Clinical profiles and risk factors for outcomes in older patients with cervical and trochanteric hip fracture: similarities and differences

Subtype consideration in hip fracture research: patient variances in inter- and intra-classification levels highlight the need for future research deliberation. A 2-years follow-up prospective-historical cohort

Current research on elderly patients with hip fractures often neglects specific subtypes, either grouping all fracture types or overlooking them entirely. By categorizing elderly patients based on fracture subtypes, we observed diverse baseline characteristics but found no discrepancies in measured outcomes. This emphasizes the need for caution in future research dealing with different or broader measured outcomes that were not covered by the scope of this research.

PURPOSE/INTRODUCTION

Existing research in elderly patients with hip fractures often overlooks the distinct subtypes or lumps all fracture types together. We aim to examine the differences between hip fracture subtypes to assess if these differences are meaningful for clinical outcomes and should be considered in future research.

METHODS

Patients above 65 years who underwent hip fracture surgeries during a three-year period were retrospectively reviewed. Cases were grouped based on fracture subtype: non-displaced femoral neck (nDFN), displaced femoral neck (DFN), stable intertrochanteric (sIT), and unstable intertrochanteric (uIT).

RESULTS

Among the 1,285 included cases, the nDFN-group had lower ASA scores (p = 0.009) and younger patients (p < 0.001), followed by the DFN-group (p = 0.014). The uIT-group had a higher proportion of female patients (72.3%, p = 0.004). Differences in preoperative ambulation status were observed (p = 0.001). However, no significant associations were found between fracture type and postoperative outcomes, including ambulation, transfusions, complications, reoperations, or mortality. Gender and preoperative ambulation status were predictors of mortality across all time frames. ASA score predicted mortality only within the first year after surgery. Age and gender were predictors of postoperative blood transfusions, while age and preoperative ambulation status were predictors of postoperative complications.

CONCLUSIONS

Variations in baseline characteristics of hip fractures were observed, but no significant differences were found in measured outcomes. This indicates that the hip fracture group is not homogeneous, emphasizing the need for caution in research involving this population. While grouping all types of proximal femur fractures may be acceptable depending on the outcome being studied, it's essential not to extrapolate these results to outcomes beyond the study's scope. Therefore, we recommend consider hip fracture subtypes when researching different outcomes not covered by this study.

Is There a "Black Friday" for Geriatric Hip Fracture Surgery?

OBJECTIVES

Reports show an increase in the short-term mortality rates of hip fracture patients admitted on weekends. However, there are few studies on whether there is a similar effect in Friday admissions of geriatric hip fracture patients. The aim of this study was to evaluate the effects of Friday admission on mortality and clinical outcomes in elderly patients with hip fractures.

METHODS

A retrospective cohort study was performed at a single orthopaedic trauma centre and included all patients who underwent hip fracture surgery between January 2018 and December 2021. Patient characteristics, including age, sex, BMI, fracture type, time of admission, ASA grade, comorbidities, and laboratory examinations, were collected. Data pertaining to surgery and hospitalization were extracted from the electronic medical record system and tabulated. The corresponding follow-up was performed. The Shapiro-Wilk test was applied to evaluate the distributions of all continuous variables for normality. The overall data were analyzed by Student's t test or the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables, as appropriate. Univariate and multivariate analyses were used to further test for the independent influencing factors of prolonged time to surgery.

RESULTS

A total of 596 patients were included, and 83 patients (13.9%) were admitted on Friday. There was no evidence supporting that Friday admission had an effect on mortality and outcomes, including length of stay, total hospital costs and postoperative complications. However, the patients admitted on Friday had delayed surgery. Then, patients were regrouped into two groups according to whether surgery was delayed, and 317 patients (53.2%) underwent delayed surgery. The multivariate analysis showed that younger age (p = 0.014), Friday admission (p < 0.001), ASA classification III-IV (p = 0.019), femoral neck fracture (p = 0.002), time from injury to admission more than 24 h (p = 0.025), and diabetes (p = 0.023) were risk factors for delayed surgery.

CONCLUSIONS

Mortality and adverse outcome rates for elderly hip fracture patients admitted on Friday were similar to those admitted at other time periods. However, Friday admission was identified as one of the risk factors for delayed surgery.

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.

Low muscle mass affect hip fracture treatment outcomes in older individuals: a single-institution case-control study

Background

Although sarcopenia has been known as a risk factor for hip fracture, only a few reports have described the impact of muscle mass on hip fracture treatment outcomes. The current study aimed to investigate the impact of muscle mass on hip fracture treatment outcomes.

