone loss is accelerated after menopause in women, as is the risk of hip fracture, but little is known about the importance of age at menopause, time since menopause, and total reproductive years for risk of hip fracture.

METHODS

Between 2004 and 2008, the China Kadoorie Biobank recruited 125,336 postmenopausal women who had a natural menopause and recorded 1,327 incident cases of hip fracture during the first 10 years of follow-up. Multivariable Cox regression was used to estimate hazard ratios and 95% CIs for incident hip fracture for age at menopause, time since menopause, and total reproductive years.

RESULTS

The mean (SD) age at menopause was 48.8 (4.0) years. Compared with women who reached menopause before age 53 years, women with a later age at menopause had a 22% (95% CI, 11%-35%) lower risk of hip fracture. Compared with women who were <5 years since menopause, those who were 5 to 9, 10 to 14, 15 to 19, and ≥20 years since menopause had hazard ratios of hip fracture of 1.43 (95% CI, 1.01-2.04), 2.10 (95% CI, 1.71-2.57), 2.50 (95% CI, 2.21-2.83), and 2.33 (95% CI, 1.97-2.75), respectively. Women with a longer (≥36 y) versus shorter (<30 y) duration of total reproductive years had a 19% (95% CI, 9-28) lower risk of hip fracture.

CONCLUSIONS

Women with younger age at menopause, longer interval since menopause, or shorter duration of total reproductive years had the highest risks of hip fracture.

Association between airflow limitation severity and reduced bone mineral density in Japanese men

Introduction

This study aimed to assess the association between airflow limitation (AL) severity and reduced bone mineral density (BMD) in Japanese men.

Subjects and methods

This cross-sectional study included 290 subjects aged over 40 years (mean age 72.0, SD 11.6), who underwent a comprehensive health examination, including spirometry and measurement of BMD at the left femoral neck using dual-energy X-ray absorptiometry (DXA), between 2016 and 2017 at Japanese Red Cross Kumamoto Health Care Center. AL was defined as forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) of <0.7. Reversibility tests were not performed in this study. The criteria used for the AL staging were developed according to the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines. The subjects were divided into the following three groups: a control group (normal pulmonary function), GOLD Stage I group (mild AL), and GOLD Stage II-IV group (moderate-to-very severe AL). BMD was classified based on the young adult mean (YAM) as normal (88.6% ≦ YAM [-1 SD ≦]), osteopenia (70% -2.5 SD]), or osteoporosis (YAM ≦ 70% [≦ -2.5 SD]). Reduced BMD was defined as osteopenia, osteoporosis, or medication used for osteoporosis. Logistic regression analysis was used to assess the association between AL severity and the reduced BMD.

Results

The prevalence of reduced BMD in subjects with moderate-to-severe AL (76.2%) was significantly higher than in those without AL (47.9%) (p=0.030). In logistic regression models adjusted for age, body mass index, pack-years, physical activity, and alcohol drinking, the risk of reduced BMD (odds ratio: 3.87; 95% confidence interval: 1.20-12.49; p=0.024) was significantly higher in subjects with moderate-to-severe AL than in those with normal pulmonary function.

Conclusion

Present results suggest that reduced BMD is associated with AL severity in Japanese men.

The Role of Comorbidity in Mortality After Hip Fracture: A Nationwide Norwegian Study of 38,126 Women With Hip Fracture Matched to a General-Population Comparison Cohort

Hip fracture patients often have comorbid conditions. We investigated whether the combination of comorbidity and hip fracture could explain the previously observed excess mortality among hip fracture patients as compared with the general population. Using a population-based matched study design with 38,126 Norwegian women who suffered a hip fracture during the period 2009–2015 and the same number of women in a matched comparison cohort, we matched participants on prefracture comorbidity, age, and education. We estimated relative survival and additive and multiplicative comorbidity–hip fracture interactions. An additive comorbidity–hip fracture interaction of 4 or 9 additional deaths per 100 patients, depending on Charlson Comorbidity Index (CCI) score, was observed 1 year after hip fracture. Among women with a CCI score of ≥3, 15 additional deaths per 100 patients were observed; of these, 9 deaths could be attributed to the interaction and 6 to the hip fracture per se. On the relative scale, we observed increasing heterogeneity in survival by comorbidity over time; survival was reduced by 39% after 6 years among patients with a CCI score of ≥3, while among women with no comorbidity, survival was reduced by 17% (hip fracture vs. no hip fracture). In summary, prefracture comorbidity was associated with short-term absolute excess mortality and long-term relative excess mortality.

