The Danish Multidisciplinary Hip Fracture Registry 13-Year Results from a Population-Based Cohort of Hip Fracture Patients

Intensified acute in-hospital physiotherapy for patients after hip fracture surgery: a pragmatic, randomized, controlled feasibility trial

PURPOSE

Intensified acute in-hospital physiotherapy (IP) after hip fracture (HF) may enhance patient's ability to regain basic mobility at discharge. The primary objective was to assess the feasibility of IP. Secondary to estimate the effect of IP on regained basic mobility at discharge.

MATERIALS AND METHODS

In a pragmatic, randomized, unblinded feasibility trial, 60 patients (mean age 79 years, 41 women) with HF and an independent pre-fracture basic mobility level were randomized (2:1) to IP with two daily sessions on weekdays focusing on functional training and weight-bearing activities (n = 40) versus usual care (UC) physiotherapy once daily (n = 20). Feasibility outcomes included physiotherapy completion rates, reasons for non-successful completion, and adverse events. The primary effect outcome was recovery of basic mobility (Cumulated Ambulation Score (CAS)).

RESULTS

Eighty-two percent of the sessions in the IP group were successfully- or partially completed versus 94% of the sessions in the UC group. No adverse events occurred. The main reason for not completing physiotherapy was fatigue. At discharge (median 7 days), 50% in the IP group had regained their pre-fracture basic mobility level (CAS = 6) versus 16% in the UC group; odds ratio = 5.33, 95%CI [1.3;21.5].

CONCLUSIONS

IP seems feasible for patients after HF surgery, and it may enhance recovery. Fatigue was the primary obstacle to completing IP.

The epidemiology of geriatric fractures: A nationwide analysis of 1 million fractures

OBJECTIVE

Fractures among the geriatric population impose a substantial burden on healthcare systems. This study aims to investigate the incidence and distribution of fractures among geriatric individuals over seven years, analyzing changes by age and sex. The findings will inform national healthcare strategies for addressing the growing impact of geriatric fractures.

MATERIALS AND METHODS

Electronic health records from a nationwide personal health records system were analyzed, focusing on ICD-10 codes for fractures. Recurrent codes for the same patients within three months were excluded. Patients were categorized into three age groups (65-74, 75-84, and 85+ years), and fractures were grouped anatomically. Incidence rates for specific fracture locations were calculated based on the actual population at risk annually. Incidence rates were further stratified by sex and age groups using Turkey's age- and sex-specific populations.

RESULTS

A total of 1,004,663 geriatric fractures (66.9 % female, 33.1 % male) were identified over seven years. The overall fracture incidence among the geriatric population was 1.9 % (1910/100,000). Hip fractures were the most common (25.2 %), followed by wrist (15 %) and lumbar-pelvic fractures (11.9 %). Femur fractures were predominant in the 75-84 and 85+ age groups, while wrist fractures were more common in the 65-74 age group. Fracture incidences generally increased with age, except for ankle, foot, and toe fractures, which decreased with age for both sexes (p < 0.05). The male/female ratio was lowest for wrist, elbow, and humeral shaft fractures (1:3.2, 1:2.7, and 1:2.7, respectively). The lowest overall fracture incidence was observed in 2020 (1568/100,000), while the highest was in 2017 (2523/100,000).

CONCLUSION

With Turkey's aging population, the socioeconomic impact of geriatric fractures is anticipated to rise. Fracture patterns and incidence vary by age and sex among geriatric individuals. These findings provide valuable insights for healthcare planning and the development of community-based preventive measures tailored to specific fracture locations and demographics.

Major comorbid diseases as predictors of infection in the first month after hip fracture surgery: a population-based cohort study in 92,239 patients

PURPOSE

Comorbidity level is a predictor of infection in the first 30 days after hip fracture surgery. However, the roles of individual comorbid diseases as predictors of infection remain unclear. We investigated individual major comorbid diseases as predictors of infection after hip fracture surgery.

METHODS

We obtained Danish population-based medical registry data for patients undergoing hip fracture surgery (2004-2018). Information was obtained on 27 comorbidities, included in various comorbidity indices, 5 years before surgery. The primary outcome was any hospital-treated infection within 30 days after surgery. Cumulative incidence of infection was calculated by considering death as competing risk. We used logistic regression to compute mutually adjusted odds ratios with 95% confidence interval for infection.

RESULTS

Of 92,239 patients with hip fracture, 71% were women, and the median age was 83 years. The most prevalent comorbidities were hypertension (23%), heart arrhythmia (15%), and cerebrovascular disease (14%). The 30-day incidence of infection was 15% and 12% among the total cohort and among patients with no record of comorbidities, respectively. Infection incidence was highest among patients with renal disease (24%), depression/anxiety (23%), and chronic pulmonary disease (23%), and lowest among patients with metastatic solid tumor (15%). Adjusted odds ratios of infection ranged from 0.94 [0.80-1.10] for metastatic solid tumor to 1.77 [1.63-1.92] for renal disease.

CONCLUSION

Most comorbid diseases were predictors of infection after surgery for hip fracture. Awareness of patients' comorbidity profiles might help clinicians initiate preventive measures or inform patients of their expected risk.

Impact of diabetes on the risk of subsequent fractures in 92,600 patients with an incident hip fracture: A Danish nationwide cohort study 2004-2018

PURPOSE

We investigated the incidence rates of a subsequent hip fracture (HF) and other subsequent fractures than HF after first incident HF, comparing patients with and without diabetes.

