Hip fracture type: important role of parathyroid hormone (PTH) response to hypovitaminosis D

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

Vitamin D Deficiency in Patients With Low-Energy Hip Fractures in Accordance With the Mediterranean Paradox

Introduction Vitamin D deficiency (VDD) is considered one of the leading causes of poor bone quality. It may also be related to severe muscular weakness, especially in the elderly, which leads to frequent falls. Thus, VDD might be associated with fragility fractures of the hip, wrist, and spine in this age category. In this cross-sectional study, our goal was to present vitamin D levels in an elderly Mediterranean population with hip fractures and to assess whether its levels are related to the incidence or prevention of such injuries. Methods Between January and December 2021, 140 patients aged 65 years or older were hospitalized in our department with a fracture involving the hip joint. Serum calcium and vitamin D level control was performed upon admission, as well as recording whether anti-osteoporosis medication had been prescribed. Only patients with low-energy fractures were included, whereas oncologic patients and those with high-energy trauma were excluded. Results Thirty-eight men and 102 women, with a mean age of 83.12 and 84.88 years, respectively, participated in our study. Intertrochanteric fractures were the most common injuries (50.72%). Low vitamin D levels (<30 ng/mL) were observed in 132 patients (94.28%). A bone density scan during the last year had been conducted by only seven patients (5%), whereas in 136 patients (97.14%), no anti-osteoporotic medication was given. Conclusion There is an excessive percentage of aged patients with hip fractures in Greece, demonstrating a significant vitamin D insufficiency despite the high annual frequency of sunny days in this Mediterranean region. Presumably, most of these patients neither perform the routine bone density scan nor do they take any kind of preventive pharmaceutical treatment, which might reveal devaluation of osteoporosis from this age group due to contingent comorbidities.

Comparative Clinical Effects and Risk Factors Associated With Vitamin D in Foot and Ankle Fracture and Arthrodesis Healing

Vitamin D deficiency in relation to bone metabolism and healing has been controversial and not well studied. However, hypovitaminosis has been widely identified within the orthopedic patient population. The current best evidence suggests a lack of data on this important topic. The ability to assess patients for optimum bone healing and metabolism is still in question due to lack of a suitable reliable biomarker and multiple other unknown variables affecting bone metabolism. To compound this effect, popular dermatological precautions in the last 20 to 30 years of avoiding sunlight also have the effect of further reducing serum vitamin D production in the skin. As a proof of concept, we performed a preliminary comparative observational retrospective review of orthopedic patients undergoing fracture and arthrodesis osseous healing to determine how serum vitamin D levels are associated with bone healing along with their confounding comorbidities. Based on our review, the current accepted vitamin D levels (≥20 ng/mL) are low and insufficient for fractures and for arthrodesis osseous healing due to observed high rates (>35%) of delayed unions, and an increased (>90%) in the number of multiple confounding comorbidities affecting bone healing process that are often not mentioned or captured in this type of study in previous literature. Obesity and diabetes are significant contributory risks factors, and the preliminary findings suggest that the current accepted adequate levels may not be enough for osseous healing. These low vitamin D levels appear to affect bone healing and prolong treatment, with worsening trends with diabetes and obesity comorbidities.

Different types of hip fragility fractures have different values of 25-hydroxyvitamin D and parathyroid hormone

BACKGROUND

Vitamin D insufficiency/deficiency is related to fragility fracture. In most previous studies, there was no assessment of vitamin D deficiency status separately for hip fracture types. The first aim is to evaluate vitamin D and parathyroid hormone (PTH) status in patients with hip fracture. The second objective is to determine whether there are differences in vitamin D and PTH between the femoral neck fracture and the femoral metaphyseal fracture group.

METHODS

62 men and 248 women with fragility hip fractures were enrolled. 25-hydroxyviamin D [25(OH)D] and intact PTH (iPTH) values were evaluated, and femoral neck bone mineral density (BMD) was measured on the uninjured side. Vertebral fractures (VFs) were assessed using radiographs of the thoracic and lumbar spine. We examined the relationships of 25(OH)D value with the number of prevalent VFs, T-score of femoral neck, and iPTH level. These analyses were also performed, neck fracture and trochanteric fracture separately.

RESULTS

Mean age was 85 years. The mean 25(OH)D was 11.2 (range, 4.0-26.1) ng/ml, whereas the mean iPTH value was 48.9 pg/ml (range, 9-429 pg/ml). The mean number of VFs was 1.5 (range, 0-11), and the mean T-score was -3.3 (range, -5.2 to -0.5). There was a weak correlation between the 25(OH)D value and the number of VFs. There was a weak but significant correlation between 25(OH)D and iPTH values. In the patients with trochanteric fractures, 25(OH)D value was significantly lower and iPTH value was significantly higher than those with neck fractures. There was a significant correlation between the 25(OH)D value and number of the VFs, 25(OH)D, and iPTH values only in trochanteric fractures.