Changes in Rehabilitation Outcomes by new Guidelines of Hong Kong Hospital Authority in Implant Choice for Femoral Neck Fractures—Austin Moore versus Cemented Exeter Hemiarthroplasty

Background

In 2013, Hospital Authority of Hong Kong replaced Austin Moore Arthroplasty (AMA) with cemented Exeter hemiarthroplasty for displaced femoral neck fractures. This study evaluated whether this new guidelines resulted in better mortality, hospital service reattendances and rehabilitation outcomes.

Methods

Patients aged 65–84 years with hemiarthroplasty done in a tertiary hospital during 2012–2014 were reviewed retrospectively. AMA group included AMAs carried out during years 2012–2013, and Exeter group included cemented modular Exeter hemiarthroplasties carried out during years 2013–2014. All patients were followed-up for 2 years.

Results

The Exeter group performed significantly better in rehabilitation outcomes than AMA group in terms of mobility score, independent and outdoor walking and community dwelling. They also had less hospital service reattendances due to falls, refractures and implant-related causes. There was a trend towards lower mortality in the Exeter group with increasing duration from operation.

Conclusion

The new guidelines in replacing AMA with cemented Exeter hemiarthroplasty resulted in better patient outcomes.

Incidence Rates of and Mortality after Hip Fracture among German Nursing Home Residents

Little is known about hip fracture rates and post-fracture mortality among nursing home residents. This retrospective cohort study examined incidence rates (IR) of and mortality after hip fracture in this population focusing on sex differences. A cohort of >127,000 residents ≥65 years, newly admitted to German nursing homes between 2010 and 2014 were used to calculate age-, sex-, care-need- and time after admission-specific IR. To determine mortality, the Kaplan-Meier-method was applied. Using Cox regression, we studied mortality and estimated time-dependent hazard ratios (HRs). For this purpose, to each person with a hip fracture, one resident without a hip fracture was matched by sex, age and care-need using risk-set sampling. 75% were women (mean age: 84.0 years). During 168,588 person-years (PY), 8537 residents with at least one hip fracture were observed. The IR for women and men were 52.9 and 42.5/1000 PY. For both sexes, IR increased with rising age and decreased with increasing care-level. IR were highest in the first months after admission and subsequently declined afterwards. The impact of hip fractures on mortality was time-dependent. Mortality of residents with hip fracture was highest in the first two months after fracture compared to those without (HR): 2.82; 95% CI 2.57–3.11) and after six months, no differences were found (HR: 1.10; 95% CI 0.98–1.22) Further research should always include analyses stratified by sex, age and time period after admission.

Thiazide diuretics and the risk of hip fracture after stroke: a population-based propensity-matched cohort study using Taiwan's National Health Insurance Research Database

OBJECTIVES

This study aimed to investigate the association between thiazide use and the risk of hip fracture after stroke.

SETTING

A population-based, propensity-matched cohort study was conducted on the basis of Taiwan's National Health Insurance Research Database.

PARTICIPANTS

Patients with newly diagnosed ischaemic stroke between 2000 and 2011 were included. After propensity score matching, 7470 patients were included, of whom 3735 received thiazides and 3735 did not.

OUTCOME MEASURES

HRs for developing hip fractures within 2 years after stroke were calculated using Cox proportional hazards regression model with adjustments for sociodemographic and coexisting medical conditions.

RESULTS

Overall, patients using thiazides after stroke had a lower risk of hip fracture than those not using thiazides (8.5 vs 13.9 per 1000 person-years, adjusted HR=0.64, 95% CI 0.46 to 0.89, p=0.007). Further sensitivity analysis based on the duration of thiazide use revealed that the risk of hip fracture tended to decrease as the duration of exposure of thiazides increased. However, the effect was significant only in patients with long-term use of thiazides (using thiazides for >365 days within 2 years after stroke), with a 59% reduction in the risk of hip fracture when compared with patients not using thiazide (adjusted HR=0.41, 95% CI 0.22 to 0.79, p=0.008).