METHODS

Using Danish medical databases, we identified 92,600 incident HF patients in the period 2004-2018. Diabetes exposure was examined overall, by type of diabetes (T2D and T1D), and by presence of diabetes complications. We estimated cumulative incidence of subsequent HFs and fractures other than HF within two years of the incident HF. Using Cox regression, adjusted hazard ratios (aHRs) with 95 % confidence interval (CI) were calculated.

RESULTS

Among incident HF patients, 11,469 (12 %) had diabetes, of whom 10,253 (89 %) had T2D and 1216 (11 %) had T1D. The 2-year incidence rates for a new subsequent HF were 4.8 % (95 % CI: 4.6-4.9) for patients without diabetes (reference group), 4.1 % (95 % CI: 3.8-4.6) for T2D, and 4.3 % (95 % CI: 3.3-5.6) for T1D. Corresponding aHRs were 1.01 (95 % CI 0.90-1.14) for T2D and 1.17 (95 % CI 0.87-1.58) for T1D. There was effect modification by sex, as women with T1D had an aHR of 1.52 (95 % CI: 1.09-2.11) for subsequent HF, and by specific diabetes complications (for example, patients with T2D and prior hypoglycemia had an aHR of 1.75 (95 % CI: 1.24-2.42) for subsequent HF, while patients with T1D and neuropathy had an aHR of 1.73 (95 %: 1.09-2.75), when compared with patients without diabetes). For fractures other than HF, the 2-year incidence rates were 7.3 % (95 % CI: 7.2-7.5) for patients without diabetes, 6.6 % (95 % CI: 6.1-7.1) for T2D, and 8.5 % (95 % CI: 7.0-10.1) for T1D, with corresponding aHRs of 1.01 (95 % CI 0.92-1.11) for T2D and 1.43 (95 % CI: 1.16-1.78) for T1D. T2D was only a risk factor for other subsequent fractures among HF patients of high age (age 86-89 years: aHR 1.22 (95 % CI 0.99-1.55), age 90+ years: aHR 1.37 (95 % CI 1.08-1.74)), whereas T1D was robustly associated with increased risk of fractures other than HF in all subgroups.

CONCLUSION

Among HF patients, we found no strong overall association of T2D or T1D with increased risk of subsequent HF, but diabetes patients with prior hypoglycemic events or neuropathy were at increased risk. In contrast, patients with T1D had a clearly increased risk of subsequent fractures other than HF.

The relationship between extent of mobilisation within the first postoperative day and 30-day mortality after hip fracture surgery

OBJECTIVE

To determine the association between the extent of mobilisation within the first postoperative day and 30-day mortality after hip fracture.

DESIGN

Cohort study.

SETTING

Acute orthopaedic hospital ward.

PARTICIPANTS

Consecutive sample of 701 patients, 65 years of age or older, 80% from own home, 49% with a trochanteric fracture, and 61% with an American Society of Anesthesiology grade > 2.

INTERVENTION

n/a.

MAIN MEASURES

Cumulated ambulation score (CAS) (0-6 points) on the first postoperative day and 30-day postoperative mortality. A CAS = 0 reflects no functional mobility (bedridden), while a CAS = 6 reflects independent out-of-bed-transfer, chair-stand, and indoor walking status.

RESULTS

Overall, 86% of patients were mobilised to standing or seated in chair (CAS ≥ 1) on the first postoperative day. A CAS of 0, 1-3, and 4-6 was observed for 97 (14%), 519 (74%), and 85 (12%) patients, respectively. Overall, 61 (8.7%) patients died within 30 days with the highest mortality (23.7%, n = 23) seen for those not mobilised (CAS = 0). Only one patient (1.2%) with a CAS of 4-6 points died. Cox regression analysis adjusted for age, sex, residential status, pre-fracture CAS, fracture type, and American Society of Anesthesiology grade, showed that a one-unit increase in CAS was associated with a 38% lower risk of 30-day mortality (Hazard Ratio = 0.63, 95%Confidence Interval, 0.50-0.78).

CONCLUSION

Mobility on the first postoperative day was associated with 30-day postoperative mortality, with a lower risk observed for those completing greater mobility. National registries may consider extending collection of mobility on the first postoperative day from a binary indicator to the CAS which captures the extent of mobility achieved.

Any infection among patients with hip fracture: Predictive ability of Charlson, Elixhauser, Rx-Risk, and Nordic comorbidity indices

BACKGROUND

In studies on infection after hip fracture surgery, a common and serious complication, it remains unknown which comorbidity index is best for case-mix confounder adjustment. We evaluated the predictive ability of Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Rx-Risk Index (Rx-Risk), and Nordic Multimorbidity Index (NMI) for any infection up to 1 year from discharge after hip fracture surgery.

METHODS

Using Danish medical registries, we included 92,600 patients (mean age 83 years) surgically treated for hip fracture between 2004 and 2018. Comorbidity-index scores were calculated using prevalence of diagnosis codes, prescription codes, or both. Lookback periods of 1, 5, and 10 years were applied. Logistic regression was used to calculate c-index to assess discrimination of comorbidity indices individually and in combination with a base model of age and sex. Outcome was any infection (not only surgical site infection) in-hospital and 1 year after discharge.