Methods

This case–control study involved 337 patients (67 males and 270 females) with hip fracture aged ≥65 years (mean age: 84.1 ± 7.1 years) who underwent orthopedic surgery from January 2013 to June 2019. The mean follow-up period was 17.1 (1–60) months. Upon admission, all patients were assessed for low muscle mass according to the Asian Working Group for Sarcopenia criteria (male, SMI < 7.00 kg/m²; female, SMI < 5.40 kg/m²) using dual-energy X-ray absorptiometry. Treatment outcomes (stays at acute care institutions, hospital mortality, the Barthel index at discharge, and home discharge rates, and one-year mortality) were compared between patients with and without low muscle mass by Student’s t-test, Mann-Whitney U test and the Pearson Chi-Square test. A multivariate logistic regression model was used to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for factors related to low muscle mass. Kaplan–Meier survival curves on one-year mortality of hip fracture patients for those with and without low muscle mass were prepared, and log-rank tests were performed. Furthermore, we determined whether low muscle mass was a risk factor for one-year mortality in hip fracture patients using a Cox proportional hazards model.

Results

The prevalence of low muscle mass in patients with hip fracture was 231(68.5%). Those with low muscle mass had a lower Barthel index (P < 0.0001), hospital discharge rate (P = 0.035) and higher one-year mortality (P = 0.010). Cox proportional hazards regression analysis adjusted for age and sex found that low muscle mass was a risk factor for one-year mortality (hazard ratio, 3.182, 95% confidence interval, 1.097–9.226, P = 0.033).

Conclusions

Patients with hip fracture who had low muscle mass had a lower Barthel index, lower home discharge rate, and higher one-year mortality. Moreover, low muscle mass was identified as a risk factor for one-year mortality among those with hip fracture. The aforementioned findings may help clinicians better manage those with hip fracture.

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

The Associations of Serum Vitamin D and Bone Turnover Markers with the Type and Severity of Hip Fractures in Older Women

Purpose

Vitamin D (25[OH]D) status and bone turnover markers (BTMs) are considered important determinants of bone quality, which is associated with the risk of hip fractures, including both femoral neck and intertrochanteric fractures, in older adults; however, the exact relationship of 25(OH)D and BTMs with the type and severity of hip fractures remains unclear and the present study aimed to identify any specific associations.

Patients and Methods

According to the inclusion and exclusion criteria, 441 older female patients with hip fractures from 2015 to 2020 and 215 women without hip fractures were included in this cross-sectional study. According to Garden and AO/OTA classifications for femoral neck and intertrochanteric fractures, patients were divided into less severe (Garden I and Garden II; 31A1) and more severe (Garden III and Garden IV; 31A2 and 31A3) fracture groups. Levels of the serum osteoblast indicator, N-terminal/mid region (N-MID); the osteoclast indicator, beta-carboxy terminal telopeptide (β-CTX); and 25(OH)D were analyzed.

Results

For patients with less severe fractures, mean 25(OH)D levels were significantly higher than those with more severe fractures (17.67 vs 15.30 ng/mL, p = 0.006). Higher 25(OH)D levels were also observed in patients with less severe intertrochanteric fractures (p = 0.01). After adjustments for confounders, 25(OH)D remained a risk factor for patients with more severe fractures (p = 0.01), particularly those with intertrochanteric fractures (p = 0.011). No significant differences in BTMS were found between patients with less severe and more severe fractures.

Conclusion

Levels of 25(OH)D were significantly associated with the severity of intertrochanteric, but not femoral neck, fractures. Neither 25(OH)D nor BTMs were associated with the type of hip fracture in older women. Separate consideration of intertrochanteric and femoral neck fractures may be appropriate when investigating the clinical association between 25(OH)D and the severity of hip fractures in older women.