CONCLUSIONS

The long-term use of thiazides is associated with a decreased risk of hip fracture after stroke.

The impact of comorbidities on hip fracture mortality: a retrospective population-based cohort study

The impact of comorbidities on hip fracture-related excess mortality was assessed in a population-based age- and sex-matched cohort over 10 years. On average, only 1 out of 12 excess deaths over 10 years was related to pre-fracture life-threatening comorbidities. The presence of life-threatening comorbidities increased the excess risk of death after hip fracture.

PURPOSE

This work aimed to estimate the impact of pre-fracture comorbidities on the 10-year excess risk of all-cause death after hip fracture among Estonian men and women ≥ 50 years of age.

METHODS

Retrospective, population-based 10-year study of people aged ≥ 50 in two cohorts: those with a hip fracture and an age- and sex-matched random sample from the national health insurance fund for comparison.

RESULTS

We found that hip fracture was a strong independent risk factor for death. Upon adjustment for Charlson Comorbidities Index (CCI) score, the impact of life-threatening comorbidities on average hip fracture-related excess mortality was modest: only 8% of excess deaths over 10 years were related to comorbidities. Upon stratification by CCI groups, the excess risk of patients in CCI groups ≥ 3 and 1-2 exceeded that in the CCI 0 group over 5-7 years, indicating that in patients with life-threatening comorbidities, a hip fracture accelerates the chain of lethal events and brings deaths from other conditions forward. The impact of comorbidities was age- and time-dependent: in younger hip fracture patients, the comorbidities almost doubled the excess risk from a fracture in 10 years; in older patients, the effect was shorter and modest.

CONCLUSIONS

The presence of pre-fracture comorbidities increases the risk of excess death in hip fracture patients, but the comorbidity impact on aggregated excess mortality is modest.

Decreases in heart rate variability are associated with postoperative complications in hip fracture patients

Background

To explore relevant associations between deviations in linear and nonlinear heart rate variability (HRV) scores, and short-term morbidity and mortality in patients undergoing hip-surgery after a fracture.

Methods

165 patients with hip fractures being admitted for surgery at two hospitals were included in a prospective cohort study. A short-term ECG was recorded within 24 hours of arrival. 15 patients had to be excluded due to insufficient quality of the ECG recordings. 150 patients were included in the final analysis. Linear parameters were calculated in time domain: standard deviation of NN intervals (SDNN), root mean square of successive differences (rMSSD); and frequency domain: Total Power (TP), High Frequency Power (HF), Low Frequency Power (LF), Very Low Frequency Power (VLF), and the ratio of LF/HF. Postoperative outcome was evaluated at the time of discharge. This included occurrence of pneumonia, overall infection rate, stroke, myocardial infarction, and all-cause mortality.

Results

Patients experiencing complications had significantly lower rMSSD (p = 0.04), and TP (p = 0.03) preoperatively. Postoperative infections were predicted by decreased VLF preoperatively (p = 0.04). There was a significant association between pneumonia and LF/HF<1 (p = 0.03). The likelihood ratio to develop pneumonia when LF/HF < 1 was 6,1.

Conclusion

HRV seems to reflect the general frailty of the patient with hip fracture and might be used to identify patients in need of increased surveillance or prophylactic treatment.

Efficacy of Panoramic Radiography in the Detection of Osteoporosis in Post-Menopausal Women When Compared to Dual Energy X-Ray Absorptiometry

OBJECTIVE

It is a well-known fact that osteoporosis affects the people with old age and remains unnoticeable until the patient presents with fracture. Various studies in the literature reveal that panoramic radiographs may prove to be beneficial in the detection of Osteoporosis in patients. Henceforth this present study was aimed to validate the use of Klemetti Index (KI) on panoramic radiographs so as to detect osteoporosis in the patients at an early stage.

METHODS

60 postmenopausal women were selected. A panoramic radiograph was taken to grade their mandibular cortex on the basis of Klemetti Index. All the panoramic radiographs were evaluated by 5 different Oral Medicine and Radiology specialists. Later all the patients were subjected to dual energy X-ray absorptimetry (DEXA) scan for bone mineral density evaluation. The results were evaluated statistically.

RESULTS

The average accuracy of the five observers to demonstrate normal bone, osteopenia and osteoporosis when compared to DEXA scan was 58.08%, 63.3% and 64.74% respectively. The observations of the 5 observers on the basis of KI were not statistically different from the BMD evaluation done with the help of DEXA Scan.

