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

What Is the Best Treatment Choice for Concomitant Ipsilateral Femoral Neck and Intertrochanteric Fracture? A Retrospective Comparative Analysis of 115 Consecutive Patients

PURPOSE

Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture.

METHODS

The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients.

RESULTS

The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function.

CONCLUSIONS

For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient's age, the displacement of the femoral neck, and one's expertise.

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

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

Tibio-Talar-Calcaneal Nail Fixation for Ankle Fractures: A Systematic Review and Meta-Analysis

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multidatabase literature search was performed on December 14, 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36-104 weeks). Surgical site infection occurred in 11.2% (95% confidence interval [CI] 6.3%-19%) of patients, implant failure occurred in 8.1% (95% CI 5%-12.8%) of patients, and unplanned return to operating room occurred in 10.1% (95% CI 6.1%-16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7%-34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (95% CI: 67.4%-90.4%) of patients were able to return to similar preoperative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for nonoperative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. About 81.5% (95% CI 67.4%-90.4%) of patients were able to return to a similar preinjury mobility status after tibio-talar-calcaneal nailing.

Reduced Awareness for Osteoporosis in Hip Fracture Patients Compared to Elderly Patients Undergoing Elective Hip Replacement

Background: Osteoporotic fractures are associated with a loss of quality of life, but only few patients receive an appropriate therapy. Therefore, the present study aims to investigate the awareness of musculoskeletal patients to participate in osteoporosis assessment and to evaluate whether there are significant differences between acute care patients treated for major fractures of the hip compared to elective patients treated for hip joint replacement.; Methods: From May 2015 to December 2016 patients who were undergoing surgical treatment for proximal femur fracture or total hip replacement due to osteoarthritis and were at risk for an underlying osteoporosis (female > 60 and male > 70 years) were included in the study and asked to complete a questionnaire assessing the awareness for an underlying osteoporosis. ASA Score, FRAX Score, and demographic information have also been examined. Results: In total 268 patients (female = 194 (72.0%)/male = 74 (28%)), mean age 77.7 years (±7.7) undergoing hip surgery were included. Of these, 118 were treated for fracture-related etiology and 150 underwent total hip arthroplasty in an elective care setting. Patients were interviewed about their need for osteoporosis examination during hospitalization. Overall, 76 of 150 patients receiving elective care (50.7%) considered that an examination was necessary, whereas in proximal femur fracture patients the awareness was lower, and the disease osteoporosis was assessed as threatening by significantly fewer newly fractured patients. By comparison, patients undergoing trauma surgery had a considerably greater risk of developing another osteoporotic fracture than patients undergoing elective surgery determined by the FRAX® Score (p ≤ 0.001).; Conclusions: The patients’ motivation to endure additional osteoporosis diagnostic testing is notoriously low and needs to be increased. Patients who underwent acute care surgery for a fragility proximal femur fracture, although acutely affected by the potential consequences of underlying osteoporosis, showed lower awareness than the elective comparison population that was also on average 6.1 years younger. Although elective patients were younger and at a lower risk, they seemed to be much more willing to undergo further osteoporosis assessment. In order to better identify and care for patients at risk, interventions such as effective screening, early initiation of osteoporosis therapy in the inpatient setting and a fracture liaison service are important measures.

Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients

Introduction

Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure.

Methods

This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality.

Results

Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved.

Conclusions

Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.

Montreal cognitive assessment (MoCA) is highly correlated with 1-year mortality in hip fracture patients

Prevalence of cognitive impairment in hip fractures was 86.5%. MoCA is an independent risk factor of mortality. MoCA score of < 15 is correlated with 11.71 times increased risk of mortality. Early attention and caution should be given to these patients for appropriate intervention to decrease mortality rates.

INTRODUCTION

Hip fractures rank amongst the top 10 causes of disability and current mortality of hip fractures is high. Objectives were to determine 1) prevalence of cognitive impairment, 2) whether Montreal Cognitive Assessment (MoCA) score was an independent risk factor associated with mortality, 3) MoCA cut-off that result in high risk of mortality.

METHODS

This was a cohort study between July 2019 to June 2020. Inclusion criteria were 1) hip fracture, 2) >  = 65 years old, and 3) low-energy trauma. Patients undergo assessment for cognitive impairment with MoCA. Prevalence was assessed, MoCA cut-off point, and accuracy of statistical model was evaluated. Logistic regression modelling was used to assess association between mortality and MoCA.

RESULTS

There were 260 patients recruited. Two hundred twenty-five patients had MoCA score < 22 signifying cognitive impairment, and 202 patients had MoCA score of < 19. 46 hip fracture patients died at 1-year follow-up. 45 of these patients had MoCA score < 19, and 1 patient had a MoCA > 22. Results showed statistical significance and good model effect (at least 0.8) with MoCA cut-off points between < 15 and < 19 (p < 0.05). After controlling confounding factors, statistical significance still existed in MoCA cut-off point at < 15 (odds ratio (95% CI) = 11.71 (1.14, 120.71); p = 0.04).

CONCLUSION

Prevalence of cognitive impairment in hip fractures was 86.5%. MoCA is an independent risk factor of mortality in hip fracture patients. MoCA score of < 15 is correlated with 11.71 times increased risk of mortality at 1-year after a hip fracture. AUC with MoCA score < 15 was 0.948. Early attention and caution should be given to these patients for appropriate intervention to decrease mortality rates.

Geographic variation in hip fracture surgery rate, care quality and outcomes: a comparison between national registries in Ireland and Denmark

Ireland and Denmark have similar hip fracture surgery rates but differences in care quality indicators and patterns of intracapsular fracture repair. Very high variation in total hip arthroplasty rate within both countries and higher observed early mortality in Denmark require further investigation.

PURPOSE

To explore and compare geographic variation of hip fracture surgery rate, care quality and outcomes in Ireland and Denmark.

METHODS

Patients aged ≥ 65 years with surgically treated hip fracture were included from the Irish Hip Fracture Database (years = 2017-2020, n = 12,904) and the Danish Multidisciplinary Hip Fracture Registry (years = 2016-2017, n = 12,924). The age and sex standardised rate of hip fracture surgery and the proportion of patients with seven process quality indicators, three surgery types and four outcomes were calculated. Systematic components of variation (SCV) were calculated based on hospital area (6 Irish hospital groups, 5 Danish regions).

