Mortality following fragility hip fracture in China: a record linkage study

Frailty as a determinant of mortality, surgical timing and hospital stay in proximal femur fractures: a retrospective cohort study

BACKGROUND

Proximal femur fractures are common in elderly patients and are strongly associated with frailty, increased mortality, and functional decline. The Clinical Frailty Scale (CFS) has emerged as a key predictor of outcomes, influencing perioperative management and rehabilitation strategies. This study aims to evaluate the impact of frailty on mortality, surgical timing, and length of hospital stay (LOS) in patients with hip fractures.

METHODS

This single-center retrospective study analyzed data from patients aged ≥ 65 years admitted with AO type 31A and 31B proximal femur fractures between 2018 and 2023. Patients were stratified according to CFS scores to assess the relationship between frailty and in-hospital mortality, surgical delay, and LOS. Multivariate logistic regression was performed to identify independent risk factors.

RESULTS

Among 2312 patients (median age: 85 years), frailty was a significant predictor of mortality (p = 0.019). Patients with CFS 7-9 had a 6.6-fold higher mortality risk than those with CFS 1-3. Delays in surgery beyond 48 h were associated with a doubled risk of mortality (p = 0.009), particularly in frail patients. Prolonged LOS (> 7.1 days) correlated with an increased incidence of infections, cardiovascular events, and mortality (p < 0.001).

CONCLUSIONS

Frailty significantly impacts hip fracture prognosis in elderly patients, increasing mortality, complications, and LOS. Early identification of frail patients and prioritization of timely surgery are crucial to improving outcomes. Future studies should explore tailored surgical strategies and optimized rehabilitation protocols to enhance recovery in this high-risk population.

Geriatric nutritional risk index (GNRI) as a predictor of fragility fracture risk in older adults living with HIV: a 10-year retrospective longitudinal cohort study from China

This study reveals that the Geriatric Nutritional Risk Index (GNRI) is a strong predictor of fragility fracture risk in older adults living with HIV in China. Regular nutritional assessment using GNRI could identify high-risk individuals, potentially guiding interventions to reduce fracture risk in this vulnerable population.

BACKGROUND

In China, a significant proportion of the PLWH are older adults, which differs from other regions. Malnutrition and fragility fractures are major concerns in this population. This study aimed to investigate the utility of the Geriatric Nutritional Risk Index (GNRI) as a predictor of fragility fracture risk in older adults living with HIV in China.

METHODS

This retrospective longitudinal cohort study included older adults living with HIV (aged ≥ 50 years) from the Department of Orthopedics at Ditan Hospital in Beijing, China, between January 2010 and September 2023. Baseline GNRI scores were calculated using serum albumin, height, and weight, and patients were followed up for the occurrence of fragility fractures. Cox proportional hazards models were used to evaluate the association between GNRI and fragility fracture risk, adjusting for potential confounders.

RESULTS

A total of 608 patients were included in the study (mean age: 60.3 years, 84.2% male). During the median 5-year follow-up period, 117 patients (19.2%) experienced fragility fractures. After adjusting for all potential covariates, patients with higher GNRI scores had a significantly lower risk of fragility fractures. The aHR for GNRI < 92 g/L was 3.28 (95% CI: 1.35-7.97, p = 0.009) compared to GNRI ≥ 92. RCS analysis revealed a significant inverse relationship between GNRI and fragility fracture risk, with the non-linearity diminishing after full adjustment for covariates.

CONCLUSION

The GNRI is a valuable tool for predicting fragility fracture risk in older adults living with HIV in China. Routine assessment of nutritional status using the GNRI could help identify high-risk individuals and guide appropriate interventions to reduce fragility fracture risk in this vulnerable population.

Top comorbidities in osteoporotic fracture patients in a northeast population in China

BACKGROUND

Osteoporotic fractures frequently occur in conjunction with various diseases, and the comorbidity of fractures is a significant contributor to their high disability and mortality rates. This study aimed to examine the pattern of comorbidity in fracture patients and non-fracture individuals.

METHODS

Using data from community- and hospital-based populations in Jilin, China, we identified osteoporotic fracture patients over 40 years of age. We matched each fracture patient with two non-fracture individuals based on age (± 3 years) and sex. Major comorbidities including hypertension, type 2 diabetes, hyperlipidemia, obesity, coronary heart disease (CHD), stroke, hyperthyroidism, hyperparathyroidism, osteoporosis, rheumatoid arthritis, respiratory diseases, gastrointestinal diseases, and breast cancer, were ascrertained from patients' laboratory test results and self-reported data.

RESULTS

We identified 51 hospital-based fracture patients, 181 community-based fracture patients and 362 matched non-fracture individuals. The mean age for both overall fracture patients and non-fracture individuals was 67.8 years. Females accounted for 72.8% of overall fracture patients and 71.8% of non-fracture individuals. The most common comorbidity was hypertension for overall fracture patients (45.3%), hospital-based fracture patients (39.2%), and non-fracture individuals (56.4%), whereas hyperlipidemia was the most frequent condition for community-based fracture patients (63.6%). The top binary comorbidity combination pattern for community-based fracture patients (30.4%) and non-fracture individuals (29.6%) was hyperlipidemia & hypertension, while for hospital-based (15.7%) and overall (15.1%) fracture patients it was hypertension & type 2 diabetes. The average degree of comorbidity network for overall fracture patients (7.0) was higher than that for non-fracture individuals (5.4).

CONCLUSIONS

The most common comorbidities were hyperlipidemia and hypertension among fracture patients. As compared to non-fracture individuals, fracture patients exhibited a more complex comorbidity network. These findings help us better target the management of comorbidities in patients with osteoporotic fractures and reduce the burden associated with fractures.