CONCLUSION

Panoramic radiographs can be used as a screening tool for the evaluation as well as early detection of osteoporosis with the usage of Klemetti Index.

Excess mortality following hip fracture: impact of self-perceived health, smoking, and body mass index. A NOREPOS study

Self-perceived health, smoking, and body mass index measured years before the hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than subjects who did not fracture.

INTRODUCTION

This study aimed to investigate the impact of pre-fracture self-perceived health, smoking, and body mass index (BMI) on excess post-hip fracture mortality using matched peers without hip fracture as reference.

METHODS

The study was based on the Cohort of Norway (CONOR) consisting of 10 regional health studies (1994-2003) and the NOREPOS hip fracture database (1994-2008). A matched cohort design was used to compare survival between hip fracture patients and subjects without fracture (matched on gender, age at participation in CONOR, and study site). Subjects aged ≥60 years were included. Hazard ratios were estimated using stratified Cox regression. Age-standardized mortality was also calculated.

RESULTS

Overall, hip fracture patients (N = 3177) had a 2.26-fold (95 % CI 2.13, 2.40) increased mortality compared to matched subjects (N = 20,282). The highest excess mortality was found in hip fracture patients reporting poor health (HR 4.08, 95 % CI 3.17, 5.26) and daily smoking (HR 3.25, 95 % CI 2.89, 3.66) and in patients with BMI <18.5 (HR 3.07, 95 % CI 2.11, 4.47) prior to the fracture. However, excess mortality was also observed in hip fracture patients in all other categories of BMI, self-perceived health, and smoking.

CONCLUSIONS

Information on self-perceived health, smoking, and BMI collected years before hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than the matched subjects who did not fracture. This suggests that both pre-fracture health status and factors related to the hip fracture itself might affect post-hip fracture mortality.

Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project

BACKGROUND

Hip fractures are associated with diminished quality of life and survival especially amongst the elderly.

OBJECTIVE

All-cause mortality after hip fracture was investigated to assess its magnitude.

METHODS

A total of 122 808 participants from eight cohorts in Europe and the USA were followed up for a mean of 12.6 years, accumulating 4273 incident hip fractures and 27 999 deaths. Incident hip fractures were assessed through telephone interviews/questionnaires or national inpatient/fracture registries, and causes of death were verified with death certificates. Cox proportional hazards models and the time-dependent variable methodology were used to assess the association between hip fracture and mortality and its magnitude at different time intervals after the injury in each cohort. We obtained the effect estimates through a random-effects meta-analysis.

RESULTS

Hip fracture was positively associated with increased all-cause mortality; the hazard ratio (HR) in the fully adjusted model was 2.12, 95% confidence interval (CI) 1.76-2.57, after adjusting for potential confounders. This association was stronger amongst men [HR: 2.39, 95% CI: 1.72-3.31] than amongst women [HR: 1.92, 95% CI: 1.54-2.39], although this difference was not significant. Mortality was higher during the first year after the hip fracture [HR: 2.78, 95% CI: 2.12-3.64], but it remained elevated without major fluctuations after longer time since hip fracture [HR (95% CI): 1.89 (1.50-2.37) after 1-4 years; 2.15 (1.81-2.55) after 4-8 years; 1.79 (1.57-2.05) after 8 or more years].

CONCLUSION

In this large population-based sample of older persons across eight cohorts, hip fracture was associated with excess short- and long-term all-cause mortality in both sexes.

Impact of 3-Monthly Vitamin D Supplementation Plus Exercise on Survival after Surgery for Osteoporotic Hip Fracture in Adult Patients over 50 Years: A Pragmatic Randomized, Partially Blinded, Controlled Trial

OBJECTIVE

To determine whether 3-monthly supplementation of an oral vitamin D widely used in Spain (calcifediol) plus daily exercise could influence survival at one and four years after surgery for osteoporotic hip fracture.

DESIGN

A pragmatic, randomized, partially single-blind placebo-controlled study.

SETTING

Patients admitted to a tertiary university hospital for acute hip fracture.

PARTICIPANTS

675 healthy adult patients undergoing surgery for osteoporotic hip fracture were recruited from January 2004 to December 2007.

