Preoperative Vitamin D Deficiency is Associated with Increased One-Year Mortality in Chinese Geriatric Hip Fracture Patients - A Propensity Score Matching Study

Preoperative transthoracic echocardiography does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients

PURPOSE

The present study aimed to investigate the influence of preoperative TTE on postoperative short-term mortality, surgery delay, as well as other economic and clinical outcomes in Chinese geriatric hip fracture patients.

METHODS

This retrospective, matched-cohort study enrolled geriatric hip fracture patients (≥ 60 years) who underwent surgical interventions at our center between 2015 and 2020. The primary exposure was inpatient preoperative TTE. Demographic and clinical data that were reported as risk factors for postoperative mortality were retrieved from the medical data center as the covariates. The primary clinical outcomes were all-cause mortality at 30 days, 90 days, 180 days, and 1 year. Time from hospital presentation to surgery, length of stay (LOS), inpatient cost, frequency of cardiology consultation and coronary angiography (CAG) were also assessed. The propensity score matching (PSM) was performed in a ratio of 1:1.

RESULTS

447 patients were identified and 216 of them received a preoperative TTE (48.3%). After successfully matching 390 patients (87.2%), patients receiving TTE showed significantly higher 30-day mortality (6.6% vs 2.0%, P = 0.044). But no significant difference was found in 90-day, 180-day, and 365-day mortality as well as the 1-year accumulated survival rate. Receipt of TTE was also associated with significant increases in LOS (13.6 days vs 11.4 days, P = 0.017), waiting time for surgery (5.9 days vs 4.3 days, P < 0.001), and lower proportion of receiving surgery within 48 h (7.2% vs. 26.2%, P < 0.001). According to the multivariable logistic analysis, only ejection fraction (30 days, 90 days), aorta diameter (30 days, 90 days, 180 days, 365 days), left ventricular posterior wall diameter (90 days, 180 days, 365 days), aortic valve velocity (90 days) and mitral valve A-peak (90 days, 180 days) were association with postoperative mortality among the 17 parameters in the TTE reports. Besides, TTE has no influence on the frequency of preoperative cardiology consultation.

CONCLUSION

Preoperative TTE does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients. The predictive ability of TTE parameters is limited for postoperative mortality.

Increased Early Postoperative Complication Rate after Osteoporotic Hip Fracture in Patients with Low 25 (OH) Vitamin D Levels

This study investigated the association of preoperative 25-hydroxy (25 (OH)) vitamin D levels with postoperative complications in osteoporotic hip fracture patients following surgery. We hypothesized that patients with low concentrations of 25 (OH) vitamin D might have an increased risk of developing adverse outcomes. Between January 2019 and December 2020, a retrospective observational study was conducted, including low-energy fragility fractures at the proximal femur. Regarding preoperative 25 (OH) vitamin D levels, patients were divided into two groups (<30 ng/mL and ≥30 ng/mL). Early and late postoperative complications were assessed and graded according to the Clavien-Dindo classification system. Logistic regression analysis was performed to demonstrate the association between preoperative 25 (OH) vitamin D levels (<30 ng/mL, ≥30 ng/mL) and postoperative complications after adjusting for age and sex. Of 314 patients, 222 patients (70.7%) had a 25 (OH) vitamin D level of <30 ng/mL. The mean serum 25 (OH) vitamin D level was 22.6 ng/mL (SD 13.2). In 116 patients (36.9%), postoperative complications were observed, with the most occurring in the short term (95 patients, 30.2%). Late postoperative complications were present in 21 patients (6.7%), most graded as Clavien I (57.1%). Logistic regression analysis identified a low vitamin D level (<30 ng/mL) as an independent risk factor for early postoperative complications (OR 2.06, 95% CI 1.14-3.73, p = 0.016), while no significant correlation was found in late complications (OR 1.08, 95% CI 0.40-2.95, p = 0.879). In conclusion, preoperative 25 (OH) vitamin D serum level might be an independent predictor for early postoperative complications. However, future studies are warranted to determine risk factors for long-term complications and establish appropriate intervention strategies.

Nutrition, Vitamin D, and Calcium in Elderly Patients before and after a Hip Fracture and Their Impact on the Musculoskeletal System: A Narrative Review

Hip fractures are a major health issue considerably impacting patients' quality of life and well-being. This is particularly evident in elderly subjects, in which the decline in bone and muscle mass coexists and predisposes individuals to fall and fracture. Among interventions to be implemented in hip fractured patients, the assessment and management of nutritional status is pivotal, particularly in subjects older than 65. Nutrition plays a central role in both primary and secondary preventions of fracture. An adequate protein intake improves muscle mass and strength and the intestinal absorption of calcium. Other nutrients with recognized beneficial effects on bone health are calcium, vitamins D, K, and C, potassium, magnesium, folate, and carotenoids. With reference to calcium, results from longitudinal studies showed that the consumption of dairy foods has a protective role against fractures. Moreover, the most recent systematic reviews and meta-analyses and one umbrella review demonstrated that the combination of calcium and vitamin D supplementation significantly reduces hip fracture risk, with presumed higher efficacy in older and institutionalized subjects. Owing to these reasons, the adequate intake of calcium, vitamin D, protein, and other macro and micronutrients has been successfully implemented in the Fracture Liaison Services (FLSs) that represent the most reliable model of management for hip fracture patients. In this narrative review, papers (randomized controlled trials, prospective and intervention studies, and systematic reviews) retrieved by records from three different databases (PubMed, Embase, and Medline) have been analyzed, and the available information on the screening, assessment, and management of nutritional and vitamin D status and calcium intake in patients with hip fractures is presented along with specific prevention and treatment measures.

Does vitamin D deficiency affect functional outcomes in hip fracture patients? A meta-analysis of cohort studies

BACKGROUND

Vitamin D deficiency is common in patients with hip fractures and may negatively affect functional recovery and quality of life (QOL).

OBJECTIVE

This study aimed to conduct a meta-analysis to quantify the effects of vitamin D deficiency on physical function and quality of life after hip fractures.

METHODS

The PubMed, EMBASE, Scopus, and Cochrane Library databases were searched for relevant studies. The inclusion criteria were hip fracture, comparison between vitamin D deficiency and normal vitamin D levels in patients with hip fracture, and functional outcome as the primary outcome. The exclusion criteria were case reports, reviews, duplicates, studies with a high risk of bias, and non-comparable or missing data. Two independent reviewers selected studies, extracted data, assessed bias, and performed meta-analyses using the Review Manager. Heterogeneity and publication bias were also assessed. Two independent reviewers selected the studies, extracted data, and assessed the risk of bias. We performed a meta-analysis using Review Manager and assessed heterogeneity and publication bias.

RESULTS

Seven studies with 1,972 patients were included. Vitamin D deficiency was defined as a 25(OH)D level < 20 ng/mL. There were no significant differences in the ability to walk (OR 0.68, 95% CI 0.31-1.53, I2 = 69%) or length of hospital stay (MD 2.27 days, 95% CI - 2.47 to 7.01, I2 = 93%) between patients with and without vitamin D deficiency. However, patients with vitamin D deficiency had significantly worse functional ability and quality of life (SMD - 1.50, 95% CI - 2.88 to - 0.12, I2 = 96%).

CONCLUSIONS

Despite the limitations of this study, such as small sample size, heterogeneous outcome assessments, and variable vitamin D measurement techniques, the results demonstrated that screening for vitamin D status and optimizing levels through supplementation could facilitate rehabilitation, promote lifestyle changes, aid in the recovery of independence, and help reduce long-term burdens.

Impact of vitamin D deficiency on mortality in patients with hip fracture: A meta-analysis

BACKGROUND

Vitamin D deficiency has been linked to numerous health issues, including an increased risk of hip fractures. This meta-analysis aimed to investigate the relationship between vitamin D deficiency and mortality in patients with hip fracture. To assess the impact of different levels of vitamin D deficiency on mortality in patients with hip fractures and examine the influence of potential confounding factors.

METHODS

A systematic search of PubMed, EMBASE, Scopus, and Cochrane Collaboration Library was conducted, resulting in nine eligible cohort studies (n = 4409). Patients with hip fractures were categorized based on their vitamin D levels as severe, moderate, or insufficient. Mortality was the primary outcome measure in this study. Subgroup analyses were performed according to the follow-up time. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model in Review Manager 5.4.

RESULTS

Nine studies, with a pool of 4409 patients, were included. Vitamin D insufficiency was significantly associated with increased mortality (OR 1.24, 95% CI 1.05-1.46; I2  = 4%). Severe deficiency also led to a significant increase in mortality (OR 2.08, 95% CI 1.09-3.97; I2  = 42%), whereas moderate deficiency did not show a significant effect (OR 1.06, 95% CI 0.79-1.44; I2  = 0%). Subgroup analysis revealed significant associations between vitamin D insufficiency and increased mortality at 1-year (OR 1.37, 95% CI 1.06-1.77) and 2-year follow-ups (OR 1.78, 95% CI 1.01-3.15). After adjusting for potential confounders, no significant increase in the mortality rate was observed.

CONCLUSIONS

This meta-analysis suggests that vitamin D insufficiency and severe deficiency are associated with increased mortality in patients with hip fracture. However, after adjusting for confounding factors, this association was not statistically significant. Further research is necessary to understand the role of vitamin D deficiency in this population.

Bone turnover biomarkers predict one-year all-cause mortality and walking ability in geriatric hip fracture patients

PURPOSE

To investigate the utility of serum C-terminal cross-linking telopeptides (β-CTX) and procollagen type I N propeptide (PINP) for predicting one-year mortality and walking ability in Chinese geriatric hip fracture patients who underwent surgical interventions.

METHOD

Elderly patients (≥ 60 years) who underwent surgical interventions for unilateral low-energy hip fracture from 2015 to 2020 in our center were included. Demographic data was retrospectively retrieved from the electronic medical database. The PINP and β-CTX concentrations were measured before the surgery. The patients were divided into two groups according to the outcome of mortality and walking ability after hip surgery, respectively. β-CTX and PINP were divided into four grades based on quartiles [Quartile(Q)1-4] for further analysis. All the variables with p < 0.1 in univariable analysis were included in a multivariable model.

RESULTS

In univariable analysis, the levels of serum β-CTX (p = 0.007) and PINP (p = 0.025) was associated with one-year mortality, while the association between levels of serum β-CTX (p = 0.072) or PINP (p = 0.055) with one-year disability was marginally significant. After adjustment for confounders, the relative risk [OR (95 % CI), Q4 v sQ1, p-value] of one-year mortality and one-year disability were 7.28 (2.08-29.78, p = 0.003) and 3.97 (1.44-11.69, p = 0.009) for β-CTX and 5.87 (1.70-23.80, p = 0.008) and 3.48 (1.30-9.93, p = 0.016) for PINP, respectively. The coefficient of determination, AUC and bias-corrected C-index of predictive models based on previously reported predictors were significantly improved after integrating β-CTX or PINP.

CONCLUSION

Higher serum β-CTX and PINP are independently associated with an increased risk of one-year mortality and disability in patients with hip fractures. The application of BTMs improves the performance of currently available predictive models.