RESULTS

The age and sex standardised rate of hip fracture surgery per 1000 older population in 2017 was 4.7 (95% CI = 4.4-5.1) in Ireland and 5.3 (95% CI = 5.1-5.5) in Denmark. Ireland had lower rates of surgery within 36 h (59% versus 84%), nutritional assessment (27% versus 84%) and pre-discharge mobility recording (52% versus 92%). Patterns of intracapsular fracture repair also differed between countries (hemiarthroplasty: Ireland = 85%, Denmark = 52%). Both countries had very high variation for total hip arthroplasty (THA) provision (SCV Ireland = 10.6, Denmark = 97.9). Ireland had longer hospital stays (median 12 versus 7 days), but lower 7-day (1.0% versus 3.1%) and 14-day (2.0% versus 5.5%) mortality.

CONCLUSION

Ireland and Denmark have similar hip fracture surgery rates, but differences in care quality, surgery patterns and outcomes. High variation in THA provision and observed differences in mortality require further exploration. In Ireland, there is scope for improvement regarding early surgery, mobility, nutrition assessment and improved post-discharge follow-up.

The global burden of fragility fractures - what are the differences, and where are the gaps

The current burden of fragility fractures is enormous, and it is set to increase rapidly in the coming decades as humankind enters a new demographic era. The purpose of this review is to consider, in different settings: • The human and economic toll of fragility fractures. • Risk factors for fragility fractures. • Current acute management of fragility fractures. • Current care gaps in both secondary and primary fracture prevention. A summary of global, regional, and national initiatives to improve the quality of care is provided, in addition to proposals for the research agenda. Systematic approaches to improve the acute care, rehabilitation and prevention of fragility fractures need to be developed and implemented rapidly and at scale in high-, middle- and low-income countries throughout the world. This must be an essential component of our response to the ageing of the global population during the remainder of the current United Nations - World Health Organization "Decade of Healthy Ageing".

The Effects of COVID-19 on Geriatric Hip Fracture Management and 1-Year Mortality in Beijing

Objectives

Concerns about the coronavirus disease 2019 (COVID‐19) pandemic resulted in unprecedented challenges to the management of geriatric hip fractures. We aimed to evaluate the effects of the COVID‐19 surge on the time to surgery and 1 year mortality in geriatric patients with hip fracture at a large, urban Level 1 trauma center in Beijing, and to guide the management of geriatric hip fracture patients throughout the COVID‐19 pandemic.

Methods

This single‐center retrospective study included consecutive patients aged ≥65 years and injured 3 weeks prior to admission. Demographic and surgical data were collected between January 20 and May 31, 2020, and from the same period in 2019. Mortality data and functional status were collected at follow‐up of 1‐year after surgery. The primary outcomes were time to surgery and 1 year mortality.

Results

There were no significant differences in sex, fracture type, and surgical pattern between the 2020 (n = 261) and 2019 time‐matched (n = 307) cohorts. The time from admission to surgery was significantly delayed in the 2020 cohort compared with that in the 2019 cohort (48.9 h vs 20.5 h, p < 0.001). Fewer patients underwent surgery within 48 h in the 2020 cohort (65.5% vs 87.6%, p < 0.001). Surgical delay was also associated with an increased risk of inpatient complications (30.2% vs 20.8%, p = 0.010), however there was no significant difference in the 1‐year mortality rate, nor between pre‐injury and 1 year follow‐up mobility as assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility levels.

Conclusions

The COVID‐19 pandemic has significantly increased the surgery waiting time for geriatric patients with hip fractures, which resulted in increased inpatient complications without a higher mortality rate within 1 year. This reinforces the importance of maintaining timely and protocolized care for geriatric hip fractures throughout any subsequent waves of the pandemic.

A multicenter study of 1-year mortality and walking capacity after spinal fusion surgery for cervical fracture in elderly patients

Background

The 1-year mortality and functional prognoses of patients who received surgery for cervical trauma in the elderly remains unclear. The aim of this study is to investigate the rates of, and factors associated with mortality and the deterioration in walking capacity occurring 1 year after spinal fusion surgery for cervical fractures in patients 65 years of age or older.

Methods

Three hundred thirteen patients aged 65 years or more with a traumatic cervical fracture who received spinal fusion surgery were enrolled. The patients were divided into a survival group and a mortality group, or a maintained walking capacity group and a deteriorated walking capacity group. We compared patients’ backgrounds, trauma, and surgical parameters between the two groups. To identify factors associated with mortality or a deteriorated walking capacity 1 year postoperatively, a multivariate logistic regression analysis was conducted.

Results

One year postoperatively, the rate of mortality was 8%. A higher Charlson comorbidity index (CCI) score, a more severe the American Spinal Cord Injury Association impairment scale (AIS), and longer surgical time were identified as independent factors associated with an increase in 1-year mortality. The rate of deterioration in walking capacity between pre-trauma and 1 year postoperatively was 33%. A more severe AIS, lower albumin (Alb) and hemoglobin (Hb) values, and a larger number of fused segments were identified as independent factors associated with the increased risk of deteriorated walking capacity 1 year postoperatively.

Conclusions

The 1-year rate of mortality after spinal fusion surgery for cervical fracture in patients 65 years of age or older was 8%, and its associated factors were a higher CCI score, a more severe AIS, and a longer surgical time. The rate of deterioration in walking capacity was 33%, and its associated factors were a more severe AIS, lower Alb, lower Hb values, and a larger number of fused segments.

Hip Fracture as a Predictive Marker for the Risk of Dementia: A Population-Based Cohort Study

OBJECTIVES

This study aimed to investigate the association between hip fracture and the risk of dementia.

DESIGN

A retrospective real-world propensity score-matched cohort study was conducted using the real-world hip fracture cohort (RHFC).

SETTING AND PARTICIPANTS

Electronic health record data from the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong were used. A total of 52,848 patients aged ≥65 years and with at least an event of fall from 2006 to 2015 were included in the RHFC.

METHODS

The incidence of fall, hip fracture, and dementia was determined using their International Classification of Diseases, Ninth Revision (ICD-9) codes. Competing risk regression models were used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

Hip fracture was associated with an increased risk of dementia (HR 1.09, 95% CI 1.04-1.15, P < .001). The subgroup analysis showed that association was significant in women but not in men.

CONCLUSIONS AND IMPLICATIONS

Hip fracture was associated with the increased risk of dementia among older adults. Further studies investigating the potential roles of hip fracture in the development of dementia could benefit the management of both conditions in older adults.