RESULTS

At 10-year lookback period, the c-index for individual comorbidity indices for in-hospital infections varied from 0.53 to 0.56, similar to base model alone (0.56). The predictive ability of comorbidity indices in combination with base model varied from 0.56 to 0.57. Within 1 year after discharge, NMI in combination with base model had best predictive ability for infection (c-index = 0.62), followed by CCI and ECI (c-index = 0.60) and Rx-Risk (c-index = 0.58). Discrimination was similar for all lookback periods.

CONCLUSIONS

Comorbidity indices have low predictive ability for any infection up to 1 year after hip fracture surgery, similar to that of age and sex alone. For case-mix adjustment, evaluated comorbidity indices are of equal value.

Comorbidity and risk of infection among patients with hip fracture: a Danish population-based cohort study

Impact of comorbidity on infection risk among hip fracture patients is unclear. We found high incidence of infection. Comorbidity was an important risk factor for infection up to 1 year after surgery. Results indicates a need for additional investment in pre- and postoperative programs that assist patients with high comorbidity.

PURPOSE

Comorbidity level and incidence of infection have increased among older patients with hip fracture. The impact of comorbidity on infection risk is unclear. We conducted a cohort study examining the absolute and relative risks of infection in relation to comorbidity level among hip fracture patients.

METHODS

Utilizing Danish population-based medical registries, we identified 92,600 patients aged ≥ 65 years undergoing hip fracture surgery between 2004 and 2018. Comorbidity was categorized by Charlson comorbidity index scores (CCI): none (CCI = 0), moderate (CCI = 1-2), or severe (CCI ≥ 3). Primary outcome was any hospital-treated infection. Secondary outcomes were hospital-treated pneumonia, urinary tract infection, sepsis, reoperation due to surgical-site infection (SSI), and a composite of any hospital- or community-treated infection. We calculated cumulative incidence and hazard ratios (aHRs) adjusted for age, sex, and surgery year, including 95% confidence intervals (CIs).

RESULTS

Prevalence of moderate and severe comorbidity was 40% and 19%, respectively. Incidence of any hospital-treated infection increased with comorbidity level within 0-30 days (none 13% vs. severe 20%) and 0-365 days (none 22% vs. 37% severe). Patients with moderate and severe comorbidity, compared to no comorbidity, had aHRs of 1.3 (CI: 1.3-1.4) and 1.6 (CI: 1.5-1.7) within 0-30 days, and 1.4 (CI: 1.4-1.5) and 1.9 (CI: 1.9-2.0) within 0-365, respectively. Highest incidence was observed for any hospital- or community-treated infection (severe 72%) within 0-365 days. Highest aHR was observed for sepsis within 0-365 days (severe vs. none: 2.7 (CI: 2.4-2.9)).

CONCLUSION

Comorbidity is an important risk factor for infection up to 1 year after hip fracture surgery.

Standardization of global hip fracture audit could facilitate learning, improve quality, and guide evidence-based practice

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Methods

We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD.

Results

The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription.

Conclusion

There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement.

Current Trends in Comorbidity Prevalence and Associated Mortality in a Population-Based Cohort of Hip Fracture Patients in Denmark

Background and Purpose

Patients with hip fractures often have comorbidities, but detailed data on comorbidity and its impact on prognosis are lacking. We described the current trends in the prevalence of comorbidity and the magnitude of the associated mortality.

Patients and Methods

From the Danish Multidisciplinary Hip Fracture Registry we included 31,443 hip fracture patients (diagnosed in 2014-2018). We calculated the prevalence of individual diseases and comorbidity measured with the Charlson Comorbidity Index (CCI), the Elixhauser Index, and the Rx-Risk Index. We calculated sex and age-adjusted odds ratios (aORs) for 30-day mortality and hazard ratios (aHRS) for one-year mortality with 95% confidence intervals (CI).

Results

The most common diseases identified with the CCI were cerebrovascular diseases (18%), malignancies (17%), chronic pulmonary disease (14%), and dementia (11%). Using the Elixhauser Index, hypertension (37%), cardiac arrhythmias (21%), and fluid and electrolyte disorders (15%) were most prevalent, while ischemic heart disease (42%), hypertension (39%), and use of antiplatelets (37%) were most prevalent when using the Rx-Risk Index. Using the Rx-Risk Index, only 28% of patients had no comorbidity compared to 38% for CCI and 44% for the Elixhauser Index, and the prevalence was stable through the years. Compared to patients with no comorbidity, patients with very severe comorbidity had an aORs for 30-day mortality of 2.6 (CI: 2.4-2.9) using CCI, 2.6 (CI: 2.4-3.1) using the Elixhauser Index, and 3.1 (CI: 2.7-3.4) using the Rx-Risk Index.

Interpretation

More than 50% of the patients with hip fractures have moderate to very severe comorbidity, with considerable variation between indices. The prevalence of individual diseases varies considerably. All indices had comparable dose-response associations with mortality. These results are relevant for clinicians to amend prevention and target care, and for researchers to decide which comorbidity measure to use depending on the research question.

Hip fracture registries in low- and middle-income countries: a scoping review

PURPOSE

The study aims to identify, describe, and organize the currently available evidence regarding hip fracture (HF) registries in low- and middle-income countries (LMICs).

METHODS

We conducted a scoping review adhering to PRISMA-ScR guidelines. We searched MEDLINE (PubMed), Google Scholar, Global Index Medicus, websites related to HF, and study references for eligible studies. Two reviewers independently performed the study selection and data extraction, including studies describing the use of individual patient records with the aim to improve the quality of care in older people with HF in LMICs.