Relationship between the AB0 Blood System and Proximal Femoral Fracture Patterns in the Turkish Population

Objective. AB0 blood groups have shown to be associated with increased risk of several orthopedic disorders such as Achilles tendon rupture and hip osteoarthritis. The objective of this study was to investigate relationships between the AB0 blood system and hip fracture patterns, duration of hospitalization, and amount of blood transfusion. Methods. Data of 308 patients treated due to hip fractures in our hospital between 2017 and 2019 were evaluated. Epicrisis reports and X-rays of the patients included in this study were retrospectively screened, and hip fractures were classified as intracapsular and extracapsular fractures. Patients were divided into A, B, 0, and AB groups according to blood groups. Results. The mean age of the patients was 75.54±13.5 years. Of all patients, 103 had an intracapsular fracture and 205 had an extracapsular fracture. No statistically significant correlation was found between blood groups and fracture patterns. No statistically significant difference was found between the amounts of transfusion according to the blood groups, and no significant difference between the durations of hospitalizations according to the blood groups. Conclusion. In our study population, we could not find a significant relationship between the AB0 blood system and fracture patterns. We think that these potential relationships could be explained with further comprehensive studies with larger populations.

Analysis of Bone Impairment by 3D DXA Hip Measures in Patients With Primary Hyperparathyroidism: A Pilot Study

CONTEXT

Primary hyperparathyroidism (PHPT) has been related to bone loss. Dual-energy x-ray absorptiometry (DXA) cannot distinguish between trabecular and cortical bone compartments but the recently developed three-dimensional (3D)-DXA software might overcome this issue.

OBJECTIVE

To examine the differences in DXA-derived areal bone mineral density (aBMD) and 3D-DXA parameters at the hip site between patients with PHPT and a healthy control group.

DESIGN

Cross-sectional pilot study.

SETTING

Hospital.

PATIENTS

80 adults (59.5 ± 9.1 yrs), 40 with PHPT and 40 age- and sex-matched healthy controls.

MEASURES

aBMD (g/cm2) of the femoral neck, trochanter, shaft, and total hip was assessed using DXA. Cortical surface (sBMD, mg/cm2), cortical volumetric BMD (vBMD, mg/cm3), trabecular vBMD (mg/cm3), integral vBMD (mg/cm3) and cortical thickness (mm) was assessed using 3D-DXA software.

RESULTS

Mean-adjusted values showed lower aBMD (7.5%-12.2%, effect size: 0.51-1.01) in the PHPT group compared with the control group (all P < 0.05). 3D-DXA revealed bone impairment (3.7%-8.5%, effect size: 0.47-0.65) in patients with PHPT, mainly in cortical parameters (all P < 0.05). However, differences in trabecular vBMD were not statistically significant (P = 0.055). The 3D mapping showed lower cortical sBMD, cortical vBMD, and cortical thickness at the trochanter and diaphysis in the PHPT group (P < 0.05) compared with the control group. In both groups, the presence of osteopenia or osteoporosis is related to lower cortical bone.

CONCLUSIONS

aBMD and cortical 3D parameters are impaired in patients with PHPT versus healthy controls. The vBMD of the trabecular compartment seems to be affected, although to a lesser extent.

The role of parathyroid hormone (PTH) and vitamin D in falls and hip fracture type

BACKGROUND

Fragility fractures of the hip are associated with high morbidity and mortality, and represent a rather devastating consequence of osteoporosis. Hip fractures are traditionally investigated as a whole, although it has been recently implied that distinct pathogenic mechanisms may lead either to trochanteric or subcapital fractures.

AIMS

To investigate whether differences exist by hip fracture type with respect to serum 25(OH)D (vitamin D) and parathyroid hormone (PTH) levels, in addition to epidemiological and demographic data, including history of falls.

METHODS

The inclusion criteria were met by 116 patients [48 men and 68 women; mean age 80.8 ± 8.5 (range 62-94) years]. Patients were analyzed according to hip fracture type, history of falls, and vitamin D and PTH status.

RESULTS

Older age, recurrent falls, serum levels of PTH > 65 pg/ml, and severe vitamin D deficiency were found to be associated with trochanteric fractures. Additionally, older age, female gender, PTH > 65 pg/ml, and severe vitamin D deficiency were related to recurrent falls. Meanwhile, patients with absence of PTH response to low vitamin D levels, were not repeated fallers and suffered mostly from subcapital fractures.

DISCUSSION AND CONCLUSION

Elevated PTH levels predispose both to falls and trochanteric fractures, while vitamin D-deficient patients with normal PTH levels are mostly related to subcapital fractures. It is thereby indicated that different pathophysiological processes lie behind subcapital and trochanteric fractures. A better understanding of these mechanisms may assist in the development of prevention strategies for individuals recognized at risk for falls and either type of hip fracture.

Preoperative myocardial troponin T elevation is associated with the fracture type in patients with proximal femoral fracture

BACKGROUND AND AIMS

Cardiovascular complications are common in hip fracture patients but the role of fracture type and operative method in these is unclear. This prospective cohort study aimed to evaluate the impact of fracture- and operative characteristics on perioperative cardiovascular complications and prognosis in unselected hip fracture patients.