Mortality Risk Following Atypical Femoral Fracture: a Systematic Review and Meta-analysis

OBJECTIVE

To summarize all available data, using systematic review and meta-analysis, to estimate 1.) one-year mortality risk following AFF and 2.) risk ratio of mortality following AFF versus TFF.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to February 2022 using search strategy that comprised of terms for "Atypical Femoral Fracture" and "Mortality". Eligible study must consist of a cohort of patients with atypical femoral fracture. Then, the study must report one-year mortality rate following AFF or report effect estimates with 95% confidence intervals (95% CIs) comparing incident mortality between patients with AFF and TFF. Point estimates with standard errors were retrieved from each study and were combined using the generic inverse variance method.

RESULTS

A total of 8,967 articles were identified. After two rounds of independent review by three investigators, we identified seven studies reporting one-year mortality rate of AFF and three studies comparing mortality rate of AFF versus TFF. Pooled analysis revealed pooled one-year mortality rate following AFF of 0.10 (95% CI, 0.05 - 0.16, I² 93.3%). Two studies compared mortality risks of the AFF versus TFF and revealed conflicting results.

CONCLUSION

One-year mortality rate following AFF was approximately 10%. However, evidence is insufficient to conclude if there was difference in mortality risk between AFF and TFF.

Mortality Rates in Femoral Neck Fractures Treated With Arthroplasty in South Africa

Objectives

To investigate the mortality rate for neck of femur fractures treated with arthroplasty at a tertiary level unit in South Africa and to evaluate the effect of known risk factors for mortality in neck of femur fractures treated with arthroplasty in the South African context.

Design

Retrospective cohort study. The main outcome was to determine mortality rates during in hospital stay, at 3 months, 6 months 1 year post surgery. The secondary outcome was to determine factors influencing mortality at 30 days, 6 months and 12 months post-surgery.

Results

Mortality rate was 3.3% in hospital, 5.6% at 30 days and 26.7% at 1 year. Age >79, ASA score >3, and cementing of the femur had statistically increased mortality risk (P < .001). Average length of hospital stay was 12.3 ± 5.1 days (range 3.0-41.0 days) with 73% of patients discharged back to pre-hospital home.

Conclusion

Mortality rates after femur neck fracture arthroplasty in South Africa are slightly higher at 1 year compared to international data. However, the rates are comparably low during hospital stay, 30 day and at 6 months post-surgical intervals.

Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type.

OBJECTIVE

Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland.

METHODS

A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years.

RESULTS

We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m², age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m², ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities.

CONCLUSIONS

Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Would giving priority in surgery timing to the oldest patients result in lower mortality?

PURPOSE

Early hip fracture surgery in elderly patients is recognized as a positive prognostic factor. When applied as an intervention, it does not always reduce overall patient mortality. A plausible explanation for this is that not all patients equally benefit from early surgery. The purpose of the study is to investigate the effect of early surgery on mortality in patients ages 80 and older.

METHODS

This is a retrospective cohort of 3463 patients with hip fractures, operated upon within seven days of admission in a tertiary medical center between 2010 and 2018. Patients were divided into five groups: ages 80-84, 85-89, 90-94, 95-99, and 100 or above. Baseline characteristics were compared between groups. Mortality at one year post-operatively as a function of surgery delay was visualized for each group, using restricted spline curve analysis.

RESULTS

Patients with increasing age were operated on earlier, had increased co-morbidities with a higher ASA score and experienced higher mortality. Spline curve analysis in younger patients, ages 80 to 94, demonstrated an inflection point at 48 hours after admission, prior to which mortality was rising rapidly and after which it continued rising slowly. In the two oldest age cohorts, there was no increased mortality with an increasing surgical delay.

CONCLUSIONS

In patients ages 80-94 surgery on day one may be preferable to surgery on day two. In patients ages 95 and older, surgery time did not influence mortality. Pursuit of better patient outcomes may include prioritizing early surgery in younger patients.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures

OBJECTIVE

To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients.

DESIGN

Retrospective case series.

SETTING

Level-1 trauma center.

PATIENTS

One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures.

INTERVENTION

Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures.

MAIN OUTCOME MEASURES

Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges.

RESULTS

Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year.

CONCLUSIONS

Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries.

LEVEL OF EVIDENCE

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

Gait Biomechanics for Fall Prevention among Older Adults

In our currently ageing society, fall prevention is important for better healthy life expectancy and sustainable healthcare systems. While active outdoor walking is recommended as adequate exercise for the senior population, falls due to tripping and slipping exist as the primary causes of severe injuries. Minimum foot clearance (MFC) is the lowest vertical height of the foot during the mid-swing phase and indicates the risk of tripping. In contrast, coefficient of friction (COF) factors determine the occurrence of falls from slipping. Optimisation of the MFC and the COF for every step cycle prevents tripping and slipping, respectively. Even after the initiation of hazardous balance loss (i.e., tripping and slipping), falls can still be prevented as long as the requirements for balance are restored. Biomechanically, dynamic balance is defined by the bodily centre of mass and by the base of support: spatially—margin of stability and temporally—available response time. Fall prevention strategies should, therefore, target controlling the MFC, the COF and dynamic balance. Practical intervention strategies include footwear modification (i.e., shoe-insole geometry and slip-resistant outsoles), exercise (i.e., ankle dorsiflexors and core stabilisers) and technological rehabilitation (i.e., electrical stimulators and active exoskeletons). Biomechanical concepts can be practically applied to various everyday settings for fall prevention among the older population.

Trends in data quality and quality indicators 5 years after implementation of the Dutch Hip Fracture Audit

PURPOSE

The Dutch Hip Fracture Audit (DHFA), a nationwide hip fracture registry in the Netherlands, registers hip fracture patients and aims to improve quality of care since 2016. This study shows trends in the data quality during the first 5 years of data acquisition within the DHFA, as well as trends over time for designated quality indicators (QI).

METHODS

All patients registered in the DHFA between 1-1-2016 and 31-12-2020 were included. Data quality-registry case coverage and data completeness-and baseline characteristics are reported. Five QI are analysed: Time to surgery < 48 h, assessment for osteoporosis, orthogeriatric co-management, registration of functional outcomes at three months, 30-day mortality. The independent association between QI results and report year was tested using mixed-effects logistic models and in the case of 30-day mortality adjusted for casemix.

RESULTS

In 2020, the case capture of the DHFA comprised 85% of the Dutch hip fracture patients, 66/68 hospitals participated. The average of missing clinical values was 7.5% in 2016 and 3.2% in 2020. The 3 months follow-up completeness was 36.2% (2016) and 46.8% (2020). The QI 'time to surgery' was consistently high, assessment for osteoporosis remained low, orthogeriatric co-management scores increased without significance, registration of functional outcomes improved significantly and 30-day mortality rates remained unchanged.

