Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

Is the Rate of Early mobilization in Hip fracture patients using Alfentanil Better than standard opioid analgesia (REHAB)? A protocol for a prospective cohort study

Aims

The primary aim of this study is to compare mobility status of patients receiving oral oxycodone with those receiving subcutaneous alfentanil as analgesic methods prior to mobilization to help physiotherapy compliance after hip fracture surgery. The secondary aims are to assess postoperative pain, health-related quality of life, in-hospital length of stay, total use of analgesia over postoperative days 1 and 2 (POD 1 and POD 2), complication rates within 30 days, and 30-day mortality rates.

Methods

A single-centre, prospective cohort study of 64 patients will be undertaken. Patients undergoing surgery for femoral neck fractures at the study centre will be recruited. Patients with a hip fracture meeting the inclusion/exclusion criteria will be enrolled on admission. Patients who have been administered oral oxycodone will be compared to those prescribed alfentanil for pain prior to mobilization with physiotherapists on POD 1 and POD 2. Which drug a patient receives is reliant of the prescriptions given by the medical team, and in current practice this varies at approximately 50:50. Mobilization will be defined as the ability to stand on and weightbear both feet with or without assistance.

Results

Visual analogue scale pain scores, mobility status, and total analgesia use will be assessed on POD 1 and POD 2. EuroQol five-dimension health questionnaire scores, complication rates, and mortality rates will be assessed up to 30 days following surgery (POD 1, 2, 7, and 30).

Conclusion

This study will help to build a wider protocol aiming to improve early mobilization after hip fracture surgery. The results of this study will provide pain scores and mobility status which will either support use of subcutaneous alfentanil as the standard analgesic modality prior to physiotherapy sessions, or highlight its limitations compared to the standard oral oxycodone. Secondary outcomes will also help to assess if early mobilization improves outcomes compared to delayed mobilization.

Effects of Protocol-driven Care by Internists on Adherence to Clinical Practice Guidelines for Hip Fracture Surgery Patients: An Interrupted Time Series Study Using a Nationwide Inpatient Database

Background Patients with hip fractures tend to have a poor prognosis. Although guideline-compliant practices are known to improve patient outcomes, there is a lack of evidence regarding the use of intervention to improve guideline adherence in hip fracture patients. The objective of our study was to evaluate guideline adherence by internists providing care to patients with hip fractures, using a protocol developed based on various guidelines. Method Protocol-driven care for hip fracture patients by internists began in April 2018 at our hospital. After its initiation, orthopedic surgeons performed the surgery, and the internists provided all other medical care. A controlled interrupted time-series analysis was used to evaluate the effects of protocol-driven care on guideline adherence to compare our hospital with other hospitals, using data extracted from a nationwide Japanese inpatient database covering the period April 2014 to March 2023. Results A total of 221,620 inpatients from 373 hospitals were included in the study. The initiation of protocol-driven care was associated with the guideline-recommended prescriptions: osteoporosis medication (Incidence rate ratio (IRR): 8.09; 95% CI 4.02-17.74), acetaminophen (IRR: 2.11; 95% CI 1.55-2.90), non-steroidal anti-inflammatory drugs (IRR: 0.16; 95% CI 0.11-0.24), and opioids (IRR: 5.96; 95% CI 3.14-12.15). However, there was no effect on the proportion of benzodiazepine prescriptions, surgery within 48 hours, deep venous thrombosis prophylaxis, or other perioperative outcomes, including medical fees. Conclusions The initiation of protocol-driven care by internists resulted in improved adherence to osteoporosis medication prescriptions and postoperative analgesic use compared with orthopedic care. This approach can be used as an effective method of care for elderly patients undergoing surgery.

Perceived usability and acceptability of the My-Hip Fracture risk communication tool from the perspective of academic clinicians

Objective

We evaluated the usability and acceptability of My-Hip Fracture (My-HF), a web application that assists providers in delivering individualized prognostic information to patients hospitalized for hip fracture (HF).