MATERIAL AND METHODS

During a 7-month trial registration period, a population of 197 consecutive hip fracture patients (median age 84 years) diagnosed with femoral neck or pertrochanteric fracture was formed. The exclusion criteria were patient refusal, subtrochanteric fracture, or death preoperatively. Pre- and postoperative troponin T (TnT) elevation, perioperative N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) level, perioperative cardiovascular adverse events, and all-cause 30-day and 2- and 5-year mortalities were studied.

RESULTS

Femoral neck fracture was independently associated with preoperative myocardial injury witnessed by TnT elevation (HR 2.95, 95% confidence interval 1.21-7.19, p = 0.018). The fracture type, surgery delay, or operative method were not significantly associated with NT-proBNP levels, cardiovascular adverse event diagnoses, or prognosis. Cardiovascular adverse events were clinically diagnosed in 28 (14%) participants, and these had a higher mortality compared to participants without such diagnosis (at 30 days, 32% vs 5%; 2 years, 71% vs 31%; and 5 years, 86% vs 59%; p < 0.001).

CONCLUSION

While the femoral neck fracture independently predicts preoperative cardiovascular morbidity, the operative method does not affect perioperative cardiovascular complications or the prognosis, and it may be selected by the treating clinician based on other criteria.

ABO system is not associated with proximal femoral fracture pattern in Southern Italy

INTRODUCTION:

The mechanism that leads to a given fracture pattern is not understood. Heredity could act in this field through the ABO system. We investigated the relationship between ABO blood system and hip fracture pattern in a population from Southern Italy.

METHODS:

Hip fractures were identified through a registry evaluation of the activity of a level I Hospital, and subsequently classified in 'intracapsular' or 'extracapsular' according to their anatomical location. Information on these patients' ABO blood type was collected and compared with general population data from the report on blood donors of the Salerno division of Italian Blood Volunteers Association (AVIS).

RESULTS:

590 hip fractures were included (414 extracapsular, 176 intracapsular) and compared with 709 blood donors. Fractured patients presented a blood group A more often and blood group O less often than the AVIS population ( p A vs. non-A = 0.0033; p O vs. non-O = 0.0024). None of the ABO blood groups were associated with fracture pattern ( p O vs. non-O = 0.5858, p A vs. non-A = 0.409; p B vs. non-B = 0.253; p AB vs. non-AB = 0.212). The rhesus factor was not associated the fracture pattern ( p = 0.34).

CONCLUSIONS:

The ABO blood type could play a role as a risk factor for proximal femoral fractures, but in our population its relevance in influencing the fracture pattern is unclear.

Usefulness of simple biomarkers at admission as independent indicators and predictors of in-hospital mortality in older hip fracture patients

INTRODUCTION

The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.

PATIENTS AND METHODS

In 1820 consecutive patients with low-trauma osteoporotic HF aged >60 years (mean age 82.8 ± 8.1 years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (≥60 years of age) HF patients (mean age 82.1 ± 8.0 years, 72.1% women).

RESULTS

The mortality rate was 6% (n = 109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33 g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8 pmol/L; 25(OH)vitamin D < 25 nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60 ml/min/1.73 m²] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70-0.80). The risk of in-hospital death was 1.6-2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6-6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% -none RF to 16.8%- ≥4RF). The prognostic value of a single RF was low (AUC ≤0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77-0.90) when ≥4 RFs (versus 0-1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or ≥4 RFs and observed deaths were practically similar.

CONCLUSIONS

In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management.

Risk factors for trochanteric and femoral neck fracture

INTRODUCTION AND OBJECTIVES

The differences between the two main types of fracture of proximal end of the femur, trochanteric and cervical fractures, are still a subject of study, and could be the key to a better understanding of its pathophysiology and prevention. The aim of this study is to determine whether epidemiological differences in the distribution of risk factors associated with hip fracture exist between these two entities.

PATIENTS AND METHOD

A descriptive cross-sectional study of 428 patients over the age of 65 admitted for trochanteric or cervical fractures in 2015, in which gender, age, previous diagnosis, external causes associated with fracture and place of the event were recorded.