RESULTS

A total of 222 abstracts were screened, 59 full-text articles were reviewed, and 10 studies regarding 3 registries were included in the analysis. Malaysia and Mexico implemented a HF registry in public hospitals whereas Argentina implemented a registry in the private setting. The Mexican registry, the most recent one, is the only one that publishes annual reports. There was significant variability in data fields between registries, particularly in functional evaluation and follow-up. The Ministry of Health finances the Malaysian registry, while Argentinian and Mexican registries founding was unclear.

CONCLUSION

The adoption of HF registries in LMICs is scarce. The few experiences show promising results but higher support is required to develop more registries. Long-term sustainability remains a challenge.

Association of anticholinergic drug use with postoperative mortality among patients with hip fracture. A nationwide cohort study

PURPOSE

Anticholinergic (AC) drugs are associated with various determinantal outcomes. Data regarding the effect of AC drugs on mortality among geriatric hip fracture patients are limited and inconsistent.

METHODS

Using Danish health registries, we identified 31,443 patients aged ≥65 years undergoing hip fracture surgery. AC burden was assessed 90 days before surgery by the Anticholinergic Cognitive Burden (ACB) score and number of AC drugs. Logistic and Cox regression producing odds ratios (OR) and hazard ratios (HR) for 30- and 365- day mortality, adjusting for age, sex, and comorbidities were computed.

RESULTS

AC drugs were redeemed by 42% of patients. The 30-day mortality increased from 7% for patients with ACB score of 0 to 16% for patients with ACB score of ≥5, corresponding to an adjusted OR 2.5 (CI: 2.0-3.1). The equivalent adjusted HR for 365-mortality was 1.9 (CI: 1.6-2.1). Using count of AC drugs as exposure we found a stepwise increase in ORs and HRs with increased number of AC drugs; Compared to non-users, adjusted ORs for 30-days mortality were 1.6 (CI: 1.4-1.7), 1.9 (CI: 1.7-2.1), and 2.3 (CI: 1.9-2.7) for users of 1, 2 and 3+ AC drugs. HRs for 365-day mortality were 1.4 (CI: 1.3-1.5), 1.6 (CI: 1.5-1.7) and 1.8 (CI: 1.7-2.0).

CONCLUSION

Use of AC drugs was associated with increased 30-day and 365-day mortality among older adults with hip fracture. Simply counting the number of AC drugs may be a clinically relevant and easy AC risk assessment tool. Continued effort to reduce AC drug-use is relevant.

A nomogram to predict postoperative infection for older hip fracture patients

INTRODUCTION

Postoperative infection is one of the most common postoperative complications in hip fracture surgery. It is related with increased morbidity and mortality. This study aimed at developing a nomogram to predict the individual probability of postoperative infection to facilitate perioperative decision-making.

MATERIALS AND METHODS

In this retrospective study, we included all patients over 65 years old admitted for hip fracture in West China Hospital of Sichuan University from 1 January 2015 to 31 December 2019. Univariate and multivariate logistic regression analyses were used to identify significant predictors. We used all-subsets regression to screen an optimal model, and visualized the model through drawing nomogram. To evaluate the model performance, we applied receiver operating characteristic curve and calibration curve.

RESULTS

We enrolled 677 older patients. 136 (20.1%) patients developed postoperative infection during hospitalization. Variables retained in the final model were albumin [odds ratio (OR) 0.90, 95% confidence interval (CI) 0.84-0.96], cholesterol (OR 1.49, 95% CI 1.04-2.15), blood phosphorus (OR 0.16, 95% CI 0.05-0.48), high-density lipoprotein (OR 0.42, 95% CI 0.19-0.89), surgery type (OR 2.27, 95% CI 1.35-3.90), smoking (OR 1.95, 95% CI 1.02-3.66), American Society of Anesthesiologists classification [class III (OR 1.02, 95% CI 0.55-1.93); class IV (OR 1.93, 95% CI 0.76-4.82)], and chronic pulmonary disease (OR 2.16, 95% CI 1.25-3.68). The C-index of the nomogram was 0.752 (95% CI 0.697-0.806). Calibration curve showed good agreement between predicted value and observed outcome. In the validation group, our nomogram showed an area under the receiver operating characteristic curve of 0.723 (95% CI 0.639-0.807).

CONCLUSION

Our nomogram showed good discrimination ability in predicting individual probability of postoperative infection among older patients with hip fracture surgery. The nomogram could help clinicians identify patients at high risk of postoperative infection before surgery.

Impact of Stroke History on the Risk of Recurrent Hip Fracture or Major Osteoporotic Fractures among Patients with Incident Hip Fracture: A Nationwide Cohort Study