INTERVENTION

Patients were randomized to receive either 3-monthly oral doses of 3 mg calcifediol (Hidroferol Choque®) or placebo in the 12 months postsurgery. Patients who received calcifediol were also given an exercise programme. The placebo group received standard health recommendations only.

MEASUREMENTS

The primary endpoint was survival at 1 year and at 4 year follow-up. We also recorded new fractures, medical complications and anti-osteoporotic treatment compliance.

RESULTS

We included a total of 88 patients, aged 62 to 99 years. Mean age was 82 years and 88.6% were women. At 12 months, 10 (11.3%) patients had died, 9 of them, from the non-intervention group. At 4 years after surgery, 20 (22.7%) had died, 3 (3.4%) from the intervention group and 17 (19.3%) from the non-intervention group. At this time, survival curve analysis showed 93% survival in the intervention group and 62% in the non-intervention group (p=0.001). At 12-month follow up, there were 18 new fractures, 9 in each group. The non-intervention group had more medical complications, with significant differences at visit 2 (p = 0.04) and 3 (p = 0.02) but not at visit 4 (p = 0.18). No significant differences between groups were found regarding treatment compliance.

CONCLUSION

3-monthly, oral supplements of 3 mg calcifediol plus daily exercise improved survival at one-year and four-year follow up after surgery for an osteoporotic hip fracture.

Excess mortality of 1 year in elderly hip fracture patients compared with the general population in Beijing, China

In a rapidly aging population, hip fractures have become an important public health issue in China. Presently, there is no study on the excess mortality of hip fractures in the mainland of China. This is the first study that presents excess mortality following hip fracture in Beijing, China.

PURPOSE

This study aims to assess the incidence and excess mortality of hip fracture patients aged 60 years or older from a municipal population database of Beijing.

METHODS

We retrieved the Beijing municipal health insurance database of 2013 to identify beneficiaries who were at least 60 years older as total population of this age group and obtained the number of mortalities in a year. Among those people, subjects who have suffered hip fractures during the year were selected and a determination of the number of deaths in this period. Annual incidence of hip fracture, mortality, and excess mortalities was calculated and stratified by gender and age.

RESULTS

During 2013, the annual incidence of elderly hip fracture in Beijing was 0.27 % and 1-year mortality was 23.44 %. Excess mortality odds ratios of males and females in three age groups were as follows: males, 2.23 (60-69 years old, 95% CI, 1.43-3.49), 2.99 (70-79 years old, 95% CI, 2.57-3.50), and 1.90 (≥80 years old, 95% CI, 1.64-2.22 ) and females, 3.12 (60-69 years old, 95% CI, 2.04-4.79), 1.93 (70-79 years old, 95% CI, 1.64-2.27), and 1.36 (≥80 years old, 95% CI, 1.21-1.55). Pulmonary complications were the leading cause of death, which accounts for 52.27 % of all.

CONCLUSION

Compared with the control population, hip fractures caused approximately twofold excess mortality rate during 1 year 2014 for elderly citizens in Beijing. Future studies are needed to explore the actual mechanism to design the most effective strategies for optimizing recovery from hip fracture.

Atypical Femur Fractures in Patients Treated with Bisphosphonates: Identification, Management, and Prevention

Osteoporosis is a common condition with significant health care costs. First-line therapy is with bisphosphonates, which have proven anti-fracture efficacy. Around 10 years after the introduction of bisphosphonates reports began to be published of atypical femoral fractures (AFFs) that may be associated with this therapy. These fractures are associated with significant morbidity although lower mortality than the more common osteoporotic neck-of-femur fractures. A case definition has been described to allow identification of this class of fracture. Further work has established a high relative risk of AFFs in patients treated with bisphosphonates, but a low absolute risk in comparison to that of osteoporotic fractures. Proposed pathological mechanisms include low bone turnover states leading to stress/insufficiency fractures. Clinicians should be aware of the risk of AFFs and in particular the high rate of prodromal thigh/groin pain that warrants investigation in a patient receiving a bisphosphonate. If an incomplete fracture is diagnosed then bisphosphonate therapy needs to be stopped and prophylactic surgery may be considered. Due to these rare side effects patients on bisphosphonates require regular review, and this is particularly advised after 5 years of oral or 3 years of intravenous therapy.