Methods

We observed a sample of 16 clinicians as they navigated My-HF. We then administered a structured questionnaire and conducted semi-structured interviews to explore participants' opinions about the app's content and the feasibility of incorporating the app into clinical workflows.

Results

Clinicians required a median of 2-min and 45 s to navigate through the app. Nearly all participants indicated that My-HF was easy to use and would be useful for their practice. About half of participants had suggestions for additional useful peri-operative content. A few expressed concerns about communicating mortality risk. About half expressed concerns about how My-HF might be integrated into existing clinical workflows.

Conclusions

Though clinicians rated My-HF high on usefulness in a structured usability questionnaire, qualitative interviews identified a number of suggestions for optimizing integration into clinical practice. Creating shared goals, establishing a decision coach, and developing a framework of communication across care settings could facilitate integration of My-HF by the multidisciplinary HF team.

Innovation

My-Hip Fracture is a unique web application which provides personalized prognostic information to patients and families after HF. My-HF has potential to facilitate informed decision-making between clinicians and patients, but adaptations will be necessary to enhance its usability.

miR-21-5p Enriched Exosomes from Human Embryonic Stem Cells Promote Osteogenesis via YAP1 Modulation

Purpose

To investigate the osteogenic potential of human embryonic stem cell-derived exosomes (hESC-Exos) and their effects on the differentiation of human umbilical cord mesenchymal stem cells (hUCMSCs).

Methods

hESC-Exos were isolated and characterized using transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA), and Western blotting. hUCMSCs were cultured with hESC-Exos to assess osteogenic differentiation through alizarin red staining, quantitative PCR (qPCR), and Western blotting. miRNA profiling of hESC-Exos was performed using miRNA microarray analysis. In vivo bone regeneration was evaluated using an ovariectomized rat model with bone defects treated with exosome-loaded scaffolds.

Results

hESC-Exos significantly promoted the osteogenic differentiation of hUCMSCs, as evidenced by increased alizarin red staining and the upregulation of osteogenesis-related genes and proteins (ALP, RUNX2, OCN). miRNA analysis revealed that miR-21-5p is a key regulator that targets YAP1 and activates the Wnt/β-catenin signaling pathway. In vivo, hESC-Exos enhanced bone repair in ovariectomized rats, as demonstrated by increased bone mineral density and improved bone microarchitecture compared to those in controls.

Conclusion

hESC-Exos exhibit significant osteogenic potential by promoting the differentiation of hUCMSCs and enhancing bone regeneration in vivo. This study revealed that the miR-21-5p-YAP1/β-catenin axis is a critical pathway, suggesting that the use of hESC-Exos is a promising therapeutic strategy for bone regeneration and repair.

Psoas Muscle Volume as an Indicator of Sarcopenia and Disposition in Traumatic Hip Fracture Patients

INTRODUCTION

Sarcopenia, or the loss of lean muscle mass, is associated with increased morbidity and mortality as well as poor surgical outcomes. The aim of our study was to utilize computed tomography imaging to obtain the total psoas volume (TPV) as a potential marker of sarcopenia. We then investigated the relationship between TPV and outcomes in surgically managed hip fracture patients, particularly their discharge disposition.

METHODS

A retrospective review of surgically managed hip fracture patients at a single institution level one American College of Surgeons verified trauma center between 2017 and 2022 was performed. The primary endpoint was patient disposition after hospitalization. TPV was collected via three dimension reconstruction of computed tomography images. Student's t-test was used to assess for association between TPV and demographic variables. Binary logistic regressions were performed to examine variables that could predict patient disposition among the patients.

RESULTS

We identified 64 surgically managed hip fracture patients, 57.8% of whom were males, with a median age of 74 (IQR: 62, 88). Black race (244.4 vs. 190.3, P = 0.032) and younger age (252.2 vs. 181.8, P = 0.004) were associated with higher TPV. Male patients with higher TPV had a higher likelihood of being discharged home as opposed to a skilled nursing or rehabilitation facility (251.3 vs. 191.1, P = 0.02). In multivariable analysis adjusting for sex, race, body mass index, and age, males with a higher TPV were more likely to be discharged home (odds ratio: 1.012; 95% confidence interval: 1.004 1.020; P = 0.028).

CONCLUSIONS

Psoas muscle volume can be used to predict which male patients are likely to be discharged home postoperatively after surgically managed traumatic hip fracture.

Hearing impairment increases the risk of hip fracture-related mortality and recurrent hip fractures: A propensity score matching analysis

PURPOSE

Despite the ongoing rise in hip fractures and the adverse effects of hearing impairment (HI) on increased mortality and morbidity, research addressing the influence of HI on mortality risk or complications in patients with hip fractures remains absent. This study aimed to analyze the effects of HI on mortality and treatment outcomes among patients with hip fracture.

METHODS

We retrospectively collected data from consecutive patients diagnosed with hip fractures between January 2007 and March 2022 who had auditory examination records. From the initially enrolled 265 patients, data for 58 with HI and 58 without HI (control group) were extracted using a 1:1 propensity score matching. The primary outcome included comparison of mortality rates, and the secondary outcome encompassed the comparison of postoperative medical and surgical complications.

RESULTS

The 1-year cumulative mortality rate was not significantly different between the HI and control groups, but the overall cumulative mortality rate was significantly higher in the HI than in the control group (63.0 % and 48.6, respectively; P = 0.046) in a follow-up period of up to 16 years. The HI group had a significantly higher incidence of "second hip fractures due to falls" than the control group (P = 0.016), although no differences in other medical and surgical complications were revealed.

CONCLUSIONS

Awareness of the long-term risk of higher mortality when managing patients with hip fracture and HI is important. To reduce the risk of second hip fractures, paying more attention to fall prevention education and taking a more proactive approach, especially for those with HI.

Hip Fractures in Malta: Does Delay in Surgery Affect Clinical Outcomes?

INTRODUCTION

Hip fractures are common and are a major cause of significant morbidity and mortality in the elderly population, particularly when treatment is delayed. The British Orthopaedic Association's (BOA) guidelines state that surgical treatment should be performed within 36 hours of admission. This study aimed to investigate the effects of delays in surgery on clinical outcomes and to evaluate mortality rates over a three-year follow-up period following proximal femoral fractures.

METHODOLOGY

This was a single-center, retrospective observational study of all patients aged ≥60 years admitted with low-energy hip fractures between June 1, 2020, and November 30, 2020. A total of 205 patients were included and followed up for three years. Data were collected from electronic medical records and operating theater notes. Statistical analysis was performed to analyze the effects of delay in surgery on clinical outcomes.

RESULTS

A 45.9% all-cause mortality rate was observed at three years post-hip fracture in this study. A delay of more than 36 hours to surgery was associated with a statistically significant increase in both length of hospital stay and mortality at one and three years, while no difference was observed in hip-related complications.

CONCLUSIONS

The three-year mortality rate compares well with those found in the literature. A delay in the surgical management of hip fractures is associated with overall worse clinical outcomes, with a higher mortality rate at three years.

Incidence of and Risk of Mortality After Hip Fractures in Rheumatoid Arthritis Relative to the General Population

OBJECTIVE

Osteoporosis, a known complication of rheumatoid arthritis (RA), increases the risk of hip fracture, which is associated with high morbidity and mortality. Fracture risk estimates in patients with RA treated with contemporary treatment strategies are lacking. The objectives were (1) estimate age-specific and sex-specific incidence rates and compare the risk of hip fractures in RA relative to age-matched and sex-matched general population controls, and (2) compare the risk of all-cause mortality in RA and general population controls after hip fracture.

METHODS

A longitudinal study of a population-based incident cohort of patients with RA diagnosed between 1997 and 2009, followed until 2014, with age-matched and sex-matched controls from the general population of British Columbia, using administrative health data. Hip fracture outcomes (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 820.0 or 820.2; ICD-10-Canada code S72.0 to S72.2) and mortality at predefined intervals after fracture (in hospital, 90 days, 1-year, 5-year) were identified. Hip fracture incidence rates for RA and controls, and incidence rate ratios (IRRs), were calculated. Cox proportional hazards models compared hip fracture and mortality risk in RA versus controls; logistic regression compared in-hospital mortality risk.

RESULTS

Overall, 1,314 hip fractures over 360,521 person-years were identified in 37,616 individuals with RA and 2,083 over 732,249 person-years in 75,213 controls, yielding a 28% greater fracture risk in RA (IRR 1.28 [95% confidence interval 1.20-1.37]). Mean age at time of fracture was slightly younger for RA than controls (79.6 ± 10.8 vs 81.6 ± 9.3 years). Postfracture mortality risk at one-year and five-years did not differ between RA and general population controls. Results were similar in a sensitivity analysis including only individuals with RA who received disease-modifying antirheumatic drugs.

CONCLUSION

People with RA had a greater risk of hip fractures, but no greater risk of mortality post fracture, than the general population. The relative risk of hip fractures observed was not as high as previously reported, likely reflecting better treatment of inflammation and management of osteoporosis and its risk factors.

Trends in hip fracture surgery in the United States from 2016 to 2021: patient characteristics, clinical management, and outcomes

INTRODUCTION

Hip fractures are a serious health concern and a major contributor to healthcare resource utilisation. We aimed to investigate nationwide trends in the USA in patient characteristics and outcomes in patients after hip fracture repair surgery.

METHODS

From the Premier Healthcare dataset, we extracted patient encounters for surgical hip fracture repair from 2016 to 2021. Patient characteristics, comorbidities, complications, and anaesthetic and surgical details were analysed. Cochran-Armitage trend tests and simple linear regression were used to determine trends.

RESULTS

We included 347 086 hip fracture repair encounters. Notable trends included the following: median patient age declined from 82 yr [interquartile range: 73-88 yr] to 81 yr [interquartile range: 73-88 yr], (P-value=0.002), the proportion of female patients decreased from 68% to 66.2% (P-value=0.019); internal fixation was the most common intervention initially, but with a declining percentage from 49.9% to 43.8% (P-value <0.001); in general, patients carried a greater comorbidity burden, with the proportion with three or more Elixhauser comorbidities increasing from 56.4% to 58.6% (P-value=0.006); general anaesthesia remained the most common anaesthetic technique, from 68.90% to 56.80% without a significant trend; per 1000 inpatient days, the most common complication remained acute renal failure; despite a higher comorbidity burden, no complication showed a statistically significant upward trend, and many showed downward trends.

CONCLUSIONS

Over the 6-yr period from 2016 to 2021, a majority of hip fracture repairs continued to be performed under general anaesthesia but with that percentage declining over time. Notable trends included a lower percentage of female patients, an increase in femoral neck fractures, a higher comorbidity burden among patients, and a decrease in complications.

The management of anticoagulated fragility femoral fracture patients

Approximately 20% of patients sustaining a fragility femur fracture use an anticoagulant, and over 30% use an antiplatelet medication, both of which can result in surgical delay. Previously confined to fractures of the proximal femur, performance assessment, outcome and surgical delay is now assessed for all fractures of the femur in older patients, including those involving implants. This narrative review draws together all literature pertaining to anticoagulation and antiplatelet management in older patients with a fracture of the femur to address 5 key points: prevalence of anticoagulant and antiplatelet use; analysis of management protocols; collation of national guidelines; comparison of perioperative management; timing of surgery and perioperative outcomes.Our review found that the prevalence of fragility femur fracture patients taking anticoagulant and antiplatelet medication ranges from 20-40% and 25-35% respectively. More anticoagulated patients are taking direct oral anticoagulants compared to vitamin k antagonists with growing implications for variation in practice and delays to surgery.Several national guidelines exist although these are characterised by marked variation, there is little standardisation, and none are generalised across all fragility femur fractures.Expedited surgery within 36 hours of admission in patients taking an anticoagulant or antiplatelet medication is safe and has been demonstrated in fractures of the proximal femur across many small number studies although no such evidence exists in non-proximal femur fractures despite this population sharing similar characteristics. There is a need for all fractures of the femur in older people to be considered when researching and assessing performance in this population to prevent needless variation and delay.

Fermented Dairy Products, Musculoskeletal and Mental Health in Older Adults: is There Evidence to Support Benefits that go Beyond Those of Non-Fermented Dairy Products?

Fermented dairy products have recently gained popularity due to their purported health benefits, nevertheless, their role in ageing remains uncertain. This narrative review aims to evaluate evidence from observational (prospective) and interventional studies on the potential benefits of fermented dairy product consumption for musculoskeletal and mental health in older adults. Additionally, it seeks to determine whether any observed benefits surpass those of non-fermented dairy products and to identify directions for future research. Prospective studies support either favourable or neutral associations of fermented dairy products with outcomes of musculoskeletal health or neutral associations with mental health outcomes, whilst it remains unclear if the benefits observed with fermented dairy products go beyond those of the non-fermented dairy foods. Few interventional studies suggest overall favourable effects of yogurt and cheese on musculoskeletal health in older adults but given their small number (N = 6) and heterogeneity, they do not allow a clear assessment or definitive recommendations for fermented dairy intake. Interventional studies reporting mental health outcomes are largely lacking for this age group (N = 1). Given the very limited evidence for the effectiveness of fermented dairy products, future well-designed prospective and randomized controlled trials are needed to better understand their benefits (especially compared to those of non-fermented dairy foods), their characteristics and the quantities required to offer protection against musculoskeletal and/or mental health ageing.

Variation in mortality following hip fracture across the Asia Pacific region: Systematic review and proportional meta-analysis

OBJECTIVE

To determine country/region-specific mortality (in-hospital, 30-day and 1-year) following hip fracture across the Asia Pacific region.

METHODS

Five databases MEDLINE, PUBMED, EMBASE, Web of Science and the Cochrane Library were searched to identify studies that reported mortality following hospitalisation for low-trauma hip fracture in adults aged ≥50 years with data from 2010 to 30 September 2021. There were no restrictions on study design or language. Pooled mortality estimates for countries/regions with ≥2 studies were calculated using random-effects models.

RESULTS

In total 244 studies were included in the meta-analysis. 123 studies (1,382,810 patients, 13 countries/regions) reported in-hospital mortality which ranged from 1.4 % in Japan [95 %CI 1.2-1.7], Singapore [95 %CI 1.0-1.6], China [95 %CI 0.8-2.3] and Hong Kong SAR [95 %CI 0.8-2.6] to 5.5 % [95 %CI 4.1-7.2] in New Zealand. 92 studies (628,450 patients, 13 countries/regions) reported 30-day mortality which ranged from 1.2 % in Japan [95 %CI 0.9-1.5] and Thailand [95 %CI 0.7-2.0] to 7.4 % [95 %CI 7.0-7.8] in Australia. 142 studies (1,139,752 patients, 14 countries/regions) reported 1-year mortality which ranged from 10.8 % [95 %CI 9.6-12.1] in Singapore to 23.3 % [95 %CI 22.3-24.5] in Australia and 23.8 % in New Zealand.

CONCLUSION

There is substantial variation in mortality across the Asia Pacific region. Short-term mortality rates in Asian countries, notably Japan and Singapore, are up to four-fold lower than for Australia and New Zealand. This difference, although less marked, is sustained at 1-year with a two-fold lower mortality rate in Asia. This meta-analysis is the first to delineate these differences, further studies are required to understand the reasons for this variation.

The Patient with Hip Fracture

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment.

Analysis of the risk factors for contralateral refracture after hip fracture surgery in elderly individuals: a retrospective study

BACKGROUND

The risk factors for contralateral hip refracture after primary hip fracture are not fully understood; therefore, this study compared the clinical characteristics of patients with first and second hip fractures and explored and analyzed the risk factors for contralateral refracture after hip fracture in elderly individuals to provide a reference for the clinical prevention of postoperative refracture of hip fracture in elderly individuals.

METHODS

A retrospective study was conducted on 458 elderly patients with hip fractures who underwent surgical treatment and were discharged from our hospital from March 2016 to March 2019. The clinical data of the patients were analyzed retrospectively. Patients were divided into a case group (postoperative refracture) and a control group (no postoperative refracture) based on whether they experienced refracture within five years after surgery. The clinical data of the two groups were compared and analyzed via univariate and multivariate logistic regression analyses and receiver operating characteristic (ROC) regression analysis to identify the risk factors for refractures after hip fracture surgery in elderly patients.

RESULTS

Sixty-one patients experienced refracture, with an incidence rate of 13.3%. Age ≥ 80.5 years, female sex, poor knee joint function, FRAX score ≥ 15.5, anemia, visual impairment, osteoporosis, and Alzheimer's disease (AD) were identified as risk factors for refracture after hip fracture surgery in elderly individuals (P < 0.05).

CONCLUSION

Elderly patients with hip fractures are susceptible to refracture after surgery because of factors such as advanced age, female sex, high FRAX score, poor knee joint function, anemia, osteoporosis, visual impairment, and AD. Targeted interventions should be implemented based on the above risk factors.

Sleep and risk of hip fracture and falls among middle-aged and older Chinese

The study aimed to assess the prospective associations between sleep duration, sleep restfulness, midday napping and hip fracture (HF) and falls in a nationally representative Chinese population. Data were from the China Health and Retirement Longitudinal Study which was conducted from 2013 to 2018. In total, 10,508 individuals without a history of HF in 2013 were included. Nighttime sleep duration, sleep restfulness and midday napping were self-reported. Logistic regression analyses were performed to examine the relationships between sleep problems and HF as well as falls, adjusting for covariates. A total of 313 (3.0%) participants reported HF, and 3899 (37.1%) experienced at least one fall event over the following 5-year period. Participants who had a short sleep duration (≤ 6) were more likely to report HF (OR = 1.27, 95% CI = 1.00-1.62) and falls (OR = 1.18, 95% CI = 1.07-1.30) than those who had a normal sleep duration (6-9 h) in the fully adjusted model. Participants having unrestful sleep were also more likely to report falls (OR = 1.23, 95% CI = 1.11-1.36) than those who had restful sleep. However, there was no significant association between midday napping and HF and falls. In conclusion, short sleep duration and sleep restfulness were independently associated with an increased risk of HF and falls, which may have important clinical and public health implications. Interventions to improve sleep quality may reduce the risk of HF and fall accidents among middle-aged and older people.

Long-term Outcomes in Orthogeriatric Co-management: a Literature Review

Fragility fractures of the hip are one of the most important triggers of poor health outcomes in older adults. They often result in limitations in the ability of patients to care for themselves and mortality remains high. Orthogeriatric co-management may improve outcomes for this high-risk population. However, the impact on long-term results has not yet been definitively clarified. The purpose of this study was to present the influence of orthogeriatric co-management on mortality and self-care ability, as measured by the Barthel score, one year after hip fracture in people ≥ 60 years.A systematic literature search was performed in accordance with the process steps of identification, selection, and evaluation, with a systematic search of the MEDLINE, CINAHL Complete and Cochrane Library databases in the period from February to March 2022. Articles in English and German published between 2012 and 2022 were included. Twelve studies were finally used.Six studies demonstrated a statistically significant reduction in the one-year mortality rate. Only one of four studies evaluating self-care ability showed a significant improvement when the patient was treated on a specialised ward.Orthogeriatric co-management seems to be beneficial in positively influencing one-year mortality and self-care ability. In view of the heterogeneous results, the implementation of this care model can only be recommended to a limited extent.

Relationship between Helicobacter pylori infection, osteoporosis, and fracture

Osteoporotic fracture is a prevalent noncommunicable disease globally, causing significant mortality, morbidity, and disability. As the population ages, the healthcare and economic burden of osteoporotic fracture is expected to increase further. Due to its multifactorial features, the development of osteoporotic fracture involves a complex interplay of multiple risk factors, including genetic, environmental, and lifestyle factors. Helicobacter pylori, which infects approximately 43% of the world's population, has been associated with increased fracture risk due to hypochlorhydria from atrophic gastritis and systemic inflammation from elevated pro-inflammatory cytokines. However, the potential impact of H. pylori infection and eradication on fracture risk remains contentious among various studies due to the study design and inadequate adjustment of confounding factors including baseline gastritis phenotype. In this review, we provided a comprehensive evaluation of the current evidence focusing on the underlying mechanisms and clinical evidence of the association between H. pylori infection and osteoporotic fracture. We also discussed the potential benefits of H. pylori eradication on fracture risk.

The impact of ethnicity on care and outcome after hip fracture in England and Wales

Aims

To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome.

Methods

This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients' odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates.

Results

A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%).

Conclusion

Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates.

Bone Loss and Fractures in Post-Menopausal Women Living with HIV: A Narrative Review

INTRODUCTION

Post-menopausal women living with Human Immunodeficiency Virus (WLHIV) face an increased risk of bone fractures due to the relationship between HIV-related factors and menopause. This narrative review aims to summarise the current knowledge about fracture risk among post-menopausal WLHIV in particular looking at hormonal changes, combined antiretroviral therapy (cART), lifestyle factors, and psychosocial implications. We also profiled a summary of the significant, recent studies of post-menopausal WLHIV residing in low-income countries (LIC).

METHODS

A thorough search of the literature was performed across PubMed, Medline, Scopus, and Google Scholar, focussing on studies published between 2000 and 2024. Inclusion criteria entailed original research, reviews, and meta-analyses addressing bone mineral density (BMD), fracture incidence, and related risk factors in post-menopausal WLHIV.

RESULTS

The review identified 223 relevant studies. Post-menopausal WLHIV exhibit significantly lower BMD and higher fracture rates compared to both HIV-negative post-menopausal women and pre-menopausal WLHIV. cART, particularly tenofovir disoproxil fumarate (TDF), contributes to reduced BMD. Menopausal status exacerbates this risk through decreased oestrogen levels, leading to increased bone resorption. Moreover, lifestyle choices such as smoking, alcohol consumption, and low physical activity are more prevalent in PWHIV, which further elevates fracture risk. Different psychosocial factors may make WLWHIV more vulnerable at this stage of their life, such as depression, isolation, stigma, and housing and nutritional issues. Women living in LICs face a variety of challenges in accessing HIV care. There are gaps in research related to the prevalence of osteoporosis and bone loss in post-menopausal WLHIV in LICs.

CONCLUSION

Post-menopausal women living with HIV face a significantly higher risk of bone loss and fractures due to the combined effects of HIV and menopause. Antiretroviral therapy (particularly TDF), lifestyle factors, and psychosocial challenges exacerbate this risk. There is a need for careful selection of cART, hormone replacement therapy (HRT), and emerging treatments such as Abaloparatide. A holistic approach including lifestyle changes and psychosocial support is crucial to reduce fracture risk in WLHIV, especially in low-income countries.