CONCLUSIONS

Vitamin D deficiency was severe and PTH levels were higher in the trochanteric fractures. Both vitamin D deficiency and high PTH levels were suggested to have association with bone fragility.

Osteomalacia Prevalence, Biochemical Profile, and Histology in Patients with Low-Energy Hip Fractures Over the Age of 45

Our objective was to determine the prevalence of osteomalacia in low-energy hip fracture patients over the age of 45, based on biochemical and histological measures. This cross-sectional study included 72 patients over 45 with low-energy mechanism hip fractures. Samples of fasting venous blood were taken for hemograms and serum biochemistry analyses. Bicortical biopsies of the iliac crest were obtained, processed, and evaluated by an expert pathologist for osteomalacia. Biochemical osteomalacia (b-OM) is defined according to a distinct criterion. A low level of serum calcium, phosphorus, albumin, and 25OHD was found in 43.1, 16.7, 73.6, and 59.7% of patients, respectively. 50.0% of patients had high serum alkaline phosphatase (ALP) levels. b-OM was found in 30 (41.7%), and no significant association was found with PTH, Cr, Alb, age, sex, fracture type, side of the trauma, and season were not associated with osteomalacia. Osteomalacia was diagnosed on histopathological analysis in 19/72 (26.7%), and 54/72 (75.0%) of all cases fulfilled b-OM criteria. In the histologic evaluation, osteoid seam width, osteoid surface, and osteoid volume were 28.5 µm, 25.6, and 12.1%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the biochemical test for detecting osteomalacia were 73.6, 64.2, 42.4, 87.2, and 66.7%, respectively. Up to 30% of elderly patients with low-energy hip fractures are affected by osteomalacia. A biochemical screening along with a bone biopsy and histopathologic evaluation may be logical in a high-risk population for osteomalacia diagnosis.

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.

Seasonality in hip fracture among hemodialysis patients and kidney transplant recipients in South Korea

BACKGROUND

The seasonality of hip fracture in hemodialysis (HD) patients and kidney transplant recipients (KTRs) have not been reported. We assessed seasonal variations in hip fractures among patients with end-stage kidney disease who undergo maintenance HD and KTRs.

METHODS

Using the Korean National Health Insurance System database from January 2012 to December 2017, monthly counts of hip fracture were calculated among HD patients (n = 77,420) and KTRs (n = 8,921). The 6-year normalized monthly fraction and seasonal fractions of hip fractures were calculated. A cosinor analysis was performed to determine the seasonality of the monthly incidence of hip fractures.

RESULTS

The 6-year average monthly fraction of hip fractures was lowest in June and highest in October in HD patients, and lowest in February and highest in November in KTRs. The 6-year average seasonal fraction among HD patients was lowest in summer and highest in winter, and lowest in summer and highest in autumn among KTRs, but there was no significant difference. The incidence ratio of hip fractures was lowest in June and highest in January in HD patients, and lowest in August and highest in November in KTRs. On cosinor analysis, HD patients showed significant seasonality in hip fracture incidence, with a trough in summer and a peak in winter (P = 0.031), whereas KTRs did not exhibit a significant trend (P = 0.44).

CONCLUSION

Hip fractures occurred more frequently in winter and less frequently in summer in patients undergoing HD, whereas KTRs did not show a seasonal trend.

The Phenotype of Bone Turnover in Patients with Fragility Hip Fracture: Experience in a Fracture Liaison Service Population

Background: Hip fragility fractures are becoming one of the main health care problems in countries with an aging population. This study aimed to evaluate the clinical characteristics and the usefulness of bone turnover markers in patients with a hip fracture. Methods: In a cohort of 363 patients (84.1 ± 9.2 years) with hip fractures we measured 25-hydroxyvitamin D (25OHD), bone alkaline phosphatase, type I collagen β carboxy telopeptide (βCTX), and parathyroid hormone (PTH). We recorded patients’ Charlson Comorbidity Index (CCI) and previous history of fragility fractures. Results: Vitamin D and PTH levels were inversely correlated (r = −024; p < 0.001). The prevalence of 25OHD deficiency was 57.8%, the PTH levels greater than 65 pg/mL was in 47.0 %, and in those who had βCTX values the upper limit was 61.8%. Moreover, 62% of patients with a fragility hip fracture had a history of a previous fracture. The 25OHD serum levels were inversely associated with CCI and a previous fragility fracture. On the contrary, PTH and βCTX serum levels showed a positive significant correlation with CCI and previous fragility fractures. Conclusion: This study confirmed the usefulness of a bone turnover markers assessment, along with the comorbidities and history of previous fragility fractures in order to better identify the risk of hip fracture.

