Sub-optimal serum 25-hydroxyvitamin D level affects 2-year survival after hip fracture surgery

Impact of Vitamin D Deficiency on Short- and Long-Term Mortality in Patients Receiving Hip Fracture Surgery Under General Anesthesia: A Matched Cohort Study

BACKGROUND

Although vitamin D deficiency (VDD) is common in patients who have hip fractures, the relationship between VDD and mortality risk remains unclear.

METHODS

Using a network database (2010 to 2023), we conducted a matched cohort study of adult patients undergoing hip fracture surgery under general anesthesia. Patients were stratified according to preoperative 25-hydroxyvitamin D levels into VDD (≤ 20 ng/mL) and control groups (≥ 30 ng/mL). After 1:1 propensity score matching, 4,736 pairs were analyzed. The primary outcome was 12-month all-cause mortality. Secondary outcomes included 30- and 90-day all-cause mortality.

RESULTS

The 12-month mortality rate was significantly higher in the VDD group than in the control group (13.6 versus 11.6%, hazard ratio [HR]: 1.23, 95% confidence interval [CI]: 1.09 to 1.37, P = 0.0005). Similar patterns were observed at 30 days (3.4 versus 2.3%, HR: 1.52, P = 0.0007) and 90 days (7.1 versus 5.2%, HR: 1.41, P < 0.0001). Subgroup analyses based on age (18 to 65 versus > 65 years) and sex revealed a consistent association between VDD and mortality at 12 months. Vitamin D insufficiency (20 to 30 ng/mL) showed no significant association with increased mortality compared to the control group. Among patients who had VDD, malnutrition, neoplasms, diabetes mellitus, and heart disease have been identified as risk factors for 12-month mortality.

CONCLUSIONS

Preoperative VDD was significantly associated with increased mortality risk after hip fracture surgery, with particularly pronounced effects in the early postoperative period. These findings highlight the importance of preoperative vitamin D screening and potential supplementation strategies for patients who have vitamin D levels below 20 ng/mL.

Association of preoperative blood biomarkers with postoperative major adverse cardiac events and mortality in major orthopaedic surgery: a systematic review and meta-analysis

OBJECTIVE

The association between preoperative blood biomarkers and major adverse cardiac events (MACEs) as well as mortality after major orthopaedic surgery remains unclear. This study aimed to assess the association between preoperative blood biomarkers and postoperative MACEs as well as all-cause mortality in patients undergoing major orthopaedic surgery.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, the Cochrane Controlled Trials Register and Cochrane Database of Systematic Reviews from inception to 20 October 2024 were searched.

ELIGIBILITY CRITERIA

Observational or experimental studies reporting the correlation between preoperative blood biomarkers and postoperative MACEs-categorised as short-term (within 3 months) or long-term (beyond 3 months)-and all-cause mortality in patients undergoing major orthopaedic surgery.

DATA EXTRACTION AND SYNTHESIS

Data from studies reporting OR or HR and its 95% CI were pooled for analysis using random-effects model.

RESULTS

21 preoperative blood-based biomarkers from 80 studies with 226 468 patients were analysed. Elevated preoperative cardiac biomarkers were correlated with a heightened risk of MACEs within 3 months (natriuretic peptide: OR 3.37, 95% CI 2.07 to 5.47, I2=87.9%; cardiac troponin: OR 4.89, 95% CI 1.52 to 15.75, I2=69.5%) with significant heterogeneity. Only natriuretic peptide was associated with a high-risk long-term MACEs (>3 months) (OR 3.52, 95% CI 1.73 to 7.17, I2=86.2%). In contrast, cardiac biomarkers were not identified as having prognostic value for all-cause mortality in this patient cohort. Additionally, an increased risk of all-cause mortality was associated with preoperative abnormal levels of albumin (OR 1.15, 95% CI 1.06 to 1.24, I2=84.8%), creatinine (OR 1.54, 95% CI 1.12 to 1.95, I2=0), 25(OH)D (OR 1.58, 95% CI 1.01 to 2.14, I2=0) and glomerular filtration rate (GFR) (OR 1.12, 95% CI 1.06 to 1.17, I2=0), rather than cardiac biomarkers.

CONCLUSIONS

The study proposed that cardiac biomarkers assessed before surgery could offer prognostic insight into short-term MACEs, while preoperative abnormal levels of albumin, creatinine, 25 (OH)D and GFR might be prognostic valuable for all-cause mortality following major orthopaedic surgery.

PROSPERO REGISTRATION NUMBER

CRD42022352091.

Vitamin D deficiency in hip fracture patients is associated with an increased mortality risk

PURPOSE

The aims were to assess whether vitamin D deficiency influenced mortality risk and length of acute hospital stay in patients presenting with a hip fracture.

METHODS

A retrospective study was undertaken including all patients aged over 50 years that were admitted with a hip fracture to a single centre during a 24-month period. Serum vitamin D levels on admission, patient demographics, perioperative variables and mortality were collected. Cox regression analysis was utilised to determine the independent association between serum vitamin D levels and patient mortality.