RESULTS

There were 220 patients with a cervical fracture (51.4%) and 208 patients with a trochanteric fracture (48.6%). The average age was higher in the trochanteric fracture, observing a constant increase with age only in women with trochanteric fractures. Cervical fracture showed a significant association with cerebrovascular disease (p=0.039) and trochanteric fracture with accidental falls (p=0.047) and presence of 5-9 previous diseases (p=0.014). A regression analysis maintained this association in the case of a cerebrovascular disease (OR 2.6, 95%CI 1.1-6.4) and the presence of 5-9 diseases (OR 1.5, 95%CI 1.1-2.3).

CONCLUSIONS

Trochanteric fractures are associated with women patients of more advanced ages, 5-9 previous diseases and accidental falls. Cerebrovascular disease shows a higher prevalence in cervical fractures.

The role of adipokines as prognostic factors of one-year mortality in hip fracture patients

This study investigated the impact of anthropometric parameters, adiponectin, leptin, homeostatic model assessment for insulin resistance (HOMA-IR), beta-isomerised C-terminal telopeptide of collagen type I (β-CTX), and routine biochemical tests on one-year mortality in hip fracture patients. We found that male patients with high adiponectin, leptin, and β-CTX levels had a 5-fold increase in all-cause one-year mortality.

INTRODUCTION

Several predictors of one-year hip fracture mortality have been identified including advanced age, male sex, low bone mineral density, and preexisting comorbidities. However, the impact of metabolic parameters on hip fracture mortality remains unknown. The aim of this study was to examine the effect of serum leptin and adiponectin levels, as well as other metabolic parameters on all-cause one-year hip fracture mortality.

METHODS

This prospective study included 236 patients of all ages with non-traumatic hip fractures. Anthropometric parameters, adiponectin, leptin, HOMA-IR, β-CTX, and routine biochemical tests were recorded at admission and correlated with one-year mortality by using multivariate Cox proportional hazard models.

RESULTS

The median patient age was 82 (75-87) years, and one-year mortality rate was 28.4%. In univariate analysis, adiponectin, age, β-CTX, and renal function were associated with mortality. However, in a multivariate model, male gender, high β-CTX, adiponectin, and leptin were independently associated with increased mortality. Thus, we constructed a nomogram that included all the latter variables in addition to age. The nomogram predicted mortality with a sensitivity of 74.8% (66.0-82.3) and specificity of 74.4% (57.9-87.0), and had an area under the curve of 0.784. Patients that scored <9.2 had a mortality of 10.1%, while those with >9.2 had a mortality of 49.2% (relative risk 5.4, 95% CI 2.8-10.2, P < 0.001).

CONCLUSION

Male patients with high adiponectin, leptin, and β-CTX levels have a 5-fold increase in all-cause one-year mortality after hip fracture.

The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

AIM

To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients.

METHODS

On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF.

RESULTS

Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR.

CONCLUSIONS

In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease

INTRODUCTION

Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients.

SOURCES OF DATA

A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications.

AREAS OF AGREEMENT

Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture.

AREAS OF CONTROVERSY

Regain of mobility and return to previous residential status have been variably reported.

GROWING POINTS

All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization.

RESEARCH

Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

Differential impact of some risk factors on trochanteric and cervical hip fractures

AIM

To investigate the potential distinct risk factors associated with trochanteric and cervical hip fractures.

METHODS

Elderly patients aged 65 years and older (n = 1161) were admitted to the orthopedic department with hip fractures during the years 2006-2011. Demographic and clinical data, as well as routine blood tests, were retrieved from the patient electronic medical records.

RESULTS

Approximately 58% of patients had trochanteric fractures and 42% had cervical fractures. Women were more likely to have trochanteric fractures than men (P = 0.002). Female sex, frailty, falls, diabetes and subnormal calcium, as well as subnormal hemoglobin levels, were significant risk factors for trochanteric fractures (OR 1.39, P = 0.0202, OR 1.36, P = 0.0166, OR 1.49, P = 0.0015, OR 1.33, P = 0.0343, OR 0.68, P = 0.0054, OR 0.70, P = 0.0036, respectively). Patients with Parkinson's disease were at a lower risk for trochanteric fractures (OR 0.6, P = 0.007).

CONCLUSION

As there are some differences between risk factors for trochanteric and cervical hip fractures, there is a need for further studies in order to understand the etiology of fractures and to be able to carry out effective preventive efforts.

Poststroke hip fracture: prevalence, clinical characteristics, mineral-bone metabolism, outcomes, and gaps in prevention

Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years (82.3 ± 8.8 years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%). This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed.