Treatment and survival among elderly Americans with hip fractures: a population-based study

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures.

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed.

RESULTS

In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025).

CONCLUSIONS

Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used

BACKGROUND

Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking.

QUESTIONS/PURPOSES

(1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway?

METHODS

In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes.

RESULTS

After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints.

CONCLUSION

In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bone health and predictors of 15-year mortality in a physically active population

OBJECTIVE

To analyse determinants of mortality at 15 years in a population over 60 years of age and physically active.

METHODS

This is a prospective longitudinal study. After 15 years of participating in an active ageing programme, participants were contacted by telephone to verify their state of health and to determine whether in that time they had had any fractures.

RESULTS

561 individuals over 60 years of age were included, 82% of whom were women. Only differences in densitometric data, FRAX values and history of previous fracture at baseline characteristics were found between the group that died at 15 years and the group that remained alive. The only variables that were related to mortality risk were the basal data of the densitometric t-score (OR = .50, P < .001) and history of fracture in any location (OR = 2.44, P < .033).

CONCLUSIONS

The value of bone mineral density could be considered as a useful biomarker to calculate the risk of mortality in people over 60 years old with a physically active lifestyle.

Validation of Operational Definition to Identify Patients with Osteoporotic Hip Fractures in Administrative Claims Data

As incidences of osteoporotic hip fractures (OHFs) have increased, identifying OHFs has become important to establishing the medical guidelines for their management. This study was conducted to develop an operational definition to identify patients with OHFs using two diagnosis codes and eight procedure codes from health insurance claims data and to assess the operational definition’s validity through a chart review. The study extracted data on OHFs from 522 patients who underwent hip surgeries based on diagnosis codes. Orthopedic surgeons then reviewed these patients’ medical records and radiographs to identify those with true OHFs. The validities of nine different algorithms of operational definitions, developed using a combination of three levels of diagnosis codes and eight procedure codes, were assessed using various statistics. The developed operational definition showed an accuracy above 0.97 and an area under the receiver operating characteristic curve above 0.97, indicating excellent discriminative power. This study demonstrated that the operational definition that combines diagnosis and procedure codes shows a high validity in detecting OHFs and can be used as a valid tool to detect OHFs from big health claims data.

Analysis of Factors Affecting the Third- and Twelfth-Month Mortality in Patients with Hip Fractures Aged 80 Years and Older

BACKGROUND

The purpose of this study was to evaluate the possible risk factors that are related with mortality at third and twelfth months after hip fractures in a large population of patients aged 80 years and older.

METHODS

605 patients were evaluated in terms of the localization of the fracture, gender, age, side of the fracture, the type of applied procedure, anesthesia type, hospitalization time, time to operation, comorbidities, ASA score, the values of preoperative hemoglobin, lymphocyte and neutrophil percentage, white blood cell, albumin, sodium levels. The state mortality system was used to investigate whether patients are alive or died. Statistical analysis was performed to evaluate the important factors on third- and twelfth-month mortality.

RESULTS

Male gender, neurologic-cardiac-chronic obstructive pulmonary (COP) diseases, preoperative hemoglobin level < 10 g/dL, arthroplasty and external fixator groups, ASA grade ≥ 3, delaying the surgery more than 4 days, longer hospitalization time, lower albumin levels and advanced age were found to be statistically significant factors for 3-month mortality (p values were; 0.01, 0.02, 0.01, 0.01, 0.047, 0.01, 0.02, 0.002, < 0.001, 0.002 and 0.01, respectively). Male gender, hypertension-neurologic-cardiac diseases, preoperative hemoglobin level < 10 g/dL, delaying the surgery more than 4 days, longer hospitalization time, lower lymphocyte percentage, lower albumin levels and advanced age were found to be statistically significant factors for 12-month mortality (p values were; < 0.001, 0.01, 0.01, 0.01, 0.03, 0.01, < 0.001, 0.01, 0.004 and < 0.001, respectively).

CONCLUSION

COP, advanced age, and heart disease were the most important factors in 3-month mortality. Long hospitalization time, male gender and advanced age were the most important factors affecting the 12-month mortality.Level of Evidence Prognostic level IV.

Bone Health and Predictors of 15-Year Mortality in a Physically Active Population

OBJECTIVE

To analyse determinants of mortality at 15years in a population over 60years of age and physically active.

METHODS

This is a prospective longitudinal study. After 15years of participating in an active aging programme, participants were contacted by telephone to verify their state of health and to determine whether in that time they had had any fractures.

RESULTS

A total of 561 individuals over 60years of age were included, 82% of whom were women. Only differences in densitometric data, FRAX values and history of previous fracture at baseline characteristics were found between the group that died at 15years and the group that remained alive. The only variables that were related to mortality risk were the basal data of the densitometric T-score (OR=.50, P<.001) and history of fracture in any location (OR=2.44, P<.033).

CONCLUSIONS

The value of bone mineral density could be considered as a useful biomarker to calculate the risk of mortality in people over 60years old with a physically active lifestyle.

Banding with lesser trochanter fragment using nonabsorbable tape in trochanteric femoral fractures

Introduction: Trochanteric femoral fracture is one of the most common fractures in the elderly. Trochanteric femoral fracture with involvement of the lesser trochanter is considered unstable and recognized as having a poor prognosis. However, fixation of lesser trochanter fragment is scarce because of technical difficulties. In this study, we reported the simple surgical procedure and the effect of using nonabsorbable tape in lesser trochanter fixation. Methods: From January 2014 to December 2017, 114 patients treated with proximal intramedullary nailing for trochanteric fractures with the lesser trochanter fragment were reviewed. Among patients enrolled in this study, 73 were followed up until radiographic bone union, of which 26 were treated with lesser trochanter fragment banding (group B) and 47 without banding (group N). Radiographs and/or computed tomography images were used to evaluate bone union of the lesser trochanter fragment at three months postoperatively. Results: The bone union of the lesser trochanter fragment was achieved in 24 cases (92%) in group B and 30 cases (64%) in group N. Compared with group N, group B showed a significantly increased number of mild and moderate deformities but decreased number of severe deformity and nonunion (P < 0.001). Postoperative complications were not observed in both groups. Conclusions: From the viewpoint of increasing lesser trochanteric bone union ratio, fixation of the lesser trochanter fragment using nonabsorbable tape in the treatment of trochanteric fractures could be an effective procedure.

Sub-acute hyponatraemia more than chronic hyponatraemia is associated with serious falls and hip fractures

BACKGROUND

Falls and hip fractures among older people are associated with high morbidity and mortality. Hyponatraemia may be a risk for falls/hip fractures, but the effect of hyponatraemia duration is not well understood.

AIMS

To evaluate individuals with periods of sub-acute and chronic hyponatraemia on subsequent risk for serious falls and/or hip fractures.

METHODS

Retrospective cohort study in the period 1 January 1998 to 14 June 2016 within an integrated health system of individuals aged ≥55 years with ≥2 outpatient serum sodium measurements. Hyponatraemia was defined as sodium <135 mEq/L with sub-acute (<30 days) and chronic (≥30 days) analysed as a time-dependent exposure. Multivariable Cox proportional-hazards modelling was used to estimate hazard ratios (HR) for serious falls/hip fractures based on sodium category.

RESULTS

Among 1 062 647 individuals totalling 9 762 305 sodium measurements, 96 096 serious falls/hip fracture events occurred. Incidence (per-1000-person-years) of serious falls/hip fractures were 11.5, 27.9 and 19.8 for normonatraemia, sub-acute and chronic hyponatraemia. Any hyponatraemia duration compared to normonatraemia had a serious falls/hip fractures HR (95%CI) of 1.18 (1.15, 1.22), with sub-acute and chronic hyponatraemia having HR of 1.38 (1.33, 1.42) and 0.91 (0.87, 0.95), respectively. Examined separately, the serious falls HR was 1.37 (1.32, 1.42) and 0.92 (0.88, 0.96) in sub-acute and chronic hyponatraemia, respectively. Hip fracture HR were 1.52 (1.42, 1.62) and 1.00 (0.92, 1.08) for sub-acute and chronic hyponatraemia, respectively, compared to normonatraemia.

CONCLUSIONS

Our findings suggest that early/sub-acute hyponatraemia appears more vulnerable and associated with serious falls/hip fractures. Whether hyponatraemia is a marker of frailty or a modifiable risk factor for falls remains to be determined.

Cervical spine fragility fractures in older people: 5-year experience at a regional spine centre

BACKGROUND

cervical spine fractures are particularly prevalent in older people and commonly occur following a fall from standing height or less. Atlanto-axial complex (AAC) and, particularly, odontoid process (OP) fractures are the most prevalent injuries.

OBJECTIVE

to investigate the incidence and characteristics of cervical spine fractures in older patients presenting to a regional spine centre.

METHODS

a retrospective review of the clinical records and imaging of all patients aged 70 years and over presenting to a regional spinal unit with a cervical injury over a 5-year period was performed. Patient demographics, mechanism of injury, level of fracture, stability of the fracture, treatment modality, imaging modality and mortality rates were collected and analysed.

RESULTS

during the period between 2015 and 2019, a total of 209 patients aged 70 years and over were presented to the regional spine unit. The mean age at presentation was 82.4 (±7.5) years. Low-energy trauma was the commonest mechanism of injury (n = 169; 80.9%). MRI was undertaken in a quarter of the patients. One-hundred and fifty-one patients (72.2%) suffered an AAC Injury with OP fractures forming the majority of this group (n = 119; 78.8%). One-hundred and ninety-nine patients were treated conservatively, and the overall 30-day mortality rate was 8.1%.

CONCLUSION

cervical spine fractures are not uncommon amongst older people and are mostly the result of low-energy trauma and predominantly affect the axial cervical spine. The majority of these injuries are managed conservatively with an orthosis. The fractures nevertheless are a serious injury, with a high mortality rate at 30 days.

[Prognostic factors of mortality one year after a hip fragility fracture. Anoia hip study]

INTRODUCTION

Most of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture.

MATERIAL AND METHODS

Observational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit.

RESULTS

We have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891).

CONCLUSIONS

Prognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.

Year to year comparison of 2000-2015 in hip fracture management: same survival rate despite older and more fragile patients

PURPOSE

The aim of this study was to compare clinical data, comorbidities and survival rates at 30 days and 1 year in two groups with femoral fractures, the first including patients admitted in 2000, and the other including patients admitted in 2015. The hypothesis of the study is that patients admitted in 2015 have more comorbidities and will therefore have a lower survival rate at 30 days and 1 year from trauma.

METHODS

Patients admitted to the hospital with proximal femoral fractures in 2000 (90 patients) and 2015 (167 patients) were retrospectively reviewed. The following data were collected: age, gender, source of admission, ASA score, comorbidities, time from admission to surgery and length of hospital stay. The Charlson Comorbidity Index (CCI) score, a measure of comorbidity, and the Nottingham Hip Fracture Score (NHFS), a predictor of 30-day and 1-year mortality after hip fracture, were both calculated.

RESULTS

Patients in the 2015 group were older and more institutionalized before fracture (p < 0.05), with a significant increase in Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure and renal impairment. The length of stay was significantly lower in 2015. The NHFS and CCI were significantly higher in 2000. Mortality at 30 days and 1 year did not differ significantly in 2000 when compared to 2015. The CCI had the best predictive ability for mortality in both groups at 30 days and 1 year.

CONCLUSIONS

The increase of comorbidities was not found to be correlated to increased mortality. This could be explained by enhanced patient management permitting earlier mobilization and weight bearing.

Incidence of hip fracture among long-term care insurance beneficiaries with dementia: comparison of home care and institutional care services

Background

Hip fracture among older adults is not only a major health issue but also preventable by providing proper care, but there is a lack of studies on the association between type of long-term care (LTC) service and hip fracture. This study aimed to investigate the association between the type of LTC service and the incidence of hip fracture among older adults with dementia receiving long-term care insurance (LTCI), and to investigate how such association differs according to characteristics of beneficiaries and structural characteristic of institutional care.

Method

In this retrospective cohort study, data from 2008 to 2013 were collected from 7112 LTCI beneficiaries having benefit level 1 or 2 with dementia aged 60 years or over in the Korean elderly cohort data set. Type of LTC service was categorized into institutional or home care using the LTCI Claims Database, and the incidence of hip fracture was used as the outcome variable. A survival analysis using a time-dependent Cox regression analysis was performed to examine the association between time-varying LTC service type and hip fracture.

Results

Of the 7112 older adults, 115 (1.6%) had hip fracture during a total of 16,540 person-years. Compared to LTC beneficiaries with home care, those with institutional care had a higher adjusted hazards ratio of incidence of hip fracture (hazards ratio = 4.33, 95% confidence interval, 2.84–6.59). This association was particularly strong among beneficiaries who did not have a danger of hip fracture during the mandatory assessment for benefit eligibility, who were partially ambulatory, who were from rural areas, and females.

Conclusions

Institutional care was more likely associated with a higher incidence of hip fracture than home care. The government need to watch the institutional LTC services quality and promote improvements of the institutional care quality.

TNF-α and sTNF-RII Are Associated with Pain Following Hip Fracture Surgery in Older Adults

Objective

To explore whether plasma inflammatory mediators on postoperative day 3 (POD3) are associated with pain scores in older adults after hip fracture surgery.

Design

Cross-sectional study.

Setting

Mount Sinai Hospital, New York, New York.

Subjects

Forty patients age 60 years or older who presented with acute hip fracture at Mount Sinai Hospital between November 2011 and April 2013.

Methods

Plasma levels of six inflammatory mediators of the nuclear factor kappa B pathway were measured using blood collected on POD3. Self-reported pain scores (i.e., pain with resting, walking, and transferring) were assessed at baseline (prefracture) and on POD3. Linear regression models using log-transformed data were performed to determine associations between inflammatory mediators and postoperative pain.

Results

Interleukin 18 (IL-18) was positively associated with POD3 resting pain score in the unadjusted model (β = 0.66, P = 0.03). Tumor necrosis factor α (TNF-α) and soluble TNF receptor II (sTNF-RII) were positively associated with POD3 resting pain score in the adjusted model (β = 0.99, P = 0.03, and β = 0.86, P = 0.04, respectively). Moreover, TNF-α was positively associated with POD3 walking pain score in the adjusted model (β = 1.59, P = 0.05). Pain with transferring was not associated with these inflammatory mediators.

Conclusions

These findings suggest that TNF-α and its receptors may influence pain following hip fracture. Further study of the TNF-α pathway may inform future clinical applications that monitor and treat pain in the vulnerable elderly who are unable to accurately report pain.

Age-specific 1-year mortality rates after hip fracture based on the populations in mainland China between the years 2000 and 2018: a systematic analysis

We used statistical approaches to calculate 1-year mortality rates and reveal the relationship between age and the 1-year mortality rate after hip fracture based on data from mainland China between the years 2000 and 2018.

INTRODUCTION

Data on the 1-year mortality rates after hip fracture in mainland China remain limited and localized. We aimed to analyze the 1-year mortality rates and reveal the variations in 1-year mortality by age after hip fracture based on data from mainland China.

METHODS

We searched PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, and CBM-SinoMed for all relevant articles in English or Chinese to estimate the 1-year mortality rates after hip fracture in mainland China. A random-effects meta-analysis model was fitted to pool the overall 1-year mortality rates. A multilevel mixed-effects meta-regression model was developed. Based on the final model, the age-specific 1-year mortality rates after hip fracture in mainland China were generated.

RESULTS

The pooled estimate of the 1-year mortality rate was 13.96% after hip fracture (95% CI 12.26 to 15.86%), 17.47% after femoral intertrochanteric fracture (95% CI 14.29 to 21.20%), and 9.83% after femoral neck fracture (95% CI 6.96 to 13.72%) between the years 2000 and 2018. We found that the 1-year mortality rates ranged from 2.65% (95% CI 1.76 to 3.99%) in those aged 50~54 years to 28.91% (95% CI 24.23 to 34.30%) in those aged 95~99 years after hip fracture; ranged from 1.73% (95% CI 0.58 to 4.99%) in those aged 50~54 years to 50.11% (95% CI 46.03% to 53.97%) in those aged 95~99 years after femoral intertrochanteric fracture; and ranged from 1.66% (95% CI 1.31 to 2.11%) in those aged 60~64 years to 37.71% (95% CI 27.92 to 48.63%) in those aged 95~99 years after femoral neck fracture.

CONCLUSION

In this systematic review and meta-analysis, we calculated the 1-year mortality rate after hip fracture in mainland China and found that this rate was lower than that in most countries. We also estimated the age-specific mortality rates for different age groups after hip fracture. These findings will be beneficial for the prevention and treatment of hip fracture in mainland China.

Association Between Race and Ethnicity and Hip Fracture Outcomes in a Universally Insured Population

BACKGROUND

Prior studies have documented racial and ethnic disparities in hip fracture treatment and outcome, and unequal access is commonly cited as a potential mediator. We sought to assess whether disparities in hip fracture outcome persist within a universally insured population of patients enrolled in a managed health-care system.

METHODS

A U.S. integrated health systems registry was used to identify patients who underwent treatment for a hip fracture when they were ≥60 years of age from 2009 to 2014. Patient demographics, procedure details, and outcomes were obtained from the registry. Differences in outcome according to race/ethnicity were analyzed using multivariable regression analysis with adjustment for socioeconomic status and other potential confounders.

RESULTS

Of 17,790 patients, 79.4% were white, 3.9% were black, 9.4% were Hispanic, and 7.4% were Asian. Compared with white patients, black patients had a similar 1-year mortality rate (odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.79 to 1.09, p = 0.37), Hispanic patients had a lower rate (OR = 0.85, 95% = CI = 0.75 to 0.96, p = 0.01), and Asian patients also had a lower rate (OR = 0.65, 95% CI = 0.56 to 0.76, p < 0.001). There were no differences in terms of surgical delay, 90-day emergency department visits, or reoperations during the patient's lifetime (p > 0.05) between the groups. Compared with white patients, black and Hispanic patients had fewer 90-day postoperative complications (p = 0.04 and p = 0.01, respectively); 90-day unplanned readmissions were less common among Asian patients (p = 0.03) but more common among black patients (p = 0.01).

CONCLUSIONS

In this study of hip fractures treated in an integrated managed care system, minority patients were found to have postoperative mortality rates that were similar to, or lower than, those of white patients. These findings may be related to the equal access and/or standardized protocols associated with treatment in this managed care system.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multiple chronic condition profiles and survival among oldest-old male patients with hip fracture

To improve understanding of survival among very elderly male patients with surgically repaired hip fractures, this study applied classification techniques to multiple chronic conditions (MCC) then modeled survival by latent class. Veterans Health Administration (VHA)'s electronic medical records on male inpatients age 85-100 years (n=896) with hip fracture diagnosis and repair were used. MCC defined by Charlson and Elixhauser disorders, medications, demographic covariates, and 5 years follow-up survival were included. Latent Class Analysis (LCA) identified three classes based on patterns of MCC, medications, and demographic covariates: Low-comorbidity (16%), High-longevity (55%), and High-comorbidity (29%). Overall, survival censored at 5 years post-op averaged 717days. The Low-comorbidity group was more likely to be Hispanic, less disabled per VHA determination of eligibility for care, with less risk of postoperative emergency department (ED) visit, and taking no prescription medications. The High-longevity group had longer survival. The High-comorbidity group had more MCC, more prescription medications and shorter survival than the other two groups. Accelerated failure time (AFT) modeled associations between MCC and 5-year survival by class. In AFT models, fewer days until first postoperative ED visit was significantly associated with survival across the three classes. About one in male hip fractured veteran patients over the age of 85 had high levels of MCC and ED use and experienced shorter survival. Hip fracture patients with MCC may merit enhanced post-discharge management. Close investigation targeted to MCC and hip fractures is needed to optimize clinical practices for oldest-old patients in community healthcare systems as well as VHA.

Rate of contralateral hip fracture after dynamic hip screw vs intramedullary nail for treatment of pertrochanteric hip fractures

A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.

Mortality, readmission, and reoperation after hip fracture in nonagenarians

Background

Osteoporotic hip fractures are associated with high mortality and morbidity in people of advanced age; however, few studies have investigated the complication rates in nonagenarians. In this study, we applied a competing risk analysis to estimate the mortality, readmission, and reoperation rates after surgery for hip fracture among nonagenarians.

Methods

A total of 11,184 nonagenarians (aged ≥ 90) who received surgery for hip fracture during the period 1 January 1997 and 31 December 2010 were selected from Taiwan’s National Health Insurance (NHI) database. Nonagenarians were followed up until the end of 2012, death, or the date they left the NHI program. Cumulative mortality was estimated using the Kaplan-Meier analysis and risk factors for mortality were investigated using a Cox proportional hazards model. Competing risk analysis was used to estimate cumulative incidence rates and to assess the risk factors for reoperation and readmission.

Results

The mortality rates were 29.5% at 1 year, 45.0% at 2 years and 78.1% at 5 years. The cumulative incidence rates of reoperation were 7.3% at 1 year, 9.2% at 2 years and 11.6% at 5 years whereas those of readmission were 18.9% at 1 month and 24.1% at 3 months. Significant risk factors for death included age, male gender, trochanteric fracture, and higher Charlson comorbidity index (CCI) whereas those for reoperation were age, cervical fracture and higher CCI. Furthermore, age, male gender, and higher CCI were risk factors for readmission.

Conclusions

The overall 2-years mortality rate among nonagenarians in Taiwan was around 45%, the 2-years reoperation rate was around 9% and the 90-days medical complication rate was around 24%. High complication rates are associated with increased risk for death. Postoperative care to prevent medical complications is likely the most effective strategy to reduce mortality rates among nonagenarians with hip fracture.

Hyponatremia and bone disease

Hip fractures represent a serious health risk in the elderly, causing substantial morbidity and mortality. There is now a considerable volume of literature suggesting that chronic hyponatremia increases the adjusted odds ratio (OR) for both falls and fractures in the elderly. Hyponatremia appears to contribute to falls and fractures by two mechanisms. First, it produces mild cognitive impairment, resulting in unsteady gait and falls; this is probably due to the loss of glutamate (a neurotransmitter involved in gait function) as an osmolyte during brain adaptation to chronic hyponatremia. Second, hyponatremia directly contributes to osteoporosis and increased bone fragility by inducing increased bone resorption to mobilize sodium stores in bone. Low extracellular sodium directly stimulates osteoclastogenesis and bone resorptive activity through decreased cellular uptake of ascorbic acid and the induction of oxidative stress; these effects occur in a sodium level-dependent manner. Hyponatremic patients have elevated circulating arginine-vasopressin (AVP) levels, and AVP acting on two receptors expressed in osteoblasts and osteoclasts, Avpr1α and Avpr2, can increase bone resorption and decrease osteoblastogenesis. Should we be screening for low serum sodium in patients with osteoporosis or assessing bone mineral density (BMD) in patients with hyponatremia? The answers to these questions have not been established. Definitive answers will require randomized controlled studies that allocate elderly individuals with mild hyponatremia to receive either active treatment or no treatment for hyponatremia, to determine whether correction of hyponatremia prevents gait disturbances and changes in BMD, thereby reducing the risk of fractures. Until such studies are conducted, physicians caring for elderly patients must be aware of the association between hyponatremia and bone disorders. As serum sodium is a readily available, simple, and affordable biochemical measurement, clinicians should look for hyponatremia in elderly patients, especially in those receiving medications that can cause hyponatremia. Furthermore, elderly patients with an unsteady gait and/or confusion should be evaluated for the presence of mild hyponatremia, and if present, treatment should be initiated. Finally, elderly patients presenting with an orthopedic injury should have serum sodium checked and hyponatremia corrected, if present.

The epidemiology of mortality after fracture in England: variation by age, sex, time, geographic location, and ethnicity

One-year mortality following a fracture was greater for men compared to women, varied markedly between regions in England with the lowest rates in the London region, and was higher among black women compared to white women. The excess in mortality did not change during the study period.

INTRODUCTION

Fractures are associated with increased mortality. With the shift towards an increasingly elderly demography, and so increasing numbers of fractures, the impact of such events on mortality is of key public health importance. Therefore, we aimed to present up-to-date mortality rates following fracture in England.

METHODS

This was a population-based study within the Clinical Practice Research Datalink, linked to death certificates (1 January 2001 to 31 December 2011). Subjects were followed from their first fracture (hip, wrist, humerus, clinical spine, ribs, or pelvis) until death for up to 1 year. Rate ratios (RRs) were estimated for 1-year mortality, stratified by sex, 5-year age categories, ethnicity, and geographical region. Excess mortality was presented as standardized mortality ratios (SMRs).

RESULTS

One-year mortality following fracture increased with age and was higher for men than women. Black women (RR 1.77; 95 % CI 1.00-3.12) and women of "other" ethnicity (RR 1.59, 95 % CI 1.16-2.16) were at higher risk of death when compared to white women. Mortality was higher among women in almost all regions when compared to the London region, with the highest risk in the East Midlands (37 % higher). The 1-year mortality risk was more than 3-fold higher after fracture as compared to the general population (adjusted SMR: 3.15, 95 % CI 3.09-3.26) and did not change during the study period. Major causes of death were neoplasms, respiratory diseases, and circulatory diseases.

CONCLUSION

This study provides up-to-date mortality outcomes following fracture in England and will aid allocation of healthcare provision to those at greatest need.

Trends in Operative and Nonoperative Hip Fracture Management 1990-2014: A Longitudinal Analysis of Manitoba Administrative Data

OBJECTIVES

To evaluate longitudinal trends in the use of total hip arthroplasty (THA), hemiarthroplasty (HA), internal fixation (IF), and nonoperative management and to identify individual-level factors associated with nonoperative treatment of hip fracture (HF).

DESIGN

Longitudinal analysis of administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

All adults who experienced nontraumatic hip fractures between 1990 and 2014 (N = 19,626; mean age 80.6, 72.3% female).

MEASUREMENTS

Billing codes were used to identify surgical treatment, and trends in treatment over time were examined. Regression models were developed to identify individual factors associated with receiving nonoperative management.

RESULTS

Use of THA increased from 0.6% for all HFs in 1990-94 to 5.3% in 2010-14, use of HA increased from 19.3% to 29.7%, and use of IF declined from 71.8% to 59.9% (P < .001 for all); increase in THA and HA were largest in individuals with femoral neck fracture. Nonoperative management declined from 8.3% in 1990-94 to 5.1% in 2010-14 (P < .001). Factors associated with nonoperative management included aged 90 and older, male sex, residing in a care facility before fracture, and rural residence.

CONCLUSION

HF is increasingly treated with THA and HA, whereas rates of nonoperative management and IF are declining. Future efforts should focus on ensuring that all individuals are optimally triaged to the best procedure for them, with nonoperative management considered for individuals with extremely poor prefracture health.

Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients

BACKGROUND

Only a little is known about whether type of surgical intervention has an effect on mortality of these patients. Our primary objective was to assess whether different type of surgical procedures has an effect on mortality among elderly patients with hip fracture. A secondary objective was to examine factors that are related to mortality in our patient population. Our hypothesis is that type of surgical procedure, especially external fixation, should have an influence on mortality outcomes.

METHODS

We included 785 patients age 65 years or older, with hip fractures. Operative treatment consisted of external fixation, internal fixation, total hip arthroplasty and hip hemiarthroplasty. Age, gender, type of fracture, type of surgery performed, American Society of Anesthesiology (ASA) grade, clinical comorbidities, anesthesia type, blood transfusion requirement, time to surgery, intensive care unit requirement, operation length and length of hospital stay and number of comorbidities were documented.

RESULTS

During the study period, 785 patients (262 male, 523 female) were included to study, Overall mortality rate was 37.2 % (292/785). Their age ranged between 65 and 100 years (mean 81). Surgery type Kaplan-Meier cumulative mortality curves suggested no significant difference between four different types of surgery groups (p = 0.064). Transfusion requirement was significantly lower in external fixation group comparing to other groups (p = 0.014). Cox regression analysis showed the number of comorbidities 2 and ≥ 3 (p = 0.0027, p = 0.015), transfusion requirement (p = 0.0001), ASA 4 (p = 0.016) to be significant predictors of mortality.

CONCLUSIONS

Transfusion requirement, ASA grade 4 and having more than two comorbidities are risk factors for mortality in geriatric hip fractures. Type of surgical intervention and fracture type had similar mortality rates in our patient population.

Prolactinoma: A Massive Effect on Bone Mineral Density in a Young Patient

This case highlights a prolactinoma in a young male, and its impact on bone health. Osteoporosis has been noted to be an issue in postmenopausal women with prolactinomas. This case shows a similar impact on bone health in a young male resulting in low bone mineral density for age based on Z-score. This case report highlights the possible mechanisms for the bone loss in the setting of prolactinoma and the need for assessing bone health in such patients. Furthermore it highlights the need for a thorough evaluation in such patients.

Racial and Socioeconomic Disparities in Hip Fracture Care

BACKGROUND

Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture.

METHODS

We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality.

RESULTS

After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85).

CONCLUSIONS

There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Associations of FGF23 With Change in Bone Mineral Density and Fracture Risk in Older Individuals

Elevated levels of the phosphate-regulating hormone fibroblast growth factor 23 (FGF23) have been linked to greater risk of fractures in some studies, especially among individuals with chronic kidney disease (CKD). We evaluated FGF23 as a risk factor for bone loss and fractures in the Health, Aging, and Body Composition (Health ABC) study, which is a prospective biracial cohort of well-functioning adults aged 70 to 79 years recruited at two clinical centers in the United States. The sample for the bone mineral density (BMD) analyses consisted of 2234 participants who had at least two serial total hip areal BMD measures. The fracture analyses included 2786 participants, 567 of whom sustained a fracture during a median follow up of 4.95 years. Linear mixed-effects models were used for longitudinal measurements of total hip areal BMD and the proportional subdistribution hazard regression model subject to competing risks of death was used for risk of fracture. The median FGF23 was 46.7 (interquartile range [IQR] 36.7 to 60.2) pg/mL. The mean annualized percent change in total hip areal BMD did not vary significantly according to FGF23 quartile in all participants (p for trend = 0.70), but the effect was modified by CKD status (adjusted p for interaction <0.001). Among participants with CKD, the unadjusted mean annualized percent change in total hip areal BMD was greater with higher levels of FGF23 (unadjusted p for trend = 0.02), but the trend was attenuated with adjustment for estimated glomerular filtration rate and parathyroid hormone (adjusted p for trend = 0.30). FGF23 was not significantly associated with fracture risk in crude (hazard ratio [HR] per doubling of FGF23, 0.97; 95% CI, 0.85 to 1.12) or adjusted models (HR per doubling of FGF23, 1.02; 95% CI, 0.86 to 1.22), and these findings were not modified by gender or CKD status. FGF23 levels are not associated with bone loss or fracture risk in older adults with low prevalence of CKD.

Mild prolonged chronic hyponatremia and risk of hip fracture in the elderly

BACKGROUND

Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic hyponatremia (>90 days duration) and risk of hip fracture in the elderly.

METHODS

We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic hyponatremia, defined as plasma sodium values <135 mmol/L, lasting >90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic hyponatremia after adjustment for the propensity to have hyponatremia, fracture risk factors and relevant baseline characteristics.

RESULTS

Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)].

CONCLUSION

Mild prolonged chronic hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting hyponatremia will result in a reduction of hip fractures is lacking.

Dietary Protein and Vitamin D Intake and Risk of Falls: A Secondary Analysis of Postmenopausal Women from the Study of Osteoporotic Fractures

More than 90% of hip fractures in older Americans result from a fall. Inadequate intake of dietary protein and vitamin D are common in older adults, and diets in low these could contribute to loss of muscle mass and strength or coordination, in turn increasing the risk of falling. The objective of the study was to evaluate the relationship between protein and vitamin D intake with the occurrence of falls in older women in the Study of Osteoporotic Fracture, a prospective cohort of more than 4000 postmenopausal women participating from January 1997 to September 1998. Incident falls were ascertained for one year. Protein and vitamin D intake was assessed by a food frequency questionnaire; associations with a reported fall were estimated with logistic regression, adjusted for fall-related covariates and energy. Protein and vitamin D were modeled separately because of high correlation (rho = 0.55, P < 0.001). A total of 1429 women reported a fall within one year. In separate, unadjusted models dietary protein (per 1 g/kg increase) and vitamin D (per 100 International Unit (IU) increase) significantly increased the odds ratio (OR) of falling (OR 1.35 95% CI 1.15-1.59, OR 1.11 95% CI 1.03-1.19, respectively). Once fall-related covariates were added to each model, dietary protein and vitamin D were noncontributory to falls. While we could find no direct association between vitamin D and protein intake and fall prevention, adequate intake of these two nutrients are critical for musculoskeletal health in older adults.

Advanced Age, High β-CTX Levels, and Impaired Renal Function are Independent Risk Factors for All-Cause One-Year Mortality in Hip Fracture Patients

Risk factors for increased mortality in hip fracture patients include older age, male sex, fracture type, bone mineral density, and pre-existing co-morbidities. The role of biochemical and other anthropometric parameters on hip fracture mortality remains unclear. The aim of this study was to identify the risk factors for one-year mortality in patients with hip fractures. A total of 236 consecutive patients (59 males) with hip fractures were followed over a one-year period. Patient age, gender, type of fracture, type of treatment, time from admission to surgery, type of anesthesia, body mass index, and electrocardiograms were recorded. Complete blood counts, serum electrolytes, urea, creatinine, d-dimers, calcium, phosphate, osteocalcin, and beta-isomerised C-terminal telopeptide of collagen type I (β-CTX) were measured at admission and estimated glomerular filtration rate (eGFR) was calculated. Multivariate Cox regression models were used to analyze the association of these parameters with survival. One-year mortality rate was 28.4%. Age was independently associated with mortality (HR 1.117, 95% CI 1.062-1.174, P < 0.001). In a multivariable model, mortality was increased in patients with higher β-CTX (HR 4.63 95% CI 1.87-11.45, P = 0.001) and lower eGFR (HR 0.972, 95% CI 0.956-0.987, P < 0.001). Patients younger than 84 years, with eGFR < 55.4 ml/min had ten times higher mortality rates (3.2 vs. 24.5%, HR 9.73, 95% CI 2.06-45.93) as well as those with β-CTX > 0.276 g/L (3.5 vs. 25.7%, HR 9.5, 95% CI 2.11-42.76). Advanced age, high β-CTX levels, and impaired renal function are independent risk factors of mortality in patients with hip fractures.

Calcar Preservation Arthroplasty for Unstable Intertrochanteric Femoral Fractures in Elderly

BACKGROUND

The treatment of unstable intertrochanteric fractures in elderly is still controversial. The purpose of this study is to present treatment strategies for unstable intertrochanteric fractures with hemiarthroplasty using standard uncemented collared femoral stems and at the same time preserving the fractured calcar fragment.

METHODS

Fifty-four patients aged 75 years or older with unstable intertrochanteric fractures were included in this prospective cohort study. All patients were treated with calcar preserving hemiarthroplasty using cementless collored femoral stems. Fractured calcar fragment was stabilized either by compaction between the implant and femur or fixed with cable grip system. Follow-up evaluations were performed at least 24 months and later. Palmer and Parker mobility score and visual analogue scale (VAS) pain score were assessed. We also analyzed radiographs of the operated hip at each follow-up visit.

RESULTS

The patients were 15 males and 39 females with a mean age of 81.3 years (range, 75 to 93 years). The average operative time was 86.6 minutes. The mean transfused blood units were 1.2 units. The average duration of hospital stay was 5.3 days. The preoperative mean mobility score was 6.20. This score was found to be 4.96 on postoperative third day and 5.90 at 24 months postoperatively. The results of the statistical analysis revealed significant increase in the mobility scores at each follow-up after three days. Radiological interpretation revealed no loosening in the cable-grip systems, and no significant subsidence (> 5 mm) of prosthesis was observed.

CONCLUSIONS

Calcar preservation arthroplasty is a good option for elderly patients with severe osteoporosis, frail constitution and the patients who are at higher risk for second operation due to unstable intertrochanteric fractures.

Mortality after distal radial fractures in the Medicare population

The occurrence of a low energy fracture of the distal radius increases the risk for another, more serious fracture, such as a proximal femoral fracture. Early mortality after a proximal femoral fracture has been widely studied, but the association between a distal radial fracture and mortality is unknown. The date of death for all Medicare beneficiaries who sustained an isolated distal radial fracture in 2007 was determined using Medicare Vital Statistics files. The adjusted mortality rate for each age-sex group was calculated and compared with published US mortality tables. Distal radial fractures were not associated with an increased mortality rate. In fact, beneficiaries had a significantly lower mortality rate after distal radial fractures than the general population. This may be related to the injured beneficiaries' involvement in the healthcare system. Mortality rate did not vary significantly based on time from injury. Our results indicate that any mortality is unlikely to be attributable to the distal radial fracture or its treatment. Level of evidence: III.

Risk factor profiles for early and delayed mortality after hip fracture: Analyses of linked Australian Department of Veterans' Affairs databases

INTRODUCTION

One-year mortality after hip fracture may exceed 30% with a very large number of reported risk factors. Determinants of mortality beyond 1 year are rarely described. This study employs multiple data linkages to examine mortality rates, risk factor profiles and age-specific excess mortality at intervals from 30 days to 4 years.

METHODS

Retrospective cohort study of linked administrative datasets describing hospital episodes, residential aged care (RAC) admissions and date of death for 2552 Australian veterans and war widows hospitalised for hip fracture in 2008-09. Associations between time to death and patient age, sex, pre-fracture accommodation, fracture type, treatment options, selected comorbidities and complications were tested in Cox proportional hazards models.

RESULTS

In a population with mean age of 86.6 years (range 54-100 years), overall death rate was 11% at 30 days, 34% at 1 year, 47% at 2 years and 67% after 4 years. For males hospitalised from RAC 1-year mortality was 72%, contrasting with 19% for females from the community. Risk of death within 1 year was increased by male sex, increasing age, pre-fracture RAC residency, transfer to intensive care and coexistent cancer, cardiac and renal failure, cerebrovascular disease and pressure ulcers. Patients selected for rehabilitation had lower mortality rates. Patterns of determinants for mortality changed over time. Above-expected age-specific mortality was sustained for 4 years except for males 90 years and older.

CONCLUSION

Pre-fracture RAC residence was the strongest determinant factor for mortality. Patients selected for rehabilitation had lower mortality rates. The profiles of explanatory variables for death altered with increasing time from the index fracture event.

Mortality and complications of hip fracture in young adults: a nationwide population-based cohort study

Background

This study assessed the mortality and complications of hip fractures using in-patients aged 20–40 years from a nationwide population database in Taiwan.

Methods

Subjects were selected from Taiwan’s National Health Insurance Research Database for the period 2000–2008, and these subjects were followed up until the end of 2010. A total of 5,079 (3,879 male and 1,200 female) subjects were admitted for the first time with primary diagnosis of hip fracture and treated with operation. We calculated the long-term overall survival rate and complication-free rate. We also assessed the risk factors for mortality and complications.

Results

The 1-month, 3-month, 6-month, 1-year, 2-year, 5-year, and 10-year complication-free rates were 98.3%, 96.2%, 94.5%, 86.8%, 80.4%, 75.3%, and 73.5% for the entire cohort, respectively. The 10-year survival rates were 93.3%, 91.8%, and 94.5% for total cases, trochanteric fracture, and cervical fracture, respectively. The 10-year complication-free rates were 73.5%, 80.5%, and 67.3% for total cases, trochanteric fracture, and cervical fracture, respectively. The risk factors for overall death were male, older age, and greater number of Charlson comorbidity index (CCI) comorbidities. The risk factors for complication were cervical fracture, and greater number of CCI comorbidities. Complications resulted in 42.83% of patients receiving internal fixation implants or prothesis removal and 2.01% underwent conversion to revision arthroplasty during follow-up.

Conclusions

The overall 10-year survival rate in hip fracture patients aged 20–40 years in Taiwan was over 90%. The 10-year complication-free rates were around 70%. Preventing the occurrence of severe complications after hip fracture among young adults is an important public health issue that warrants greater attention.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-362) contains supplementary material, which is available to authorized users.

How to Treat the Complex Unstable Intertrochanteric Fractures in Elderly Patients? DHS or Arthroplasty

BACKGROUND

Due to difficulty in obtaining anatomical reduction, management of the unstable intertrochanteric fractures in elderly osteoporotic patients is challenging. The purpose of this study is to compare the results of hip arthroplasty (total, hemi, or bipolar) with DHS in the elderly patients with unstable intertrochanteric fractures.

METHODS

We prospectively studied and followed-up 80 old patients with complex unstable intertrochanteric fracture from January 2007 to December 2010. Depending on the time of the patients' admission, we alternatively treated them by DHS and arthroplasty, and placed them in Groups A and B, respectively. We followed them up radiologically and also clinically by Harris Hip Score for more than 24 months. Statistical analysis was performed using SPSS version 11.5 for Windows.

RESULTS

The mean length of follow-up and age were 34.3±4.1 months (ranged; 24-59) and the 75.2±5.2 years (ranged; 58-96), respectively. Comparing Group A with B, demographic data, mean blood loss, duration of operation, time to walking and duration of hospital stay had no significant difference but overall device related complications were significantly higher in Group A. Functional scores were also higher in Group B, but this difference was not significant statistically. In both groups, the patients with Type A3 compared with Type A2, had more duration of surgery and blood loss.

CONCLUSIONS

Arthroplasty is an alternative treatment in elderly patients with unstable intertrochanteric fractures and can provide good and satisfactory clinical outcomes associated with low complication and mortality rates.

Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis

OBJECTIVE

hip fracture is a common and serious condition associated with high mortality. This study aimed to identify pre-operative characteristics which are associated with an increased risk of mortality after hip fracture surgery.

DESIGN

systematic search of published and unpublished literature databases, including EMBASE, MEDLINE, AMED, CINAHL, PubMed and the Cochrane Library, was undertaken to identify all clinical studies on pre-operative predictors of mortality after surgery in hip fracture with at least 3-month follow-up. Data pertaining to the study objectives was extracted by two reviewers independently. Where study homogeneity was evidence, a meta-analysis of pooled relative risk and 95% confidence intervals was performed for mortality against pre-admission characteristics.

RESULTS

fifty-three studies including 544,733 participants were included. Thirteen characteristics were identified as possible pre-operative indicators for mortality. Following meta-analysis, the four key characteristics associated with the risk of mortality up to 12 months were abnormal ECG (RR: 2.00; 95% CI: 1.45, 2.76), cognitive impairment (RR: 1.91; 95% CI: 1.35, 2.70), age >85 years (RR: 0.42; 95% CI: 0.20, 0.90) and pre-fracture mobility (RR: 0.13; 95% CI: 0.05, 0.34). Other statistically significant pre-fracture predictors of increased mortality were male gender, being resident in a care institution, intra-capsular fracture type, high ASA grade and high Charlson comorbidity score on admission.

CONCLUSIONS

this review has identified the characteristics of patients with a high risk of mortality after a hip fracture surgery beyond the peri-operative period who may benefit from comprehensive assessment and appropriate management.

PROSPERO REGISTRATION NUMBER

CRD42012002107.

Total hip arthroplasty for hip fractures: 5-year follow-up of functional outcomes in the oldest independent old and very old patients

INTRODUCTION

This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care.

METHOD

Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery-geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury.

RESULTS

Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged.

CONCLUSION

This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury.

Relative mortality in U.S. Medicare beneficiaries with Parkinson disease and hip and pelvic fractures

BACKGROUND

Parkinson disease is a neurodegenerative disease that affects gait and postural stability, resulting in an increased risk of falling. The purpose of this study was to estimate mortality associated with demographic factors after hip or pelvic (hip/pelvic) fracture in people with Parkinson disease. A secondary goal was to compare the mortality associated with Parkinson disease to that associated with other common medical conditions in patients with hip/pelvic fracture.

METHODS

This was a retrospective observational cohort study of 1,980,401 elderly Medicare beneficiaries diagnosed with hip/pelvic fracture from 2000 to 2005 who were identified with use of the Beneficiary Annual Summary File. The race/ethnicity distribution of the sample was white (93.2%), black (3.8%), Hispanic (1.2%), and Asian (0.6%). Individuals with Parkinson disease (131,215) were identified with use of outpatient and carrier claims. Cox proportional hazards models were used to estimate the risk of death associated with demographic and clinical variables and to compare mortality after hip/pelvic fracture between patients with Parkinson disease and those with other medical conditions associated with high mortality after hip/pelvic fracture, after adjustment for race/ethnicity, sex, age, and modified Charlson comorbidity score.

RESULTS

Among those with Parkinson disease, women had lower mortality after hip/pelvic fracture than men (adjusted hazard ratio [HR] = 0.63, 95% confidence interval [CI]) = 0.62 to 0.64), after adjustment for covariates. Compared with whites, blacks had a higher (HR = 1.12, 95% CI = 1.09 to 1.16) and Hispanics had a lower (HR = 0.87, 95% CI = 0.81 to 0.95) mortality, after adjustment for covariates. Overall, the adjusted mortality rate after hip/pelvic fracture in individuals with Parkinson disease (HR = 2.41, 95% CI = 2.37 to 2.46) was substantially elevated compared with those without the disease, a finding similar to the increased mortality associated with a diagnosis of dementia (HR = 2.73, 95% CI = 2.68 to 2.79), kidney disease (HR = 2.66, 95% CI = 2.60 to 2.72), and chronic obstructive pulmonary disease (HR = 2.48, 95% CI = 2.43 to 2.53).

CONCLUSIONS

Mortality after hip/pelvic fracture in Parkinson disease varies according to demographic factors. Mortality after hip/pelvic fracture is substantially increased among those with Parkinson disease.

Risk factors for fracture in middle-age and older-age men of African descent

Although fracture rates are lower in individuals of African descent compared to individuals of European ancestry, morbidity and mortality following a fracture may be greater in individuals of African ancestry. However, fracture risk and associated clinical risk factors have not been well-defined among African ancestry populations, especially among men of African ancestry. We used data collected from the Tobago Bone Health Study to examine potential clinical risk factors for incident fractures, including demographic information, anthropometric measurements, medical history, lifestyle factors, bone mineral density (BMD), and hip structural geometry. Among 1933 Afro-Caribbean men aged ≥40 years at study entry (mean age: 57.2 ± 11.0 years), 65 reported at least one new fracture during 10 years of subsequent follow-up. Younger age, mixed Afro-Caribbean ancestry, prior fracture history, BMD, and hip structural geometry were statistically significant risk factors for incident fractures. A 1-SD change in several skeletal parameters (hip BMD, cross-sectional area, outer diameter, cortical thickness, and buckling ratio) were each associated with a 35% to 56% increase in incident fracture risk after adjusting for age. Men with a prior fracture history were three times more likely to experience a new fracture during follow-up, and the association remained strong after adjusting for age, mixed Afro-Caribbean ancestry, and skeletal parameters (hazard ratios ranged from 2.72 to 2.82). Our findings suggest that except for age, risk factors for fracture in men of African ancestry are similar to established risk factors in white populations. Prior fracture history is a powerful and independent risk factor for incident fractures among men of African ancestry and could easily be incorporated into clinical risk evaluation.

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

INTRODUCTION

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

METHODS

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

RESULTS

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

CONCLUSION

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.

Predictors of hip fracture mortality at a general hospital in South Brazil: an unacceptable surgical delay

OBJECTIVE

Hip fractures have been associated with increased mortality in the elderly. Several risk factors such as the time between the insult and the surgical repair have been associated with hip fracture mortality. Nevertheless, the risk of delayed surgical repair remains controversial. Few studies have examined this issue in Brazil. The aim of this study was to study the risk factors for death one year after hip fracture and in-hospital stay at a tertiary hospital in South Brazil.

METHODS

A prospective cohort study was carried out from April 2005 to April 2011 at a tertiary university hospital at Santa Maria, Brazil. Subjects admitted for hip fracture who were 65 years of age or older were followed for one year. Information about fracture type, age, gender, clinical comorbidities, time to surgery, discharge, and American Society of Anesthesiologists score were recorded. Death was evaluated during the hospital stay and at one year.

RESULTS

Four hundred and eighteen subjects were included in the final analysis. Of these, 4.3% died in-hospital and 15.3% were dead at one year. Time to surgery, American Society of Anesthesiologists score, Ischemic Heart Disease, and in-hospital stay were associated with death at one year in the univariate analysis. The American Society of Anesthesiologists score and time to surgery were one-year mortality predictors in the final regression model. In-hospital death was associated with American Society of Anesthesiologists score and age.

CONCLUSION

Time to surgery is worryingly high at the South Brazil tertiary public health center studied here. Surgical delay is a risk factor that has the potential to be modified to improve mortality.

Temporal trends in the incidence of osteoporotic fractures

Osteoporotic fractures are associated with excess mortality and decreased functional capacity and quality of life. Age-standardized incidence rates of fragility fractures, particularly of the hip and forearm, have been noted to be decreasing in the last decade across many countries with the notable exception of Asia. The causes for the observed changes in fracture risk have not been fully identified but are likely the result of multiple factors, including birth cohort and period effects, increasing obesity, and greater use of anti-osteoporosis medications. Changing rates of fragility fractures would be expected to have an important impact on the burden of osteoporosis.

Public health impact of osteoporosis

OBJECTIVE

To describe the public health impact of osteoporosis including the magnitude of the problem and important consequences of osteoporotic fractures.

METHODS

Literature review of key references selected by author.

RESULTS

Current demographic trends leading to an increased number of individuals surviving past age 65 will result in an increased number of osteoporotic fractures. Important consequences of osteoporotic fractures include an increased mortality that for hip fractures extends to 10 years after the fracture. Increased mortality risk also extends to major and minor fractures, especially, in those over 75 years. Hip and vertebral fractures have important functional consequences and reductions in quality of life. The economic impact of osteoporotic fractures is large and growing. Significant health care resources are required for all fractures.

CONCLUSIONS

To alleviate the public and private burden of osteoporosis related fractures, assessment of risk and reduction of individual risk is critical.

All-cause and cause-specific mortality after hip fracture among Chinese women and men: the Singapore Chinese Health Study

All-cause mortality risk persisted for 5 years after hip fractures in both men and women. There may be gender-specific differences in effect and duration of excess risk for cause-specific mortality after hip fracture.

INTRODUCTION

To determine all-cause and cause-specific mortality risk in the first 5 years after hip fracture in an Asian Chinese population.

METHODS

The Singapore Chinese Health Study is a population-based cohort of 63,257 middle-aged and elderly Chinese men and women in Singapore recruited between 1993 and 1998. This cohort was followed up for hip fracture and death via linkage with nationwide hospital discharge database and death registry. As of 31 December 2008, we identified 1,166 hip fracture cases and matched five non-fracture cohort subjects by age and gender for each fracture case. Cox proportional hazards and competing risks regression models with hip fracture as a time-dependent covariate were used to determine all-cause and cause-specific mortality risk, respectively.

RESULTS

Increase in all-cause mortality risk persisted till 5 years after hip fracture (adjusted hazard ratio, aHR = 1.58 [95 % CI, 1.35-1.86] for females and aHR = 1.64 [95 % CI, 1.30-2.06] for males). Men had higher mortality risk after hip fracture than women for deaths from stroke and cancer up to 1 year post-fracture but women with hip fracture had higher coronary artery mortality risk than men for 5 years post-fracture. Men had higher risk of death from pneumonia while women had increased risk of death from urinary tract infections. There was no difference in mortality risk by types of hip fracture surgery.

CONCLUSIONS

All-cause mortality risk persisted for 5 years after hip fractures in men and women. There are gender-specific differences in effect size and duration of excess mortality risk from hip fractures between specific causes of death.

Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data

INTRODUCTION

Dementia and fall-related hip fractures both contribute significantly to the burden of illness within elderly populations in Australia and elsewhere. The research presented here uses a large probabilistically linked dataset from NSW, Australia to estimate the prevalence of dementia within hip fracture patients and investigate the impact of dementia on hospitalisation length of stay (LOS) and survival.

METHOD

The cases considered were NSW residents aged 65 years and above who experienced a fall related hip fracture between 1 July 2000 and 30 June 2009. The prevalence of dementia was calculated for the incident hip fracture using two methods to infer dementia status. Cox proportional hazards regression modelling was used to estimate the relative rate of discharge from a hospitalisation episode, and the relative mortality rate of hip fracture patients suffering dementia versus those who were cognitively intact. Additional covariates used in the models included sex, age group at admission, the Charlson Comorbidity Index and separation mode.

RESULTS

Of the 44,143 fall-related incident hip fracture cases considered, between 24% (observed diagnosis) to 29% (inferred diagnosis) of these people had dementia. The median LOS for patients with dementia was shorter than those without dementia, but there was a strong interaction with age. The rate of discharge from the fracture-related hospitalisation episode of the cases with dementia was 40% greater (95% CI 1.4-1.5) than the non-demented group. Similarly, the relative mortality rate of those with dementia was greater (2.4, 95% CI 2.3-2.6) than the non-demented group. Both Cox analyses indicated evidence for main effects of age at admission and comorbidity, as well as interaction effects between age group and dementia status.

CONCLUSION

The use of linked datasets with tens of thousands of cases enables the calculation of precise estimates of various parameters. People with dementia constitute a significant proportion of the total population of elderly hip fracture patients in hospitals (up to 29%). Their mortality rate is greater than those without a diagnosis of dementia and their hospital length of stay is shorter, particularly if they are discharged to a residential aged care facility.

Understanding the burden of osteoporosis and use of the World Health Organization FRAX

Fracture prevention is a critical component of managing osteoporosis, which is not longer defined by T-score alone. The internationally validated World Health Organization Fracture Risk Assessment Tool (FRAX) provides the clinician a state-of-the-art tool for predicting patients at greatest risk for fracture. The FRAX tool takes into account country, bone mineral density of the hip (when available), age, sex, and 8 clinical risk factors to calculate the 10-year probability of a major osteoporotic fracture and the 10-year probability of a hip fracture. From this tool, an absolute fracture risk is generated, aiding clinicians in determining which patients with low bone mass and osteoporosis to treat.

Decision making and outcomes of a hospice patient hospitalized with a hip fracture

CONTEXT

Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making.

OBJECTIVES

To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services.

METHODS

This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival.

RESULTS

Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001).

CONCLUSION

Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.

Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture

BACKGROUND

It is not well established if and to what extent mild to moderate cognitive impairment predicts mortality and risk of nursing home admission after hip fracture.

OBJECTIVE

To investigate prospectively whether and to what extent mild to moderate cognitive impairment, contributes to mortality and admission to nursing home in the first year after acute hip fracture.

METHODS

We enrolled 173 patients with acute hip fracture age 65 and older who reached a Mini-Mental State Examination (MMSE) score of at least 15 during acute care after hip fracture repair. An MMSE score of 15 to 24 (median) was classified as mild to moderate cognitive impairment. Primary outcomes were mortality in all and admission to nursing home among seniors who lived at home prior to their hip fracture. Follow-up was 12 months with clinical visits at baseline, 6, and 12 months, plus monthly phone calls. We used Cox proportional hazards models controlling for age, sex, body mass index, baseline number of comorbidities and 25-hydroxyvitamin D status, and severe incident infections to assess the risk of mortality and nursing home admission. Because the study population was enrolled in a factorial design clinical trial testing high dose vitamin D and/or an exercise home program, all analyses also controlled for these treatment strategies.

RESULTS

Of 173 acute hip fracture patients enrolled, 79% were women, 77% were admitted from home, and 80% were vitamin D deficient (<20ng/ml). Mean age was 84 years. 54% had mild to moderate cognitive impairment. Over the 12-month follow-up, 20 patients died (27% of 173) and 47 (35% of 134) were newly admitted to a nursing home. Mild to moderate cognitive impairment was associated with a more than 5-fold increased risk of mortality (HR=5.77; 95% CI: 1.55-21.55) and a more than 7-fold increased risk of nursing home admission (HR=7.37; 95% CI: 1.75-30.95). Additional independent risk factors of mortality were male gender (HR=3.55; 95% CI: 1.26-9.97), low BMI (HR=7.25; 95% CI: 1.61-33.74), and baseline 25-hydroxyvitamin D level (per 1ng/ml: HR=0.93; 95% CI: 0.87-0.998; p=0.04).

CONCLUSIONS

Mild to moderate cognitive impairment in patients with acute hip fracture is associated with a high risk of mortality and nursing home admission during the first year after hip fracture. Female gender, a greater BMI and a higher 25-hydroxyvitamin D status may protect against mortality after hip fracture independent of cognitive function.

Androgen deficiency in aging and metabolically challenged men

Androgen deficiency in aging men is common, and the potential sequelae are numerous. In addition to low libido, erectile dysfunction, decreased bone density, depressed mood, and decline in cognition, studies suggest strong correlations between low testosterone, obesity, and the metabolic syndrome. Because causation and its directionality remain uncertain, the functional and cardiovascular risks associated with androgen deficiency have led to intense investigation of testosterone replacement therapy in older men. Although promising, evidence for definitive benefit or detriment is not conclusive, and treatment of late-onset hypogonadism is complicated.