RESULTS

The cohort consisted of 1510 patients with a mean age of 81.3 years and 1107 (71.4%) were female. 876 (58.0%) were vitamin D deficient (< 50 nmol/l). The median follow up was 405 (IQR 249 to 610) days. During follow-up there were 464 deaths (30.7%). Vitamin D deficiency was independently associated with higher mortality risk (hazard ratio [HR] 1.26, 95% confidence interval (CI) 1.03 to 1.53, P = 0.022). Male sex (HR 1.64, 95% CI 1.34 to 2.01, P < 0.001) was also associated with a higher mortality risk. Vitamin D deficiency was not associated with length of hospital stay (median difference 0 days, P = 0.207).

CONCLUSION

Vitamin D deficiency was independently associated with increased mortality in hip fracture patients, though this finding may be influenced by lack of comprehensive adjustment for comorbidity. While the value of routine serum vitamin D measurement is debated, supplementation during hospital stays is important to reduce falls and fracture risks associated with deficiency.

Increased Early Postoperative Complication Rate after Osteoporotic Hip Fracture in Patients with Low 25 (OH) Vitamin D Levels

This study investigated the association of preoperative 25-hydroxy (25 (OH)) vitamin D levels with postoperative complications in osteoporotic hip fracture patients following surgery. We hypothesized that patients with low concentrations of 25 (OH) vitamin D might have an increased risk of developing adverse outcomes. Between January 2019 and December 2020, a retrospective observational study was conducted, including low-energy fragility fractures at the proximal femur. Regarding preoperative 25 (OH) vitamin D levels, patients were divided into two groups (<30 ng/mL and ≥30 ng/mL). Early and late postoperative complications were assessed and graded according to the Clavien-Dindo classification system. Logistic regression analysis was performed to demonstrate the association between preoperative 25 (OH) vitamin D levels (<30 ng/mL, ≥30 ng/mL) and postoperative complications after adjusting for age and sex. Of 314 patients, 222 patients (70.7%) had a 25 (OH) vitamin D level of <30 ng/mL. The mean serum 25 (OH) vitamin D level was 22.6 ng/mL (SD 13.2). In 116 patients (36.9%), postoperative complications were observed, with the most occurring in the short term (95 patients, 30.2%). Late postoperative complications were present in 21 patients (6.7%), most graded as Clavien I (57.1%). Logistic regression analysis identified a low vitamin D level (<30 ng/mL) as an independent risk factor for early postoperative complications (OR 2.06, 95% CI 1.14-3.73, p = 0.016), while no significant correlation was found in late complications (OR 1.08, 95% CI 0.40-2.95, p = 0.879). In conclusion, preoperative 25 (OH) vitamin D serum level might be an independent predictor for early postoperative complications. However, future studies are warranted to determine risk factors for long-term complications and establish appropriate intervention strategies.

Adjuvant Vitamin D Injection in Elderly Patients Before Intertrochanteric Fracture Surgery: A Randomised Controlled Trial

BACKGROUND

There are multiple recommended protocols for Vitamin D (VitD) supplementation in elderly; however, only a few studies achieved to examine the role of VitD supplements before intertrochanteric fracture surgery on mortality and complications after surgery.

METHODS

This single-center block-randomized double-blinded trial was conducted on 80 patients with intertrochanteric fractures and a sufficient level of 25 (OH) VitD. The intervention group received an intramuscular 300,000 IU VitD ampule before surgery. The primary outcome was a 6-month mortality rate, and the secondary outcomes were 1- and 2-year mortality rates and Harris Hip Score (HHS) in 6, 12, and 24 months after surgery. Chi-square, t-test, repeated measure ANOVA, and Cox regression survival model was used for statistical analysis.

RESULTS

40 patients were allocated to each group. Demographic, clinical characteristics, and preoperative evaluations were not significantly different between the groups. Mortality rate 6-month after the surgery was 7.5% and 10% for the intervention and placebo groups respectively (P value = .71), 15% and 12.5% at 1-year (P value = .83), and 25% and 27.5% at 2-year (P value = .98). Based on the Cox regression model, only age was significantly associated with mortality (HR = 1.229, P value <.001). Significant HHS changes from baseline through 24 months after surgery were observed within both groups; however, mean differences were not significantly different between groups.

CONCLUSIONS

A single preoperative 300,000 IU VitD did not significantly impact 2-year survival and HHS in patients with intertrochanteric fractures and sufficient serum VitD level.

Impact of vitamin D deficiency on mortality in patients with hip fracture: A meta-analysis

BACKGROUND

Vitamin D deficiency has been linked to numerous health issues, including an increased risk of hip fractures. This meta-analysis aimed to investigate the relationship between vitamin D deficiency and mortality in patients with hip fracture. To assess the impact of different levels of vitamin D deficiency on mortality in patients with hip fractures and examine the influence of potential confounding factors.

METHODS

A systematic search of PubMed, EMBASE, Scopus, and Cochrane Collaboration Library was conducted, resulting in nine eligible cohort studies (n = 4409). Patients with hip fractures were categorized based on their vitamin D levels as severe, moderate, or insufficient. Mortality was the primary outcome measure in this study. Subgroup analyses were performed according to the follow-up time. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model in Review Manager 5.4.

RESULTS

Nine studies, with a pool of 4409 patients, were included. Vitamin D insufficiency was significantly associated with increased mortality (OR 1.24, 95% CI 1.05-1.46; I2  = 4%). Severe deficiency also led to a significant increase in mortality (OR 2.08, 95% CI 1.09-3.97; I2  = 42%), whereas moderate deficiency did not show a significant effect (OR 1.06, 95% CI 0.79-1.44; I2  = 0%). Subgroup analysis revealed significant associations between vitamin D insufficiency and increased mortality at 1-year (OR 1.37, 95% CI 1.06-1.77) and 2-year follow-ups (OR 1.78, 95% CI 1.01-3.15). After adjusting for potential confounders, no significant increase in the mortality rate was observed.

CONCLUSIONS

This meta-analysis suggests that vitamin D insufficiency and severe deficiency are associated with increased mortality in patients with hip fracture. However, after adjusting for confounding factors, this association was not statistically significant. Further research is necessary to understand the role of vitamin D deficiency in this population.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Risk factors of mortality and second fracture after elderly hip fracture surgery in Shanghai, China

INTRODUCTION

Hip fracture is one of the leading causes of death and disability in the elderly. We analyzed the risk factors of mortality and second fracture within 2 years after hip fracture surgery in elderly Chinese patients.

MATERIALS AND METHODS

A total of 613 elderly patients after hip fracture surgery were selected, including 181 males and 432 females, and the patients were followed for at least 24 months. Information about patients and surgery was collected from medical records. Information on death, secondary fracture, and postoperative activities of daily living (ADL) was obtained by telephone follow-up. Cox regression was performed to identify risk factors associated with mortality and second fracture, measured by hazard ratio (HR).

RESULTS

The 1-year and 2-year mortality rates after hip fracture were 13.4% and 20.7%, respectively. The second fracture rate within 2 years was 9.5%. Male gender (HR 1.51, P = 0.035), increased age (HR 1.07, P < 0.001), preoperative hypoalbuminemia (HR 1.79, P = 0.004), preoperative pneumonia (HR 2.60, P = 0.005) and poor ADL (P = 0.048) were independent risk factors for 2-year mortality, while high preoperative hemoglobin (HR 0.98, P = 0.002), high preoperative eGFR (HR 0.99, P = 0.031), high preoperative LVEF (HR 0.92, P = 0.048) were protective factors for 2-year mortality. Poor ADL (P = 0.002) was the independent risk factor for second fracture within 2 years.

CONCLUSIONS

The 2-year mortality rate and second fracture rate after hip fracture in elderly remained high, which was related to old age and complications exists. Postoperative rehabilitation and improving ADL were very important to reduce mortality and second fracture.

Relatively low and moderate pre-fracture serum 25-hydroxyvitamin D levels associated with the highest survival in elderly hip fracture patients in Finland: a minimum 3-year follow-up

The association between serum 25-hydroxyvitamin D level and post-fracture mortality indicates beneficial relatively high serum 25-hydroxyvitamin D concentrations. A 1-year cohort study on 245 hip fracture patients in Finland indicated the lowest 3-year mortality and highest survival among patients with serum 25-hydroxyvitamin D level of 50-74 nmol/L.

PURPOSE

To explore pre-fracture serum 25-hydroxyvitamin D level as a factor associated with post-fracture survival among a cohort of hip fracture patients in Finland.

METHODS

A prospectively collected cohort of hip fracture patients (n = 245, 70% women) from two hospitals was followed for 3.2 post-hip fracture years. Serum 25-hydroxyvitamin D was measured in admission to the hospital and classified: < 50, 50-74, 75-99, and ≥ 100 nmol/L. Survival was analyzed with a Bayesian multivariate model. Relative survival was explored with the life table method according to serum 25-hydroxyvitamin D. Mortality according to serum 25-hydroxyvitamin D level and to the hospital was calculated.

RESULTS

Mortality in the patients with serum 25-hydroxyvitamin D level of 50-74 nmol/L was significantly lower than in all other patients together at every post-fracture year. The most important factors for survival were age under 85 years; living in an actual/private home; serum 25-hydroxyvitamin D level of 50-74 nmol/L, followed by 75-99 nmol/L; ASA classes 1-2 and 3; and female sex. The mean age of patients with serum 25-hydroxyvitamin D level of 50-99 nmol/L was significantly higher than in other levels. Relative survival was highest in men, women, and patients in hospital B with serum 25-hydroxyvitamin D level of 50-74 nmol.

CONCLUSION

The highest 3-year survival and the lowest mortality in this cohort appeared in patients with pre-fracture serum 25-hydroxyvitamin D level of 50-74 nmol/L. This result differs from similar studies and is lower than the recommended level of 25-hydroxyvitamin D among hip fracture patients. The results should be examined in future research with larger data.

How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture?

In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.