TRIAL REGISTRATION

Not applicable.

An Updated Perspective of the Clinical Features and Parathyroidectomy Impact in Primary Hyperparathyroidism Amid Multiple Endocrine Neoplasia Type 1 (MEN1): Focus on Bone Health

Background: Multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism (MPHPT) belongs to genetic PHPT that accounts for 10% of all PHPT cases, being considered the most frequent hereditary PHPT (less than 5% of all PHPT). Objective: We aimed to provide an updated clinical perspective with a double purpose: to highlight the clinical features in MPHPT, particularly, the bone health assessment, as well as the parathyroidectomy (PTx) impact. Methods: A comprehensive review of the latest 5-year, English-published, PubMed-accessed original studies. Results: The sample-based analysis (n = 17 studies) enrolled 2426 subjects (1720 with MPHPT). The study design was retrospective, except for one prospective and one case-control study. The maximum number of patients per study was of 517. Female predominance (an overall female-to-male ratio of 1.139) was confirmed (except for three studies). Age at MPHPT diagnosis (mean/median per study): 28.7 to 43.1 years; age at PTx: 32 to 43.5 years. Asymptomatic PHPT was reported in 38.3% to 67% of MPHPT. Mean total calcium varied between 1.31 and 2.88 mmol/L and highest PTH was of 317.2 pg/mL. Two studies reported similar PTH and calcaemic levels in MPHPT vs. sporadic PHPT, while another found higher values in MPHPT. Symptomatic vs. asymptomatic patients with MPHPT had similar PTH and serum calcium levels (n = 1). Osteoporosis (n = 8, N = 723 with MPHPT) was reported in 10% to 55.5% of cases, osteopenia in 5.88% to 43.9% (per study); overall fracture rate was 10% (of note, one study showed 0%). Lower bone mineral density (BMD) at DXA (n = 4) in MPHPT vs. sporadic PHPT/controls was found by some studies (n = 3, and only a single study provided third distal radius DXA-BMD assessment), but not all (n = 1). Post-PTx DXA (n = 3, N = 190 with MPHPT) showed a BMD increase (e.g., +8.5% for lumbar spine, +2.1% for total hip, +4.3% for femoral neck BMD); however, post-operatory, BMD remains lower than controls. Trabecular bone score (TBS) analysis (n = 2, N = 142 with MPHPT vs. 397 with sporadic PHPT) showed a higher prevalence of reduced TBS (n = 1) or similar (n = 1). PTx analysis in MPHPT (n = 14): rate of subtotal PTx of 39% to 66.7% (per study) or less than subtotal PTx of 46.9% (n = 1). Post-PTx complications: persistent PHPT (5.6% to 25%), recurrent PHPT (16.87% to 30%, with the highest re-operation rate of 71% in one cohort); hypoparathyroidism (12.4% to 41.7%). Genetic analysis pointed out a higher risk of post-PTx recurrence in exon 10 MEN1 pathogenic variant. Post-PTx histological exam showed a multi-glandular disease in 40% to 52.1% of MPHPT, and a parathyroid carcinoma prevalence of 1%. Conclusions: MPHPT remains a challenging ailment amid a multi-layered genetic syndrome. Current data showed a lower age at MPHPT diagnosis and surgery than found in general population, and a rate of female predominance that is lower than seen in sporadic PHPT cases, but higher than known, for instance, in MEN2. The bone involvement showed heterogeneous results, more consistent for a lower BMD, but not necessarily for a lower TBS vs. controls. PTx involves a rather high rate of recurrence, persistence and redo surgery. About one out of ten patients with MPHPT might have a prevalent fracture and PTx improves the overall bone health, but seems not to restore it to the general population level, despite the young age of the subjects. This suggests that non-parathyroid components and potentially menin protein displays negative bone effects in MEN1.

Improving morbidity and mortality in hip fragility fractures

PURPOSE OF REVIEW

Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system.

RECENT FINDINGS

There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality.

SUMMARY

HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Risk prediction models of mortality after hip fracture surgery in older individuals: a systematic review

OBJECTIVE

This study aimed to critically assess existing risk prediction models for postoperative mortality in older individuals with hip fractures, with the objective of offering substantive insights for their clinical application.

DESIGN

A comprehensive search was conducted across prominent databases, including PubMed, Embase, Cochrane Library, SinoMed, CNKI, VIP, and Wanfang, spanning original articles in both Chinese and English up until 1 December 2023. Two researchers independently extracted pertinent research characteristics, such as predictors, model performance metrics, and modeling methodologies. Additionally, the bias risk and applicability of the incorporated risk prediction models were systematically evaluated using the Prediction Model Risk of Bias Assessment Tool (PROBAST).

RESULTS

Within the purview of this investigation, a total of 21 studies were identified, constituting 21 original risk prediction models. The discriminatory capacity of the included risk prediction models, as denoted by the minimum and maximum areas under the subject operating characteristic curve, ranged from 0.710 to 0.964. Noteworthy predictors, recurrent across various models, included age, sex, comorbidities, and nutritional status. However, among the models assessed through the PROBAST framework, only one was deemed to exhibit a low risk of bias. Beyond this assessment, the principal limitations observed in risk prediction models pertain to deficiencies in data analysis, encompassing insufficient sample size and suboptimal handling of missing data.

CONCLUSION

Subsequent research endeavors should adopt more stringent experimental designs and employ advanced statistical methodologies in the construction of risk prediction models. Moreover, large-scale external validation studies are warranted to rigorously assess the generalizability and clinical utility of existing models, thereby enhancing their relevance as valuable clinical references.