Vitamin D and the athlete-patient: state of the art

Vitamin D deficiency is common in athletes. The conventional measurement of vitamin D levels provides a general indicator of body stores. However, there are nuances in its interpretation as values of 25(OH)D do not correlate absolutely with the amount of 'bioavailable' vitamin to the cells. Vitamin D should be regarded as a hormone and influences between 5% and 10% of our total genome. Determining the precise effect of the vitamin, isolated from the actions of other cofactors, is not straightforward and restricts our complete understanding of all of its actions. Deficiency has harmful effects on not only bone and muscle but also wider areas, including immunity and respiratory and neurological activities. More caution should be applied regarding the ability of supranormal vitamin D levels to elevate athletic performance. Hopefully, future research will shed more light on optimal levels of vitamin D and supplementation regimes, and improved understanding of its intracellular control of our genetic mechanisms and how extrinsic influences modify its activity.

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

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Vitamin D levels in 577 consecutive elective foot & ankle surgery patients

BACKGROUND

Vitamin D deficiency is a global concern impacting upon large communities and certain disease populations. It can adversely affect the outcome of orthopaedic operations. We aimed to perform an audit of the Vitamin D status of patients in two centres in the United Kingdom undergoing elective foot and ankle surgery.

METHODS

Serum 25-hydroxyvitamin-D (vitamin D) levels were obtained prospectively in 577 consecutive elective patients undergoing elective foot and ankle surgery between October 2014 and March 2017 (29 months). Variables including age, gender, ethnicity, location, season, month and procedure type were recorded.

RESULTS

577 patients were included over the study period. 62.0% were female. Mean age was 53.2 (median 54.5, range 16.7-86.6). 300 patients were treated in Northampton and 277 in Leicester. The serum 25-hydroxyvitamin-D levels for the patient group were normally distributed. The mean was 52.3nmol/L (SD 28.0; range 7.5-175) and the median 47.5nmol/L. 21.7% were grossly deficient, 31.9% deficient, 28.9% insufficient and 17.5% within normal range. Age, gender and procedure type did not statistically affect vitamin D levels (p=0.5, t-test). Ethnicity, location and Winter season did affect Vitamin D levels (p<0.05). August was the most significant month with levels significantly higher than January, February, March, April, June, November and December (p<0.05, one-way ANOVA).

CONCLUSIONS

Only 1 in 5.7 patients had a normal Vitamin D level and 1 in 4.6 were grossly deficient. Ethnicity and patient location significantly affected Vitamin D results. Summer months were noted to demonstrate significantly the highest levels and August the highest. We did not find that age or gender affected Vitamin D levels in our cohort.

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

BACKGROUND AND AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Risk factors for trochanteric and femoral neck fracture

INTRODUCTION AND OBJECTIVES

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

PATIENTS AND METHOD

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

RESULTS

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

CONCLUSIONS

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

Hip osteoarthritis as a predictor of the fracture pattern in proximal femur fractures

INTRODUCTION

Several authors have suggested a correlation between the fracture patterns of proximal femur fractures and the degree of hip osteoarthritis (HOA), but the current evidence to support this are insufficient. The aim of our study was to demonstrate whether there is an association between the grade of HOA and fracture pattern observed, in patients presenting with a fragility fracture of the proximal femur.

MATERIALS AND METHODS

We contacted a retrospective review of all patients presenting to our institution with fragility fractures involving the proximal femur, between March 2012 and October 2013. Pathological fractures, high-energy injuries and patients with less than one year of follow-up were excluded from further analysis. Admission radiographs and severity of HOA were assessed according to Kellgren and Lawrence scale (minimal: Grades 1-2; severe: Grades 3-4). Fractures were classified according to AO/OTA classification.

RESULTS

A total of 1003 patients (725 females; 1003 fractures) met the inclusion criteria, having a mean age of 81.5 (46-106 years). With regards to fracture classification, 417 (41.6%) fractures were classified as extracapsular and 586 (58.4%) as intracapsular. A total of 939 (93.9%) patients presented with minimal HOA, whilst 61 (6.1%) of the patients presented with severe HOA. Of the 61 patients presenting with severe HOA, 42 patients (68.9%) sustained a 31A-interthrocanteric fracture and 19 patients (31.1%) sustained a 31B-intracapsular fracture. Regarding the patients presenting with minimal HOA (832 patients in total), 323 patients (38.8%) sustained 31A-intertrochanteric fracture and 509 patients (61.2%) sustained a 31B-intracapsular fracture. Patients presenting with severe HOA were found to have a statistically significant chance to present with an extracapsular fracture (p<0.01).

CONCLUSIONS

The degree of HOA is related to the fracture pattern in patients presenting following simple mechanical falls. More specifically, higher grades of HOA are associated with extracapsular fracture patterns, whereas lower grades of HOA are associated with intracapsular fracture patterns.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parathyroid hormone response to two levels of vitamin D deficiency is associated with high risk of medical problems during hospitalization in patients with hip fracture

BACKGROUND

Vitamin D and the parathyroid hormone (PTH) response play an important role in hip fracture patients. This study was carried out to determine the factors associated with the PTH response to different levels of vitamin D deficiency during hospitalization.

METHODS

This was a cross-sectional study of patients over 64 years of age admitted with an acute fragility hip fracture between March 1st 2009 and November 30th 2012. Demographic, clinical, functional, and cognitive function were evaluated at admission and during hospitalization. Levels of 25-hydroxyvitamin D (25-OHD) and PTH were analyzed. Two 25-OHD cut-off points were considered, <12 ng/ml and 12-20 ng/ml. Multivariate logistic regression analysis was used.

RESULTS

Mean age of the 607 patients included was 84.7 years (SD 7.10), and 81.9 % were women. The mean 25-OHD level in the total sample was 13.2 (SD 11.1) ng/ml. Levels of 25-OHD <12 ng/ml were present in 347 patients (57.2 %), of whom 158 (45.5 %) had secondary hyperparathyroidism (SHPT) (PTH >65 pg/ml). 25-OHD levels of 12-20 ng/ml were present in 168 (27.7 %) patients, of whom 47 (28 %) had SHPT. Following logistic regression, SHPT was associated in both groups (25-OHD <12 and 12-20 ng/ml) with a greater number of medical problems during hospitalization. In the 25-OHD group <12 ng/ml, SHPT was also associated with poorer glomerular filtration rates.

CONCLUSION

The PTH response to vitamin D deficiency in hip fracture patients may be a marker for patients with higher risk of developing multiple medical problems, both when considering severe (<12 ng/ml) and moderate (12-20 ng/ml) vitamin D deficiency.

Vitamin D deficiency in adult fracture patients: prevalence and risk factors

PURPOSE

Although vitamin D levels are not routinely monitored in outpatient fracture patients, identification of fracture patients with a deficient vitamin D status may be clinically relevant because of the potential role of vitamin D in fracture healing. This study aimed to determine the prevalence of and risk factors for vitamin D deficiency in non-operatively treated adult fracture patients.

PATIENTS AND METHODS

Vitamin D levels were determined in a cross-sectional study of adult patients, who were treated non-operatively for a fracture of the upper or lower extremity in the outpatient clinic of a level 1 trauma center, during one calendar year. Potential risk factors for (severe) vitamin D deficiency were analyzed using multivariable logistic regression analysis.

RESULTS

A total of 208 men and 319 women with a mean age of 49.7 years (SD 19.9) were included. In this population, 71 % had a serum calcidiol <75 nmol/L, 40 % were vitamin D deficient (serum calcidiol <50 nmol/L) and 11 % were severely vitamin D deficient (serum calcidiol <25 nmol/L). Smoking and season (winter and spring) were independent risk factors for vitamin D deficiency. An increasing age, a non-Caucasian skin type, winter and smoking were identified as independent risk factors for severe vitamin D deficiency. The use of vitamin D, alcohol consumption and higher average daily sun exposure were independent protective factors against (severe) vitamin D deficiency.

CONCLUSION

Given the potential role of vitamin D in fracture healing, clinicians treating adult fracture patients should be aware of the frequent presence of vitamin D deficiency during the winter, especially in smoking and non-Caucasian patients. Research on the effect of vitamin D deficiency or supplementation on fracture healing is needed, before suggesting routine monitoring or supplementation.

Parathyroid-hormone variance is only marginally explained by a panel of determinants: a cross-sectional study of 909 hip-fracture patients

Several factors affect the levels of parathyroid hormone (PTH) in hip-fracture patients. We hypothesized that a panel of easily assessable determinants could account for both a substantial proportion of PTH variance and the occurrence of secondary hyperparathyroidism. We evaluated 909 of 981 hip-fracture inpatients admitted consecutively to our Rehabilitation division. In each patient we assessed PTH, 25-hydroxyvitamin D, albumin-adjusted total calcium, phosphate, magnesium, and creatinine on a fasting blood sample 21.3 ± 6.1 (mean ± SD) days after fracture occurrence. Glomerular filtration rate (GFR) was estimated by the 4-variable Modification of Diet in Renal Disease Study equation. Functional level was assessed using the Barthel index. On multivariate analysis, six factors (phosphate, albumin-adjusted total calcium, estimated GFR (eGFR), 25-hydroxyvitamin D, age, and magnesium) were significantly associated with PTH levels. Overall, the panel of variables accounted for 23.7 % of PTH variance. Among the 909 patients, 304 (33.4 %) had PTH levels exceeding the normal range. Six factors (phosphate, albumin-adjusted total calcium, eGFR, 25-hydroxyvitamin D, age, and Barthel index scores) were significantly associated with the category of PTH level (either normal or elevated). The model correctly classified 70.4 % of cases. For the optimal cut-off point, sensitivity was 80 % and specificity was 61 %. Data shows that six factors were significantly associated with PTH levels in hip-fracture inpatients. However, the six factors accounted for only 23.7 % of PTH variance and the presence or absence of secondary hyperparathyroidism was correctly categorized in a modest proportion of cases. We conclude that more knowledge is needed on the factors affecting PTH levels after hip fracture.

Prospective nutritional analysis of a diverse trauma population demonstrates substantial hypovitaminosis D

OBJECTIVES

There are several metabolic factors known to be important for the maintenance of bone and muscle function. Causes of deficiency are multifactorial and can include such things as geographic region, latitude, and socioeconomic factors. The purpose of this study was to determine the prevalence of metabolic deficiencies.

SETTING

Level 1, urban trauma center.

DESIGN

Prospective laboratory evaluation.

PATIENTS

The subjects included 652 consecutive admits to the orthopaedic surgery service between July 1, 2011, and June 30, 2012.

INTERVENTION

Laboratory evaluation.

MAIN OUTCOME MEASUREMENTS

Metabolic and endocrine profiles included a serum analysis on all patients. Subject data included age, gender, body mass index, month of admission, and type of injury, and subjects' self-reported race, alcohol, recreational drug, and tobacco use were collected.

RESULTS

Six hundred fifty-two subjects with an average age of 41.2 years were evaluated. After data analysis, only 25-hydroxyvitamin D levels were found to be persistently poor across the patient population: 86.2% of subjects were insufficient in 25-hydroxyvitamin D (<30 ng/mL), 53.2% were deficient (<20 ng/mL), and 14.0% had levels <10 ng/mL (severely deficient); 76.7% of the subjects increased skin pigmentation, and the differences in 25-hydroxyvitamin D levels between races were significantly different. African Americans had the highest risk of severe deficiency. 25-Hydroxyvitamin D levels were significantly higher during summer months, with men, and with a lower body mass index, but there were no differences based on age or substance use. Additional laboratory analysis did not reveal significant nutritional deficiency.

CONCLUSIONS

The prevalence of hypovitaminosis D is widespread. This may negatively affect outcomes for orthopaedic patients but would be easily correctable. 25-Hydroxyvitamin D serologic analysis should be considered for all orthopaedic trauma patients.

LEVEL OF EVIDENCE

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

Association of ABO blood group with fracture pattern and mortality in hip fracture patients

INTRODUCTION

The mechanism of falling has been proposed as the exclusive explanation for hip fracture pattern. Evidence exists that other genetic factors also influence proximal femoral fracture configuration. The ABO blood group serotype has been associated with other pathologies but any role in hip fracture has yet to be definitively characterised.

METHODS

Our National Hip Fracture Database was interrogated over a four-year period. All patients had their blood group retrieved, and this was compared with hip fracture pattern and mortality rates. Confounding factors were accounted for using logistic regression and the Cox proportional hazards model.

RESULTS

A total of 2,987 consecutive patients presented to our institution. Those with blood group A were significantly more likely to sustain intracapsular fractures than 'non-A' individuals (p=0.009). The blood group distribution of patients with intracapsular fractures was identical to that of the national population of England. However, blood group A was less common in patients with intertrochanteric fractures than in the general population (p=0.0002). Even after correction for age and sex, blood group A was associated with a decrease in the odds of suffering an intertrochanteric fracture to 80% (p=0.002). Blood group A had inferior survivorship correcting for age, sex and hip fracture pattern (hazard ratio: 1.14, p=0.035). This may be due to associated increased prevalence of co-morbid disease in this cohort.

CONCLUSIONS

Blood group is an independent predictor of hip fracture pattern, with group A patients more likely to sustain an intracapsular fracture and non-A individuals more likely to sustain an intertrochanteric fracture. The determinants of fracture pattern are likely to be related to complex interactions at a molecular level based on genetic susceptibility. The mechanism of fall may not be the only aetiological determinant of proximal femoral fracture configuration.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nationwide data on municipal drinking water and hip fracture: could calcium and magnesium be protective? A NOREPOS study

Norway has a high incidence of hip fractures, and the incidence varies by degree of urbanization. This variation may reflect a difference in underlying environmental factors, perhaps variations in the concentration of calcium and magnesium in municipal drinking water. A trace metal survey (1986-1991) in 556 waterworks (supplying 64% of the Norwegian population) was linked geographically to hip fractures from hospitals throughout the country (1994-2000). In all, 5472 men and 13,604 women aged 50-85years suffered a hip fracture. Poisson regression models were fitted, adjusting for age, urbanization degree, region of residence, type of water source, and pH. The concentrations of calcium and magnesium in drinking water were generally low. An inverse association was found between concentration of magnesium and risk of hip fracture in both genders (IRR men highest vs. lowest tertile=0.80, 95% CI: 0.74, 0.87; IRR women highest vs. lowest tertile=0.90, 95% CI: 0.85, 0.95), but no consistent association between calcium and hip fracture risk was observed. The highest tertile of urbanization degree (city), compared to the lowest (rural), was related to a 23 and 24% increase in hip fracture risk in men and women, respectively. The association between magnesium and hip fracture did not explain the variation in hip fracture risk between city and rural areas. Magnesium in drinking water may have a protective role against hip fractures; however this association should be further investigated.

Changes in the calcium-parathyroid hormone-vitamin d axis and prognosis for critically ill patients: a prospective observational study

OBJECTIVE

Vitamin D deficiency is prevalent in critically ill patients and may contribute to suboptimal clinical outcomes, but little is known about alterations of the calcium-parathyroid hormone (PTH)-vitamin D axis and prognosis in these individuals.

METHODS

A prospective observational study was conducted on 216 patients admitted to a university-affiliated, tertiary-care medical intensive care unit(MICU) between June 2011 and December 2012. Serum levels of 25-hydroxyvitamin D, ionised calcium and intact PTH were determined within 24 h of MICU admission. The primary end point was all-cause hospital mortality within 90-days of admission.

RESULTS

95 patients (44%) showed 25-hydroxyvitamin D deficiency. Patients deficient in vitamin D showed significantly higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, rate of positive blood culture, incidence of multiple organ dysfunction syndrome, and 90-day mortality rate than did patients with vitamin D insufficiency or sufficiency (P<0.05), as well as lower levels of serum IgG. 25-Hydroxyvitamin D deficiency was identified as an independent risk factor for mortality (OR = 3.018, 95%CI 1.329-6.854, P = 0.008). Hypovitaminosis D in PTH-responders was associated with higher mortality than was the same condition in non-responders (P<0.05).

CONCLUSIONS

These results suggest that vitamin D deficiency is prevalent among MICU patients, suggesting a significant derangement of the calcium-PTH-vitamin D axis in critically ill patients. Vitamin D deficiency is an independent risk factor for 90-day mortality, and hypovitaminosis D in PTH-responders is associated with higher mortality than is the same condition in non-responders.

Vitamin D and its Relation to Bone Mineral Density in Postmenopause Women

Objective

Compare the level of vitamin D with the bone mineral density (BMD) in postmenopausal women, with or without fractures.

Methods

250 women with mean age of 71.1 were evaluated. The serum levels of vitamin D considered sufficient were ≥ 30 ng/mL, insufficient between 20 and 30 ng/mL and deficient < 20 ng/mL. The bone mineral density was measured and considered osteopenia when T value total of lumbar spine or hip was between -1 and -2.5 and osteoporosis < 2.5. The patients with fractures accounted for 25.2%.

Results

There was no significant difference in the vitamin D (ng/mL) levels among the age groups (p = 0.25), the levels of fractures (p = 0.79) and the levels of BMD (p = 0.76).

Conclusion

82% of the patients presented deficient and insufficient blood levels of vitamin D. Ours results showed any significant correlation between vitamin D levels and bone mineral density after adjusting for age.

The assessment of vertebral fractures in elderly women with recent hip fractures: the BREAK Study

This study aimed to evaluate the prevalence of vertebral fractures in elderly women with a recent hip fracture. The burden of vertebral fractures expressed by the Spinal Deformity Index (SDI) is more strictly associated with the trochanteric than the cervical localization of hip fracture and may influence short-term functional outcomes.

INTRODUCTION

This study aimed to determine the prevalence and severity of vertebral fractures in elderly women with recent hip fracture and to assess whether the burden of vertebral fractures may be differently associated with trochanteric hip fractures with respect to cervical hip fractures.

METHODS

We studied 689 Italian women aged 60 years or over with a recent low trauma hip fracture and for whom an adequate X-ray evaluation of spine was available. All radiographs were examined centrally for the presence of any vertebral deformities and radiological morphometry was performed. The SDI, which integrates both the number and the severity of fractures, was also calculated.

RESULTS

Prevalent vertebral fractures were present in 55.7% of subjects and 95 women (13.7%) had at least one severe fracture. The women with trochanteric hip fracture showed higher SDI and higher prevalence of diabetes with respect to those with cervical hip fracture, p=0.017 and p=0.001, respectively. SDI, surgical menopause, family history of fragility fracture, and type2 diabetes mellitus were independently associated with the risk of trochanteric hip fracture. Moreover, a higher SDI was associated with a higher percentage of post-surgery complications (p=0.05) and slower recovery (p<0.05).

CONCLUSIONS

Our study suggests that the burden of prevalent vertebral fractures is more strictly associated with the trochanteric than the cervical localisation of hip fracture and that elevated values of SDI negatively influence short term functional outcomes in women with hip fracture.

Cardiovascular diseases in older patients with osteoporotic hip fracture: prevalence, disturbances in mineral and bone metabolism, and bidirectional links

BACKGROUND

Considerable controversy exists regarding the contribution of mineral/bone metabolism abnormalities to the association between cardiovascular diseases (CVDs) and osteoporotic fractures.

AIMS AND METHODS

To determine the relationships between mineral/bone metabolism biomarkers and CVD in 746 older patients with hip fracture, clinical data were recorded and serum concentrations of parathyroid hormone (PTH), 25-hydroxyvitamin D, calcium, phosphate, magnesium, troponin I, parameters of bone turnover, and renal, liver, and thyroid functions were measured.

RESULTS

CVDs were diagnosed in 472 (63.3%) patients. Vitamin D deficiency was similarly prevalent in patients with (78.0%) and without (82.1%) CVD. The CVD group had significantly higher mean PTH concentrations (7.6 vs 6.0 pmol/L, P < 0.001), a higher prevalence of secondary hyperparathyroidism (SPTH) (PTH > 6.8 pmol/L, 43.0% vs 23.3%, P < 0.001), and excess bone resorption (urinary deoxypyridinoline corrected by creatinine [DPD/Cr] > 7.5 nmol/μmol, 87.9% vs 74.8%, P < 0.001). In multivariate regression analysis, SHPT (odds ratio [OR] 2.6, P = 0.007) and high DPD/Cr (OR 2.8, P = 0.016) were independent indictors of CVD. Compared to those with both PTH and DPD/Cr in the normal range, multivariate-adjusted ORs for the presence of CVD were 17.3 (P = 0.004) in subjects with SHPT and 9.7 (P < 0.001) in patients with high DPD/Cr. CVD was an independent predicator of SHPT (OR 2.8, P = 0.007) and excess DPD/Cr (OR 2.5, P = 0.031). CVD was predictive of postoperative myocardial injury, while SHPT was also an independent predictor of prolonged hospital stay and in-hospital death.

CONCLUSION

SHPT and excess bone resorption are independent pathophysiological mediators underlying the bidirectional associations between CVD and hip fracture, and therefore are important diagnostic and therapeutic targets.

Impaired bone mineralization accompanied by low vitamin D and secondary hyperparathyroidism in patients with femoral neck fracture

SUMMARY

Although it is well established that a decrease in bone mass increases the risk of osteoporotic fractures, the proportion of fractures attributable to areal bone mineral density (BMD) is rather low. Here, we have identified bone mineralization defects together with low serum 25-hydroxyvitamin D (25-(OH) D) levels as additional factors associated with femoral neck fractures.

INTRODUCTION

Osteoporotic fractures of the femoral neck are associated with increased morbidity and mortality. Although it is well established that a decrease in bone mass increases the risk of osteoporotic fractures, the proportion of fractures attributable to areal BMD is rather low. To identify possible additional factors influencing femur neck fragility, we analyzed patients with femoral neck fracture.

METHODS

We performed a detailed clinical and histomorphometrical evaluation on 103 patients with femoral neck fracture including dual-energy X-ray absorptiometry, laboratory parameters, and histomorphometric and bone mineral density distribution (BMDD) analyses of undecalcified processed biopsies of the femoral head and set them in direct comparison to skeletal healthy control individuals.

RESULTS

Patients with femoral neck fracture displayed significantly lower serum 25-(OH) D levels and increased serum parathyroid hormone (PTH) compared to controls. Histomorphometric analysis revealed not only a decreased bone volume and trabecular thickness in the biopsies of the patients, but also a significant increase of osteoid indices. BMDD analysis showed increased heterogeneity of mineralization in patients with femoral neck fracture. Moreover, patients with femoral neck fracture and serum 25-(OH) D levels below 12 μg/l displayed significantly thinner trabecular bone.

CONCLUSION

Taken together, our data suggest that impaired bone mineralization accompanied by low serum 25-(OH) D levels is of major importance in the etiology of femoral neck fractures. Therefore, balancing serum 25-(OH) D levels and thereby normalizing PTH serum levels may counteract pronounced mineralization defects and might decrease the incidence of femoral neck fractures.

Parathyroid hormone response to severe vitamin D deficiency is sex associated: an observational study of 571 hip fracture inpatients

OBJECTIVES

To investigate the association between sex and parathyroid hormone response to severe vitamin D deficiency after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

571 consecutive inpatients with hip fracture and severe vitamin D deficiency (serum 25-hydroxyvitamin D < 12ng/ml), without hypercalcemia or estimated glomerular filtration rate (GFR) < 15ml/min.

MEASUREMENTS

In each patient we assessed PTH (by two-site chemiluminescent enzyme-labelled immunometric assay), 25-hydroxyvitamin D (by immunoenzymatic assay), albumin-adjusted total calcium, phosphate, magnesium, and creatinine 21.3 ± 6.1 (mean ± SD) days after fracture occurrence. Functional level was assessed using the Barthel index. PTH response to vitamin D deficiency was classified as either secondary hyperparathyroidism (serum PTH >75pg/ml) or functional hypoparathyroidism, i.e., inappropriate normal levels of PTH (≤75pg/ml).

RESULTS

Among the 571 patients, 336 (59%) had functional hypoparathyroidism, whereas 235 (41%) had secondary hyperparathyroidism. PTH status was significantly different between sexes (p=0.003): we found functional hypoparathyroidism in 61% of women and 43% of men (secondary hyperparathyroidism in 39% of women and 57% of men). The significance of the between-sex difference was maintained after adjustment for age, estimated GFR, phosphate, albumin-adjusted total calcium, albumin, Barthel index scores, 25-hydroxyvitamin D, and hip fracture type (either cervical or trochanteric). The adjusted odds ratio was 1.85 (95%CI from 1.09 to 3.13; p=0.023).

CONCLUSIONS

Data shows that PTH response to vitamin D deficiency was sex-associated following a fracture of the hip. The higher prevalence of secondary hyperparathyroidism may play a role in the known prognostic disadvantage found in hip-fracture men.

Vitamin D in orthopaedics

Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.

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

Background

Data on clinical characteristics and outcomes in regard to hip fracture (HF) type are controversial. This study aimed to evaluate whether clinical and laboratory predictors of poorer outcomes differ by HF type.

Methods

Prospective evaluation of 761 consecutively admitted patients (mean age 82.3 ± 8.8 years; 74.9% women) with low-trauma non-pathological HF. Clinical characteristics and short-term outcomes were recorded. Haematological, renal, liver and thyroid status, C-reactive protein, cardiac troponin I, serum 25(OH) vitamin D, PTH, leptin, adiponectin and resistin were determined.

Results

The cervical compared to the tronchanteric HF group was younger, have higher mean haemoglobin, albumin, adiponectin and resistin and lower PTH levels (all P < 0.05). In-hospital mortality, length of hospital stay (LOS), incidence of post-operative myocardial injury and need of institutionalisation were similar in both groups. Multivariate analysis revealed as independent predictors for in-hospital death in patient with cervical HF male sex, hyperparathyroidism and lower leptin levels, while in patients with trochanteric HF only hyperparathyroidism; for post-operative myocardial injury dementia, smoking and renal impairment in the former group and coronary artery disease (CAD), hyperparathyroidism and hypoleptinaemia in the latter; for LOS > 20 days CAD, and age > 75 years and hyperparathyroidism, respectively. Need of institutionalisation was predicted by age > 75 years and dementia in both groups and also by hypovitaminosis D in the cervical and by hyperparathyroidism in the trochanteric HF.

Conclusions

Clinical characteristics and incidence of poorer short-term outcomes in the two main HF types are rather similar but risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms.

Hypovitaminosis D as a risk factor of hip fracture severity

SUMMARY

In a cross-sectional study including 324 patients older than 65 years admitted to our hospital for osteoporotic hip fracture, we found that those patients with a more severe vitamin D deficiency had more severe osteoporotic hip fractures (Garden grades III-IV and Kyle III-IV).

INTRODUCTION

To identify possible differences in baseline characteristics of patients with different types of osteoporotic hip fracture.

METHODS

Cross-sectional study including consecutive individuals over 65 admitted to our hospital for osteoporotic hip fracture over a year. Demographic data, fracture type, comorbidities, history of osteoporosis, functional capacity, nutritional status and vitamin D storage were evaluated.

RESULTS

We included 324 patients (83 ± 7 years, 80% women). Two hundred sixteen patients (67%) had vitamin D deficiency (25OHD3 <25 ng/ml). In patients with severe femoral neck or intertrochanteric fractures (Garden III-IV and Kyle III-IV), vitamin D deficiency was more frequent (74%) and severe (25OHD3 20 ± 15 ng/ml) than in patients with less severe fractures (57%, 25OHD3 26 ± 21 ng/ml). Forty-three percent of patients had previous fractures. Only 15% of patients had been previously diagnosed with osteoporosis and 10% were receiving treatment. Patients receiving vitamin D supplements have higher 20OHD3 levels and less severe fractures.

CONCLUSIONS

Although vitamin D levels are not different between patients with intracapsular or extracapsular hip fractures, a more severe vitamin D deficiency seems to be associated to more severe osteoporotic hip fractures. A prior vitamin D supplementation could avoid a higher severity of these fractures.

Osteocyte deficiency in hip fractures

Osteocytes play a central role in the regulation of bone remodeling. The aim of this study was to explore osteocyte function, and particularly the expression of SOST, a Wnt inhibitor, in patients with hip fractures. Serum sclerostin levels were measured by ELISA. The expression of several osteocytic genes was studied by quantitative PCR in trabecular samples of the femoral head of patients with hip fractures, hip osteoarthritis and control subjects. The presence of sclerostin protein and activated caspase 3 was revealed by immunostaining. There were no significant differences in serum sclerostin between the three groups. Patients with fractures have fewer lacunae occupied by osteocytes (60 ± 5% vs. 64 ± 6% in control subjects, P = 0.014) and higher numbers of osteocytes expressing activated caspase 3, a marker of apoptosis. The proportion of sclerostin-positive lacunae was lower in patients with fractures than in control subjects (34 ± 11% vs. 69 ± 10%, P = 2 × 10(-8)). The proportion of sclerostin-positive osteocytes was also lower in patients. RNA transcripts of SOST, FGF23 and PHEX were also less abundant in fractures than in control bones (P = 0.002, 5 × 10(-6), and 0.04, respectively). On the contrary, in patients with osteoarthritis, there was a decreased expression of SOST and FGF23, without differences in PHEX transcripts or osteocyte numbers. Osteocyte activity is altered in patients with hip fractures, with increased osteocyte apoptosis and reduced osteocyte numbers, as well as decreased transcription of osteocytic genes. Therefore, these results suggest that an osteocyte deficiency may play a role in the propensity to hip fractures.