CONCLUSION

The DHFA has successfully been implemented in the past five years. Trends show improvement on data quality. Analysis of several QI indicate points of attention. Future perspectives include lowering the burden of registration, whilst improving (registration of) hip fracture patients outcomes.

Femur geometry and body composition influence femoral neck stresses: A combined fall simulation and beam modelling approach

Metrics of femur geometry and body composition have been linked to clinical hip fracture risk. Mechanistic explanations for these relationships have generally focused on femur strength; however, impact loading also modulates fracture risk. We evaluated the potential effects of femur geometry and body composition on femoral neck stresses during lateral impacts. Fifteen female volunteers completed low-energy sideways falls on to the hip. Additionally, participants completed ultrasound and dual-energy x-ray absorptiometry imaging to characterize trochanteric soft tissue thickness (TSTT) over the hip and six metrics of femur geometry, respectively. Subject-specific beam models were developed and utilized to calculate peak femoral neck stress (σ_Neck), utilizing experimental impact dynamics. Except for femoral neck axis length, all metrics of femur geometry were positively correlated with σ_Neck (all p < 0.05). Larger/more prominent proximal femurs were associated with increased force over the proximal femur, whereas a wider neck-shaft angle was associated with greater stress generation independent of force (all p < 0.05). Body mass index (BMI) and TSTT were negatively correlated with σ_Neck (both p < 0.05). Despite strong correlations, these metrics of body composition appear to influence femoral neck stresses through different mechanisms. Increased TSTT was associated with reduced force over the proximal femur, whereas increased BMI was associated with greater resistance to stress generation (both p < 0.05). This study provided novel insights into the mechanistic pathways through which femur geometry and body composition may modulate hip fracture risk. Our findings complement clinical findings and provide one possible explanation for incongruities in the clinical fracture risk and femur strength literature.

Multivariable prediction models for long-term outcomes after hip fracture: A protocol for a systematic review

Background: Hip fracture results in high mortality and, for many survivors, long-term functional limitations. Multivariable prediction models for hip fracture outcomes have the potential to aid clinical-decision making as well as risk-adjustment in national audits of care. The aim of this study is to identify, critically appraise and synthesise published multivariable prediction models for long-term outcomes after hip fracture. Protocol: The systematic review will include a literature search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) for journal articles. Search terms related to hip fracture, prognosis and outcomes will be included. Study selection criteria includes studies of people with hip fracture where the study aimed to predict one or more long-term outcomes through derivation or validation of a multivariable prediction model. Studies will be excluded if they focus only on the predictive value of individual factors, or only include patients with periprosthetic fractures, fractures managed non-surgically or younger patients. Covidence software will be used for data management. Two review authors will independently conduct study selection, data extraction and appraisal. Data will be extracted based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist. Risk of bias assessment will be conducted using the Prediction model Risk of Bias Assessment Tool (PROBAST). Characteristics and results of all studies will be narratively synthesised and presented in tables. Where the same model has been validated in multiple studies, a meta-analysis of discrimination and calibration will be conducted. Conclusions: This systematic review will aim to identify multivariable models for hip fracture outcome prognosis that have been derived using high quality methods. Results will highlight if current models have the potential for further assessment for use in both clinical decision making and improving methods of national hip fracture audits. PROSPERO registration: CRD42022330019 (25th May 2022).

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery

INTRODUCTION

Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.

METHODS

We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold.

RESULTS

There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively).

CONCLUSION

We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function Is Associated with Increased Mortality

BACKGROUND

Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion.

QUESTIONS/PURPOSES

(1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections?

METHODS

Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD6-9], 10-19 [MELD10-19], and 20-40 [MELD20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test.

RESULTS

Patients in the MELD20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD20-40 group compared with the other two MELD classifications (13% for MELD20-40 and 0% for both MELD6-9 and MELD10-19; p = 0.02).

CONCLUSION

The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

PERIPHERAL NERVE BLOCKS FOR HIP FRACTURES IN EMERGENCY MEDICINE

Hip fractures represent a major public health issue with increasing incidence as a population ages. The aim of this review is to describe peripheral nerve block techniques (the fascia iliaca compartment block and the pericapsular nerve group block) as pain management for hip fractures in emergency medicine, and to emphasize their benefits. Hip fractures are extremely painful injuries. The pain itself is unpleasant for patients and if left untreated it can lead to multiple complications during preoperative, operative and postoperative patient management. Pain management for elderly hip fracture patients is often challenging. Non-steroidal anti-inflammatory drugs are not recommended due to their side effects, the increased risk of gastrointestinal bleeding, renal function impairment and platelet aggregation inhibition. Paracetamol alone is often insufficient, and opioids have many potentially harmful side effects, such as delirium development. Peripheral nerve blocks for hip fractures are safe and effective, also in emergency medicine settings. The benefits for patients are greater pain relief, especially during movement, less opioid requirements and decreased incidence of delirium. Regional analgesia should be routinely used in hip fracture pain management.

Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality

INTRODUCTION

Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.

PATIENTS AND METHODS

Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.

RESULTS

A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 ± 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.

CONCLUSION

Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.

Development and internal validation of a machine-learning-developed model for predicting 1-year mortality after fragility hip fracture

Background

Fragility hip fracture increases morbidity and mortality in older adult patients, especially within the first year. Identification of patients at high risk of death facilitates modification of associated perioperative factors that can reduce mortality. Various machine learning algorithms have been developed and are widely used in healthcare research, particularly for mortality prediction. This study aimed to develop and internally validate 7 machine learning models to predict 1-year mortality after fragility hip fracture.

Methods

This retrospective study included patients with fragility hip fractures from a single center (Siriraj Hospital, Bangkok, Thailand) from July 2016 to October 2018. A total of 492 patients were enrolled. They were randomly categorized into a training group (344 cases, 70%) or a testing group (148 cases, 30%). Various machine learning techniques were used: the Gradient Boosting Classifier (GB), Random Forests Classifier (RF), Artificial Neural Network Classifier (ANN), Logistic Regression Classifier (LR), Naive Bayes Classifier (NB), Support Vector Machine Classifier (SVM), and K-Nearest Neighbors Classifier (KNN). All models were internally validated by evaluating their performance and the area under a receiver operating characteristic curve (AUC).

Results

For the testing dataset, the accuracies were GB model = 0.93, RF model = 0.95, ANN model = 0.94, LR model = 0.91, NB model = 0.89, SVM model = 0.90, and KNN model = 0.90. All models achieved high AUCs that ranged between 0.81 and 0.99. The RF model also provided a negative predictive value of 0.96, a positive predictive value of 0.93, a specificity of 0.99, and a sensitivity of 0.68.

Conclusions

Our machine learning approach facilitated the successful development of an accurate model to predict 1-year mortality after fragility hip fracture. Several machine learning algorithms (eg, Gradient Boosting and Random Forest) had the potential to provide high predictive performance based on the clinical parameters of each patient. The web application is available at www.hipprediction.com. External validation in a larger group of patients or in different hospital settings is warranted to evaluate the clinical utility of this tool.

Trial registration

Thai Clinical Trials Registry (22 February 2021; reg. no. TCTR20210222003).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03152-x.

Screening and management of osteoporosis: a survey of knowledge, attitude and practice among primary care physicians in Malaysia

We surveyed primary care physicians in Malaysia for their knowledge, attitude and practice in screening and managing osteoporosis. We found a low level of screening and active management of osteoporosis in the primary care setting despite positive attitudes towards them. We advocate for the active management of osteoporosis at the primary care level.

INTRODUCTION

Prevention of osteoporotic fracture is important in primary healthcare for healthy ageing. Little is known about the knowledge, attitude, practice and barriers in the screening and managing osteoporosis among primary care doctors.

METHODS

A cross-sectional study, using an online pre-tested questionnaire after face and content validation, was conducted for primary care doctors from 1 June to 30 July 2021 across Malaysia. Pearson's chi-square test and logistic regression were employed.

RESULTS

A total of 350 primary care doctors in Malaysia, consisting of 113 (32.3%) family medicine specialists (FMS) and 237 (67.7%) medical officers, participated in this study. The mean ± SD score of osteoporosis knowledge was 50.46 ± 15.09 with minimum and maximum values of 0 and 83.64%, respectively. One hundred and ten (31.4%) respondents achieved a satisfactory overall knowledge score of ≥ 60%, 156 (44.6%) were confident in advising patients for initiation of anti-osteoporotic medication, and 243 (69.4%) perceived that bisphosphonate should be made available in health clinics. Only 97 (27.7%) practised osteoporosis screening. Inaccessibility of bone mineral densitometry (BMD) (90.6%), inadequate knowledge (87.7%) and inaccessibility of pharmacotherapy (87.1%) are perceived modifiable barriers to osteoporosis screening and management. Factors associated with a satisfactory knowledge of osteoporosis are designation as a family medicine specialist (AOR 3.034, p = 0.002), attendance at an osteoporosis management update course (AOR 2.095, p = 0.034) and the practice of osteoporosis screening for the elderly (AOR 2.767, p = 0.001).

CONCLUSION

Given the insufficient knowledge and low level of osteoporosis screening, there is a need for a national structured health programme to address the knowledge gap, increase screening practices and enhance accessibility to BMD and anti-osteoporosis medication in primary care.

Mortality after Sustaining Skeletal Fractures in Relation to Age

Age-related mortality across fractures in different anatomical regions are sparsely described, since most studies focus on specific age groups or fracture locations. The aim here was to investigate mortality at 30 days and 1 year post-fracture within four different age groups. All patients ≥ 16 years registered in the Swedish Fracture Register (SFR) 2012–2018 were included (n = 262,598 patients) and divided into four age groups: 16–49, 50–64, 65–79, and ≥80 years of age. Standardized mortality ratios (SMR) at 30 days and 1 year after sustaining a fracture were calculated using age- and gender-specific life tables from Statistics Sweden for each of the 27 fracture locations in the four age groups. Absolute mortality rates for the youngest age group for all locations were below 1% and 2% at 30 days and 1 year, respectively. For the patients in the two oldest age groups (65 and older), mortality rates were as high as 5% at 30 days and up to 25% at 1 year for certain fracture locations. For younger patients a few localizations were associated with high SMRs, whereas for the oldest age group 22 out of 27 fracture locations had an SMR of ≥2 at 30 days. Fractures of the femur (proximal, diaphysis, and distal) and humerus diaphysis fractures were among the fractures associated with the highest mortality rates and SMRs within each age group. Moderately high SMRs were further seen for pelvic, acetabulum, spine, and tibia fractures within all age groups. Regardless of age, any type of femur fractures and humerus diaphysis fractures were associated with increased mortality. In the oldest age groups, about twice as many patients died within 1 year after sustaining a fracture in almost any location, as compared with the expected mortality rates, whereas in the youngest age group only fractures in a few locations were associated with a high SMR.

Prospective association between depressive symptoms and hip fracture and fall among middle-aged and older Chinese individuals

BACKGROUND

The effect of depressive symptoms on hip fracture (HF) and falls among the Chinese population is unclear. This study aims to examine the prospective association between depressive symptoms and HF as well as fall accidents in a nationally representative Chinese population.

METHODS

We used data from 10,596 participants in the Chinese Health and Retirement Longitudinal Study (from 2011 to 2018) who were aged ≥45 years and had no HFs at baseline. Depressive symptoms were assessed using the 10-item version of the Center for Epidemiological Studied Depression scale (cutoff for distinguishing high versus low at ≥12). Logistic regression analyses adjusted for demographic characteristics, lifestyle factors and physical comorbidities were performed.

RESULTS

For the analysis of baseline depressive symptoms and HF, 399 (3.8%) participants reported HF accidents in the following 7-year period. Individuals with elevated depressive symptoms at baseline experienced a markedly higher HF risk (odds ratio [OR] = 1.33, 95% confidence interval [CI] = 1.06-1.67) than those without elevated depressive symptoms, after adjusting for a wide range of potential confounders. For the analysis of baseline depressive symptoms and falls, 3974 (37.5%) experienced fall accidents during the follow-up. The presence of elevated depressive symptoms was independently associated with an increased risk of fall events (OR = 1.21, 95% CI = 1.10-1.33). These associations were consistent across multiple characteristics.

CONCLUSIONS

In conclusion, elevated depressive symptoms were associated with an increased risk of HF and falls, which may have considerable clinical and preventive implications.

Prognostic nomogram for risk of mortality after hip fracture surgery in geriatrics

PURPOSE

Hip fracture is a significant public health problem, with associated high morbidity and mortality. Orthopedic surgeons are concerned to improve prognosis and stratify mortality risk after hip fracture surgery. This study established a nomogram that combines the Charlson Comorbidity Index (CCI) with specific laboratory parameters to predict mortality risk after hip fracture surgery in geriatrics.

METHODS

The records of consecutive patients who underwent hip fracture surgery from January 2015 through May 2020 at one medical center were reviewed for perioperative factors and mortality. Patients with age ≥ 70 years who were diagnosed with intertrochanteric or femoral neck fractures were included. Patients who were diagnosed with pathological fracture, received only conservative treatment or lost to follow-up were excluded. A multivariate Cox proportional hazards regression model was used to identify risk factors. A nomogram was established with R software and evaluated using concordance (C)-index, area under receiver operating characteristic (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

In total, 454 patients were included with a mean age of 81.6 years. The mean follow-up and one-year mortality rate were 37.2 months and 10.4%, respectively. Five identified risk variables for mortality after hip fracture surgery in geriatrics comprised age (HR 1.05, 95% CI 1.01-1.08; P = 0.003), CCI (HR 1.38, 95% CI 1.24-1.54; P = 0.000), albumin (HR 1.78, 95% CI 1.31-2.43; P = 0.000), sodium (HR 1.59, 95% CI 1.18-2.15; P = 0.002) and hemoglobin (HR 1.46, 95% CI 1.07-2.00; P = 0.02). A nomogram was proposed and evaluated, showing a C-index of 0.76 ± 0.02. The AUCs for 6-month, 1-year, and 3-year mortality predictions were 0.83, 0.79, and 0.77, respectively. The calibration curve and DCA showed good discrimination and clinical usefulness.

CONCLUSION

This novel nomogram for stratifying the mortality risk after hip fracture surgery in geriatrics incorporated age, CCI, serum albumin, sodium, and hemoglobin. Internal validation indicated that the model has good accuracy and usefulness. This nomogram had improved convenience and precision compared with other models. External validation is warranted to confirm its performance.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Incidence of hip fracture among middle-aged and older Chinese from 2013 to 2015: results from a nationally representative study

China is experiencing remarkable changes in people aging and migration. Therefore, the incidence and associated factors for hip fracture might differ from previous results. A nationally representative study of hip fracture enables policymakers to formulate preventive strategies and provide information on resource allocation.

PURPOSE

To estimate the incidence of hip fracture, between 2013 and 2015, among the middle-aged and older Chinese population.

METHODS

Individuals with hip fractures between 2013 and 2015 were identified from the China Health and Retirement Longitudinal Study. The sex-specific incidence and the associated factors of hip fracture were assessed.

RESULTS

Among 19,112 individuals (51.4% women; mean age 60.5 years) included in the analysis, 408 (2.13%) had a hip fracture between 2013 and 2015. Moreover, the annual incidence of hip fracture for men and women were 1065 and 1069 per 100,000, respectively. The incidence of hip fracture increased with age (p < 0.001). A history of chronic disease, being unmarried, and individuals without insurance were associated with a higher incidence of hip fracture. Interestingly, the incidence of hip fracture was higher among individuals with fewer years of education (p = 0.002). The North-East regions of China had the lowest incidence of hip fracture (1022 per 100,000) between 2013 and 2015, followed by the North (1602 per 100,000), South-Central (2055 per 100,000), East (2173 per 100,000), and South-West (2537 per 100,000) regions. Finally, the incidence was highest among participants living in the North-West region (3244 per 100,000).

CONCLUSION

Between 2013 and 2015, the incidence of hip fracture is high among the middle-aged and older Chinese population. Furthermore, it varied significantly according to sociodemographic and geographic factors. Therefore, the support of targeted health policies and cost-effective preventive strategies are warranted in China.

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mortality After Postoperative Periprosthetic Fracture of the Femur After Hip Arthroplasty in the Last Decade: Meta-Analysis of 35 Cohort Studies Including 4841 Patients

BACKGROUND

Postoperative periprosthetic fracture of the femur (POPFF) is associated with increased mortality. There is a lack of general estimates of mortality after POPFF and a need for higher-level evidence in this area. The aim of this study was to estimate mortality after POPFF using data reported in cohort studies from the last decade.

METHODS

Literature search was conducted using Medline and Embase. The primary outcome was all-cause mortality during time as an inpatient, within 30 days, within 90 days, and within one year of POPFF. Mortality (95% confidence interval [CI]) was estimated using metaregression.

RESULTS

A total of 4841 patients from 35 cohort studies were included. Study quality was generally low. The weighted mean follow-up was 2.3 years, and the most common POPFF was Vancouver B. The pooled mortality as an inpatient was 2.4% (95% CI 1.6% to 3.4%). The pooled mortality within 30 days was 3.3% (95% CI 2.0% to 5.0%). The pooled mortality within 90 days was 4.8% (95% CI 3.6% to 6.1%). The pooled mortality within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality after POPFF was like that of neck of femur fracture up to 30 days, but better at one year.

CONCLUSION

Mortality is like that experienced by patients after neck of femur fracture up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future.

Bone-loading exercises versus risedronate for the prevention of osteoporosis in postmenopausal women with low bone mass: a randomized controlled trial

PURPOSE

This randomized controlled trial compared changes in bone mineral density (BMD) and bone turnover in postmenopausal women with low bone mass randomized to 12 months of either risedronate, exercise, or a control group.

METHODS

Two hundred seventy-six women with low bone mass, within 6 years of menopause, were included in analysis. Treatment groups were 12 months of (a) calcium and vitamin D supplements (CaD) (control), (b) risedronate + CaD (risedronate), or (c) bone-loading exercises + CaD (exercise). BMD and serum markers for bone formation (Alkphase B) and resorption (Serum Ntx) were analyzed at baseline, 6, and 12 months.

RESULTS

Using hierarchical linear modeling, a group by time interaction was found for BMD at the spine, indicating a greater improvement in the risedronate group compared to exercise (p ≤ .010) or control groups (p ≤ .001). At 12 months, for women prescribed risedronate, changes in BMD at the spine, hip, and femoral neck from baseline were + 1.9%, + 0.9%, and + .09%; in exercise group women, + 0.2%, + 0.5%, and - 0.4%; and in control group women, - 0.7%, + 0.5%, and - 0.5%. There were also significant differences in reductions in Alkphase B (RvsE, p < .001, RvsC, p < .001) and Serum Ntx (RvsE, p = .004, RvsC, p = .007) in risedronate women compared to exercise and control groups. For risedronate, 12-month changes in Alkphase B and Serum Ntx were - 20.3% and - 19.0%; for exercise, - 6.7% and - 7.0%; and for control, - 6.3% and - 9.0%.

CONCLUSION

Postmenopausal women with low bone mass should obtain adequate calcium and vitamin D and participate in bone-loading exercises. Additional use of BPs will increase BMD, especially at the spine.

Hip, vertebral, and wrist fracture risks and schizophrenia: a nationwide longitudinal study

BACKGROUND

Fractures are a great health issue associated with morbidity, quality of life, life span, and health care expenditure. Fractures are correlated with cardiovascular disease, type 2 diabetes mellitus, cerebrovascular disease, and some psychiatric disorders. However, representative national data are few, and longitudinal cohort studies on the association between schizophrenia and the subsequent fracture risk are scant. We designed a nationwide population-based cohort study to investigate the association of schizophrenia with hip, vertebral, and wrist fractures over a 10-year follow-up.

METHODS

Data of patients with schizophrenia (International Classification of Diseases, Ninth Revision, Clinical Modification code 295) and matched over January 2000-December 2009) were extracted from Taiwan National Health Insurance Research Database. A Cox proportional-hazards regression model was constructed to calculate hazard ratios (HRs) for fractures between the schizophrenia and control cohorts.

RESULTS

Of 2028 people with schizophrenia (mean age: 36.3 years, 49.4% female), 89 (4.4%) reported newly diagnosed fractures-significantly higher than the proportion in the control population (257, 3.2%; P = 0.007). The incidences of hip (1.2%, P = 0.009) and vertebral (2.6%, P = 0.011) fractures were significantly higher in the schizophrenia cohort than in the control cohort. In Cox regression analysis, hip (adjusted HR: 1.78, 95% confidence interval [CI]: 1.08-2.93) and vertebral (adjusted HR: 1.40, 95% CI: 1.01-1.95) fracture risks were significantly higher in patients with schizophrenia. Furthermore, a sex-based subgroup analysis revealed that the risk of hip fracture remained significantly higher in female patients with schizophrenia (HR: 2.68, 95% CI: 1.32-5.44) than in female controls. On the other hand, there was no significant interaction between effects of sex and schizophrenia on the risk of fractures.

CONCLUSIONS

Over a 10-year follow-up, hip and vertebral fracture risks were higher in the people with schizophrenia than in the controls. The risk of fractures in patients with schizophrenia does not differ between female and male.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis

AIM

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators.

METHODS

Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals.

RESULTS

Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85).

CONCLUSIONS

Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management.

AUTHOR

Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

ActiveHip+: A feasible mHealth system for the recovery of older adults after hip surgery during the COVID-19 pandemic

OBJECTIVE

Half of older adults undergoing hip surgery do not recover their previous functional status. mHealth is a promising tool for rehabilitating older adults after hip surgery. This study aimed to test the feasibility of the ActiveHip+ mHealth system in older adults after hip surgery.

METHODS

Sixty-nine older adults who had undergone hip surgery and their family caregivers were recruited from hospitals in Spain and Belgium and used the ActiveHip+ mHealth system for 12 weeks. Assessments were made during hospital stay and 3 months after surgery. Feasibility assessment included: adoption (participation proportion), usage (access to the app), satisfaction with the app (Net Promoter Score) and user perception of the quality of the app (Mobile App Rating Scale). Clinical assessment included: patient-reported outcomes, such as functional status (Functional Independence Measure) and performance-based outcomes, such as physical fitness (Short Physical Performance Battery).

RESULTS

The ActiveHip+ mHealth system obtained satisfactory feasibility results in both countries. In Spain, we observed 85% adoption, 64% usage, 8.86/10 in satisfaction with the app and 4.42/5 in perceived quality of the app. In Belgium, we observed 82% adoption, 84% usage, 5.16/10 in satisfaction with the app and 3.52/5 in app's perceived quality. The intervention had positive effects on levels of functional status, pain and physical fitness.

CONCLUSIONS

The ActiveHip+ mHealth system is a feasible tool to conduct the rehabilitation in older adults after hip surgery. Although the intervention seemed beneficial clinically, we do not recommend its implementation in clinical settings until appropriately designed randomised clinical trials confirm these results.

High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care

For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly.

PURPOSE/INTRODUCTION

Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time.

METHODS

This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation.

RESULTS

Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature.

CONCLUSIONS

Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.

Increased Geriatric Treatment Frequency Improves Mobility and Secondary Fracture Prevention in Older Adult Hip Fracture Patients-An Observational Cohort Study of 23,828 Patients from the Registry for Geriatric Trauma (ATR-DGU)

Interdisciplinary orthogeriatric care of older adult hip fracture patients is of growing importance due to an ageing population, yet there is ongoing disagreement about the most effective model of care. This study aimed to compare different forms of orthogeriatric treatment, with focus on their impact on postoperative mobilization, mobility and secondary fracture prevention. In this observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery, were included from 1 January 2016 to 31 December 2019. Data were recorded from hospital stay to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a specific designed registry for older adult hip fracture patients. Of 23,828 included patients from 95 different hospitals, 72% were female, median age was 85 (IQR 80–89) years. Increased involvement of geriatricians had a significant impact on mobilization on the first day (OR 1.1, CI 1.1–1.2) and mobility seven days after surgery (OR 1.1, CI 1.1–1.2), initiation of an osteoporosis treatment during in-hospital stay (OR 2.5, CI 2.4–2.7) and of an early complex geriatric rehabilitation treatment (OR 1.3, CI 1.2–1.4). These findings were persistent after 120 days of follow-up. Interdisciplinary treatment of orthogeriatric patients is beneficial and especially during in-patient stay increased involvement of geriatricians is decisive for early mobilization, mobility and initiation of osteoporosis treatment. Standardized treatment pathways in certified geriatric trauma departments with structured data collection in specific registries improve outcome monitoring and interpretation.

Impact of non-hip fractures in elderly women: a narrative review

The association of hip fractures with adverse outcomes is well established, but for non-hip fractures this association still needs to be further investigated. The objective of this narrative review is to describe the state of the art with regards to the health impact of clinically relevant non-hip fracture locations in postmenopausal women. PubMed and Scopus databases were searched from January 2010 until December 2020. Studies were included when the crude rates and/or relative risk of 1-year subsequent fractures and/or mortality were reported as well as the precise fracture site. Twenty-three studies met the inclusion criteria. Regarding mortality rates, there was a high variability between studies, with higher rates for vertebral, proximal humerus and pelvic fractures. There was a small or no impact of wrist, ankle or tibia fractures. The mortality rate increased with age after vertebral, proximal humerus and wrist fractures. Moreover, proximal humerus and vertebral fractures were associated with a higher mortality risk. This narrative review indicates that, besides fractures of the hip, fractures of the vertebrae, proximal humerus or pelvis deserve more attention when trying to prevent adverse outcomes of osteoporosis. More studies on the topic of non-hip fractures are urgently needed.

Mortality and Incidence Rate of SARS-CoV-2 (COVID-19) Infection in Patients Admitted and Operated for Hip Fracture during SARS-CoV-2 pandemic in a London Hospital

Objective  We are doing a study on patients admitted with hip fractures to determine the impact of COVID-19 on a vulnerable patients group in the United Kingdom. This will help us in making informed decisions about restarting elective surgical services and expanding trauma surgical services. The objectives of the study are: 1) to find the incidence of COVID-19 in patients admitted with hip fractures; 2) To find the 30-day mortality in patients operated with hip fractures; 3) To find the 30-day mortality of patients with hip fracture and COVID 19; and 4) to compare this data with the mortality in hip fractures in previous years.

Methods  This is a single-center, observational, retrospective, cohort study involving 65 patients who were admitted in our trust with hip fractures. Besides epidemiological data, patient records were followed-up for 14 days to look for COVID positive polymerase chain reaction (PCR) swabs, and the patient records were followed-up for 30 days to look for mortality.

Results  A total of 64% of the patients had no significant comorbidity. The incidence of hospital-acquired COVID-19 infections in our trust was 9%. Overall, the 30-day mortality was of 15%. Mortality was much higher in COVID positive patients (40%) and in patients with “very high risk” (63%) operated during this period.

Conclusion  It should be safe to start elective surgery in patients with low, moderate and high risk without an appreciable rise in mortality. We will need more data to understand the impact of COVID-19 on very high risk patients.

Evaluation of minimal fracture liaison service resource: costs and survival in secondary fracture prevention-a prospective one-year study in South-Finland

Background

Fracture liaison service (FLS) is a secondary prevention model for identification of patients at risk for fragility fractures.

Aims

This study was conducted to evaluate the number and costs of secondary prevention of low-energy fractures in the city of Kouvola in Finland.

Methods

Women aged ≥ 45 years and men ≥ 60 years treated in the emergency department with a low-energy fracture were identified. Laboratory testing, BMI, and DXA scans were performed. Fracture Risk Assessment Tool was used. The direct FLS costs were calculated. Survival was analyzed using univariate and multivariate analysis and the life-table method.

Results

525 patients with 570 fractures were identified. The mean age of women was 73.8 years and of men 75.9 years. Most patients sustained wrist (31%), hip (21%) or proximal humerus (12%) fractures. 41.5% of the patients had osteoporosis according to DXA scans. 62% of patients used calcium and vitamin D daily and 38% started anti-osteoporotic medication. Protective factors for survival were: age < 80 years, female sex, and S-25OHD concentration of 50–119 nmol/L. Excess mortality was highest among patients with a fracture of the femur. The total annual direct costs of FLS were 1.3% of the costs of all fractures.

Discussion

Many low-energy fracture types were associated with excess mortality. The use of anti-osteoporotic medication was not optimal.

Conclusions

FLS increased the catchment of low-energy fracture patients and was inexpensive. However, identification, evaluation and post-fracture assessment of patients should be expedited. Rehabilitation of hip fracture patients needs to be improved.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01826-x.

Hip Fracture Trends and Outcomes During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) rapidly changed the landscape of health care, particularly in the New York City area. The elderly population is particularly vulnerable to both the novel coronavirus and the effects of a fracture. The goal of this study was to compare trends and outcomes of hip fracture patients during the pandemic. This was a retrospective chart review of hip fracture patients from a suburban academic hospital on Long Island, New York, who presented from March 1 to May 30, 2020. Patient COVID-19 status, demographics, and hospital outcome measures were recorded. Statistical analysis was performed using heteroscedastic t tests for quantitative variables and chi-square tests for qualitative variables. There were 82 patients in the 2020 cohort and 111 in the 2019 control group, representing a 29.9% decrease in cases. The 2020 cohort presented to the hospital an average of 2.77 days after injury compared with 1.15 days for the 2019 control group (P=.0976). Patients in the 2020 cohort were more likely to be discharged home than to rehabilitation (P<.0001) and tended to be discharged with oral anticoagulation (P=.0809). There was no increase in 1-, 3-, or 6-month complications or mortality. During the pandemic, fewer patients were admitted with hip fractures, and the time from injury to presentation doubled. Patients were significantly less likely to be discharged to rehabilitation and more were discharged with oral anticoagulants. Overall, there was no increase in complications, and these data indicate that the authors were successfully able to provide high-quality care to hip fracture patients during the pandemic. [Orthopedics. 2021;44(5):293-298.].

Subcuticular Barbed Suture and Skin Glue Wound Closure Decreases Reoperation and Length of Stay in Geriatric Hip Fractures When Compared With Staples

INTRODUCTION

Patients with geriatric hip fracture are notoriously frail and at risk for complications. Persistent postoperative wound drainage can lead to prolonged hospital stay, increased risk for infection, and need for revision surgery. The purpose of this study was to determine the effect of wound closure technique, barbed monofilament subcuticular suture and skin glue versus staples on rates of intervention for wound drainage and length of hospital stay after geriatric hip fracture fixation.

METHODS

A retrospective review of isolated hip fractures in patients older than 60 years at a single institution over a 3-year period was done. Hip fractures included femoral neck, intertrochanteric, and subtrochanteric femur fractures treated with internal fixation or arthroplasty. Skin closure technique, at the discretion of the operating surgeon, included either barbed subcuticular monofilament suture and skin glue or staples. Charts and radiographs were reviewed to determine patient characteristics, Charlson Comorbidity Index, type of wound closure, length of stay, and interventions for persistent wound drainage.

RESULTS

There were 175 patients in the barbed suture and skin glue group and 211 patients in the staples group. The barbed suture group had an average postsurgical length of stay of 5.0 days which was significantly lower than the staples group (7.0 days, P < 0.00001). In the staples group, 17 patients (8%) required incisional negative pressure wound therapy due to wound drainage with five patients (2.4%) returning to the operating room secondary to persistent wound drainage. No patients were observed in the barbed suture group that required intervention for wound drainage.

DISCUSSION

Barbed suture and skin glue closure is associated with markedly shorter hospital stay and fewer interventions for wound drainage when compared with staples after surgical treatment of geriatric hip fractures.