Considerable uncertainty prevails regarding risk factors for recurrent fracture among older patients with hip fracture. We aimed to investigate the relationship between prefracture stroke history, baseline mobility, and the risk of recurrent hip fracture. This cohort study was based on the Danish Multidisciplinary Hip Fracture Registry, 2011-2018 (n = 48,230). We estimated cumulative incidence (competing risk of death) of recurrent hip fracture and major osteoporotic fractures within 1 and 2 years comparing patients with/without prefracture stroke history. Analyses were performed overall and stratified on baseline mobility status (good mobility: Cumulated Ambulation Score ≥ 5 versus poor mobility: Cumulated Ambulation Score < 5). Using Cox regression, adjusted cause-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were obtained. The 1-year cumulative incidence was 4.6% (95% CI: 3.9-5.4) among patients with stroke history and 4.3% (95% CI: 4.1-4.5) among patients without stroke history. For patients with good mobility, the cumulative incidence of recurrent hip fracture was 5.8% (95% CI: 4.3-7.5) versus 3.7% (95% CI: 3.4-4.0) for patients with versus without stroke history. Corresponding numbers for patients with poor mobility were 4.4% (95% CI: 3.6-5.5) and 5.0% (95% CI: 4.7-5.3). Stroke history was associated with an adjusted HR of 1.55 (95% CI: 1.15-2.10) for recurrent fracture among patients with good mobility. In contrast, no association was observed among patients with poor mobility (adjusted HR 0.88 [95% CI: 0.70-1.10]). The associations were attenuated after 2 years of follow-up and for major osteoporotic fractures. In conclusion, stroke history was associated with slightly higher risk of recurrent fracture among patients with first-time hip fracture in the overall analysis, although the CI included a null result. The association was modified by baseline mobility: Patients with stroke history and good mobility had a markedly higher risk, whereas patients with stroke and poor mobility did not. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Dislocation rate, revisions and other complications of primary cemented hemiarthroplasty for displaced femoral neck fractures: a single-center cohort study of 743 unselected hips with a mean 2.7-year follow-up

INTRODUCTION

Evidence of whether to use hemiarthroplasty (HA) or total hip arthroplasty for displaced femoral neck fractures (FNF) is still widely debated, especially when taking ambulatory status, age, and patient cognitive status into account. The current study aims to report the rates of dislocations, revisions and other complications for primary cemented HA in patients with displaced FNF.

MATERIALS AND METHODS

Single-center retrospective follow-up study of an unselected historic cohort. 743 consecutive hips (551 W and 192 M) at mean (SD) age of 83.6 (8.4) years received primary cemented HA for displaced FNF by posterolateral surgical approach between January 2012 and December 2019. Patient files and radiographs were evaluated for dislocations, revisions, and other complications until death or end of the follow-up period, and the educational level of the surgeon was noted.

RESULTS

During a mean (SD) follow-up period of 2.7 (2.2) years, there were 6.1% (n = 45) dislocations, in which 82% (first dislocation) appeared within the first 30 postoperative days, and 51% (n = 23) of the dislocations requiring subsequent surgery. At the time of the last available follow-up, 57% (n = 421) of the patients were dead. A non-dislocation related revision was needed in 3.4% (n = 25) of the patients [in which infection accounted for 40% (n = 10) and traumatic periprosthetic fracture for 32% (n = 8)]. Thirty-day mortality was 9.2% and 1-year mortality 25.8%. There were no differences in patient's age, gender, or educational level of the surgeon between the dislocation and the no dislocation groups. Patients aged < 70 years presented with a higher dislocation rate (p < 0.001) than the patients aged > 70 years.

CONCLUSION

Primary HA presents a safe and robust approach with acceptable complication rates in a genuine unselected cohort of displaced FNF, particularly for patients aged > 70.

Mobilisation and physiotherapy intervention following hip fracture: snapshot survey across six countries from the Fragility Fracture Network Physiotherapy Group

PURPOSE

Hip fracture guidelines recommend early mobilisation, multidisciplinary care, physiotherapy and fall prevention interventions. This study documents mobilisation practices and physiotherapy interventions provided post-hip fracture in six countries.

MATERIALS AND METHODS

Physiotherapists from orthopaedic wards in Denmark, Australia, Spain, Brazil, Norway and Ireland provided information regarding mobilisation and physiotherapy for 10 consecutive hip fracture patients (>60 years), between 2014 and 2018.

RESULTS

Physiotherapists (n = 107) entered data on 426 patients. Two-thirds of patients (283, 66%) attempted standing 0-1 days after surgery (range: 0% of patients in Spain to 92% in Norway). Fewer patients (199, 47%) attempted walking on day 0-1 (range: 0% Spain/Brazil to 69% Norway). Physiotherapy to mobilise every weekday was provided to 356 patients (84%, range: 60% Ireland to 100% Spain). On weekends, physiotherapy to mobilise was limited (175, 40%, range: 0% Spain to 81% Brazil) but 298 patients (70%) mobilised with non-physiotherapy staff (range: 0% Spain to 96% Denmark/Ireland). Physiotherapy treatments included mobility, gait training, and range-of-motion exercises. Referral to fall prevention interventions was low (93, 22%, range: 0% Spain to 76% Ireland).

CONCLUSION

Stronger compliance with guideline recommendations on early mobilising, weekend mobilising and referral to fall prevention interventions post hip-fracture is needed in some countries.Implications for rehabilitation This study provides a snapshot of mobilisation and physiotherapy practice for hip fracture patients in six countries. The results suggest a need to improve systems and approaches in some countries to enhance compliance with recommendations specifically relating to: • early attempts at standing and walking post-surgery. • opportunities to mobilise on weekends (with physiotherapist and/or other staff). • broader range of multidisciplinary care e.g., geriatric review, occupational therapy and nutrition advice. • use of standardised tests by physiotherapists post-surgery. • referral to fall prevention interventions.

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.

Corrigendum: Risk of reoperation due to surgical site infection in 74,771 hip fracture patients: a Danish nationwide cohort study

Corrigendum of Acta Orthop 2022; 93: 760-766. doi: https://doi.org/10.2340/17453674.2022.4580.

Alliance for the development of the Argentinian Hip Fracture Registry

Age expectancy has significantly increased over the last 50 years, as well as some age-related health conditions such as hip fractures. The development of hip fracture registries has shown enhanced patient outcomes through quality improvement strategies. The development of the Argentinian Hip Fracture Registry is going in the same direction.

INTRODUCTION

Age expectancy has increased worldwide in the last 50 years, with the population over 64 growing from 4.9 to 9.1%. As fractures are an important problem in this age group, specific approaches such as hip fracture registries (HFR) are needed. Our aim is to communicate the Argentinian HFR (AHFR) development resulting from an alliance between Fundación Trauma, Fundación Navarro Viola, and the Argentinian Network of Hip Fracture in the elderly.

METHODS

Between October 2020 and May 2021, an iterative consensus process involving 5 specialty-focused meetings and 8 general meetings with more than 20 specialists was conducted. This process comprised inclusion criteria definitions, dataset proposals, website deployment with data protection and user validation, the definition of hospital-adjusted registry levels, implementation planning, and sustainability strategies.

RESULTS

By June 2021, we were able to (1) outline data fields, including epidemiological, clinical, and functional dimensions for the pre-admission, hospitalization, discharge, and follow-up stages; (2) define three levels: basic (53 fields), intermediate (85), and advanced (99); (3) identify 21 benchmarking indicators; and (4) make a correlation scheme among fracture classifications. Simultaneously, we launched a fundraising campaign to implement the AHFR in 30 centers, having completed 18.

CONCLUSION

AHFR development was based on four pillars: (1) representativeness and support, (2) solid definitions from onset, (3) committed teams, and (4) stable funding. This tool may contribute to the design of evidence-based health policies to improve patient outcomes, and we hope this experience will help other LMICs to develop their own tailored-to-their-needs registries.

Postoperative complications, mortality, and quality of in-hospital care among hip fracture patients with Parkinson's disease

AIM

The aim of this study was to investigate the association between Parkinson's disease (PD) and postoperative complications, mortality, and quality of in-hospital care in patients with hip fracture.

METHODS

We included patients aged 65+ years with an incident hip fracture from 2004-2017, registered in the Danish Multidisciplinary Hip Fracture Registry. Patients with PD were identified using diagnosis codes prior to hip fracture. Using log-binomial regression, we calculated both 30-day crude and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) for the following outcomes: any hospital-treated infections, pneumonia, urinary tract infection, sepsis, community-treated infections, cardiovascular events, mortality, and fulfilment of quality indicators of in-hospital care. Analyses were adjusted for age, sex and Charlson comorbidity index score.

RESULTS

We identified 77,550 hip fracture patients of which 1,915 had PD. Compared to non-PD, patients with PD had higher risk of any hospital-treated - (aRR = 1.27 (CI: 1.10-1.45) and community-treated infection (aRR = 1.22 (CI: 1.13-1.32)), pneumonia (aRR = 1.38 (1.11-1.69)), urinary tract infection (aRR of 1.58 (CI: 1.28-1.92)) and sepsis (aRR = 1.18 (CI: 0.67-1.89)), but a reduced risk of cardiovascular events (aRR = 0.59 (CI: 0.41-0.82)). The aRR for 30-day mortality was 1.11 (CI: 0.97-1.27) for PD vs non-PD patients, and the aHR for 1-year mortality was 1.19 (CI: 1.09-1.30). The aRRs for fulfillment of all relevant quality indicators was about 1 for PD vs non-PD patients.

CONCLUSION

Hip fracture patients with PD have a higher risk of infections and mortality within 30 days after surgery after adjustment for sex, age, and comorbidity. They do, however, receive comparable quality of in-hospital care after hip fracture compared to non-PD patients.

Changing trends in hip fracture epidemiology in the Republic of Ireland: a follow-up study

A national, population-based study of hip fracture epidemiology is reported following a previously published study for the same population to ascertain the accuracy of projected incidence rates. Results suggest a decline in age-specific incidence rates in females but not males, and an over-estimation of same in the previously reported projections.

PURPOSE

Accurate estimates of hip fracture numbers and incidence rates are necessary for health service resource planning. A study in 2009 estimated projected figures for 2016 and 2026, for the Republic of Ireland. The purpose of the current study was to scrutinize these projections, based upon actual population and fracture statistics for the year 2016.

METHODS

Population data was obtained from the Central Statistics Office, and hip fracture data was obtained from the National HIPE Database for the year 2016, using similar search criteria to the previously published study. Hip fracture numbers and incidence rates were calculated. The calculated figures were compared to projected figures from the previous report.

RESULTS

Population projection models used in the 2009 paper accurately reflected the 2016 Irish population. For younger age groups, projected number of fractures closely estimated actual numbers, however, for those over 70 years of age, hip fracture projections overestimated the actual fracture numbers observed. There was a significant difference in the age-specific hip fracture rates in the over 70 s sub-groups compared to the published results of the 2009 study.

CONCLUSIONS

Hip fracture numbers continue to increase, though the age-specific incidence rates in the Republic of Ireland are reducing in the older age groups. The previously published study over-estimated hip fracture projections for the year 2016 (and potentially 2026) due to a false assumption of a stable age-specific incidence rate in the Republic of Ireland, which is in fact reducing.

Comorbidity and Quality of In-Hospital Care for Hip Fracture Patients

OBJECTIVES

We examined whether the comorbidity burden of patients with hip fracture was associated with quality of in-hospital care reflected by fulfillment of process performance measures.

DESIGN

Population-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry (DMHFR).

SETTING AND PARTICIPANTS

Patients aged 65 years or older with an incident hip fracture from 2014 to 2018 registered in the DMHFR (n = 31,443).

METHODS

Comorbidity was measured using the Charlson Comorbidity Index based on hospital diagnoses. Quality of in-hospital care was defined as fulfillment of eligible process performance measures, including preoperative optimization, early surgery, early mobilization, pain assessment, basic mobility, nutritional risk, need for anti-osteoporotic medication, fall prevention, and a post-discharge rehabilitation program, reflecting guideline-recommended in-hospital care. The outcomes were (1) an all-or-none composite measure defined as fulfillment of all relevant process performance measures, and (2) fulfillment of the individual process performance measures. Using binary regression, we calculated relative risk (RR) for the association between comorbidity level and outcomes.

RESULTS

The overall proportion of patients with hip fracture who fulfilled the all-or-none measure was 31%. Among patients with no comorbidity, 34% fulfilled the all-or-none measure versus 29% among patients with high comorbidity (Charlson ≥ 3). This corresponds to a 15% lower chance (RR = 0.85, 95% confidence interval 0.81-0.89). Increasing comorbidity was also associated with lower fulfillment of the individual process performance measures. The largest difference was seen for preoperative optimization, early surgery, and early mobilization, where patients with high comorbidity had 6% to 11% lower chance of fulfillment of these process performance measures compared with patients without comorbidity.

CONCLUSION AND IMPLICATIONS

Increasing level of comorbidity was associated with lower quality of in-hospital care among patients with hip fracture. Our results highlight the need for tailored clinical initiatives to ensure that comorbid patients also benefit from the positive progress in hip fracture care in recent years.

Prediction Ability of Charlson, Elixhauser, and Rx-Risk Comorbidity Indices for Mortality in Patients with Hip Fracture. A Danish Population-Based Cohort Study from 2014 – 2018

Objective

Methods

Results

Conclusion

Development and validation of a model for predicting mortality in patients with hip fracture

OBJECTIVE

to develop a user-friendly prediction tool of 1-year mortality for patients with hip fracture, in order to guide clinicians and patients on appropriate targeted preventive measures.

DESIGN

population-based cohort study from 2011 to 2017 using nationwide data from the Danish Hip Fracture Registry.

SUBJECTS

a total of 28,791 patients age 65 and above undergoing surgery for a first-time hip fracture.

METHODS

patient-related prognostic factors at the time of admission were assessed as potential predictors: Nursing home residency, comorbidity (Charlson Comorbidity Index [CCI] Score), frailty (Hospital Frailty Risk Score), basic mobility (Cumulated Ambulation Score), atrial fibrillation, fracture type, body mass index (BMI), age and sex. Association with 1-year mortality examined by determining the cumulative incidence, applying univariable logistic regression and assessing discrimination (area under the receiver operating characteristics curve [AUROC]). The final model (logistic regression) was utilised on a development cohort (70% of patients). Discrimination and calibration were assessed on the validation cohort (remaining 30% of patients).

RESULTS

all predictors showed an association with 1-year mortality, but discrimination was moderate. The final model included nursing home residency, CCI Score, Cumulated Ambulation Score, BMI and age. It had an acceptable discrimination (AUROC 0.74) and calibration, and predicted 1-year mortality risk spanning from 5 to 91% depending on the combination of predictors in the individual patient.

CONCLUSIONS

using information obtainable at the time of admission, 1-year mortality among patients with hip fracture can be predicted. We present a user-friendly chart for daily clinical practice and provide new insight regarding the interplay between prognostic factors.

Risk of mortality and reoperation in hip fracture patients undergoing cemented versus uncemented hemiarthroplasty : a population-based study from Danish National Registries

AIMS

The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years.

METHODS

This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs).

RESULTS

A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83).

CONCLUSION

In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127-133.

Patient-related healthcare disparities in the quality of acute hip fracture care: a 10-year nationwide population-based cohort study

OBJECTIVES

To characterise and quantify possible patient-related disparities in hip fracture care including temporal changes.

DESIGN

Population-based cohort study.

SETTING

All Danish hospitals treating patients with hip fracture.

PARTICIPANTS

60 275 hip fracture patients from 2007 to 2016.

INTERVENTIONS

Quality of care was defined as fulfilment of eligible care process measures for the individual patient recommended by an expert panel. Using yearly logistic regression models, we predicted the individual patient's probability for receiving high-quality care, resulting in a distribution of adjusted probabilities based on age, sex, comorbidity, fracture type, education, family mean income, migration status, cohabitation status, employment status, nursing home residence and type of municipality. Based on the distribution, we identified best-off patients (ie, the 10% of patients with the highest probability) and worst-off patients (ie, the 10% of patients with the lowest probability). We evaluated disparities in quality of care by measuring the distance in fulfilment of outcomes between the best-off and worst-off patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was fulfilment of all-or-none, defined as receiving all relevant process measures. Secondary outcomes were fulfilment of the individual process measures including preoperative optimisation, early surgery, early mobilisation, assessment of pain, basic mobility, nutritional risk and need for antiosteoporotic medication, fall prevention and a postdischarge rehabilitation programme.

RESULTS

The proportion of patients receiving high-quality care varied over time for both best-off and worst-off patients. The absolute difference in percentage points between the best-off and worst-off patients for receiving all-or-none of the eligible process measures was 12 (95% CI 6 to 18) in 2007 and 23 (95% CI 19 to 28) in 2016. Disparities were consistent for a range of care processes, including assessment of pain, mobilisation within 24 hours, assessment of need for antiosteoporotic medication and nutritional risk assessment.

CONCLUSIONS

Disparity of care between best-off and worst-off patients remained substantial over time.

Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?: A Multicenter Cohort Study

BACKGROUND

The purpose of the present multicenter cohort study was to compare the rates of reoperation in elderly patients with pertrochanteric and subtrochanteric fractures that had been treated with a short or long intramedullary nail.

METHODS

Eleven orthopaedic departments across Denmark delivered data that had been obtained from the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and a review of health-care records. With use of surgical procedure codes for pertrochanteric and subtrochanteric fractures that had been treated with an intramedullary nail, the DMRHF was searched to identify patients who had been ≥65 years of age between 2008 and 2013. The health-care records for patients who had had major reoperations, defined as any reoperation with the exclusion of simple hardware removal, were retrieved from the DMHFR, were reviewed for the type of intramedullary nail and missed reoperations, including peri-implant fractures, within 2 years of follow-up. Crude logistic regression analysis with adjustment for age, sex, and comorbidity was performed, yielding odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 2,245 pertrochanteric fractures, 1,867 were treated with a short intramedullary nail and 378 were treated with a long intramedullary nail. The rate of major reoperations was 4.0% in the short intramedullary nail group and 6.3% in the long intramedullary nail group. This yielded a crude OR of 1.61 (1.01 to 2.60) and an adjusted OR of 1.67 (1.04 to 2.70). Of 909 subtrochanteric fractures, 308 were treated with a short intramedullary nail and 601 were treated with a long intramedullary nail. The rate of major reoperations was 8.4% in the short intramedullary nail group and 4.0% in the long intramedullary nail group, yielding a crude OR of 0.45 (0.25 to 0.80) and an adjusted OR of 0.45 (0.25 to 0.81).

CONCLUSIONS

This is the first study confirming the theory that, for subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail. In contrast, a short intramedullary nail has a lower rate of major reoperations compared with a long intramedullary nail for pertrochanteric fractures but with a lower absolute risk reduction compared with the results for subtrochanteric intramedullary nailing. There is a need for validation of these results in other large studies, especially for pertrochanteric fractures.

LEVEL OF EVIDENCE

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

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.

Differences in hip fracture care in Europe: a systematic review of recent annual reports of hip fracture registries

PURPOSE

Hip fractures are of growing interest due to their increasing number, subsequent functional decline and high institutionalization rate of patients, mortality, and costs. Several process measurements are essential for hip fracture care. To compare and improve these, hip fracture registries in Europe became popular. This systematic review aims to describe the differences between hip fracture registries in Europe as well as the differences in hip fracture treatment between countries.

METHODS

A systematic search using the keywords "hip fracture" AND "national" AND "database OR audit OR registry OR register" was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines till 3rd December 2020. Recent annual reports of identified hip fracture registries in Europe were additionally identified in June 2021. Comparisons of most common case-mix, process and outcome measurements were performed.

RESULTS

11 registries in Europe were identified. Differences were observed regarding inclusion criteria of the different registries. Comparison of the different registries was difficult due to differences in the way to report measurements. While mortality rates differed substantially between countries, most of the process measurements met recommendations according to recent guidelines.

CONCLUSION

Hip fracture registries were a valid tool to compare hospitals within one country. However, a comparison between registries of different countries should have also been easily possible. For this, the registries need to make their data easily accessible and further unify their way of measuring and reporting.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Loss of pre-fracture basic mobility status at hospital discharge for hip fracture is associated with 30-day post-discharge risk of infections - a four-year nationwide cohort study of 23,309 Danish patients

BACKGROUND

The loss of pre-fracture basic mobility status is associated with increased mortality and any readmission after hip fracture. However, it is less known if the loss of pre-fracture mobility has impact on acquiring a post-discharge infection.

PURPOSE

To examine if the loss of pre-fracture basic mobility status at hospital discharge was associated with hospital-treated or community-treated infections within 30-days of hospital discharge after hip fracture.

METHODS

Using the nationwide Danish Multidisciplinary Hip Fracture Registry from January 2014 through November 2017, we included 23,309 patients undergoing surgery for a first-time hip fracture. The Cumulated Ambulation Score (CAS, 0-6 points) was recorded using questionnaire at admission (pre-fracture CAS) and objectively assessed at discharge. The loss of any CAS-points at discharge compared with pre-fracture CAS was calculated and dichotomized (yes/no). Using Cox regression analyses, we estimated the hazard ratio (HR) with 95% confidence interval (CI) of any hospital-treated infection, hospital-treated pneumonia or community-treated infection adjusted for sex, age, body mass index, Charlson Comorbidity Index, residential status, type of fracture, and length of hospital stay (LOS).

RESULTS

Total of 12,046 (62%) patients lost their pre-fracture CAS status at discharge. Among patients who had lost their pre-fracture CAS, 6.0% developed a hospital-treated infection compared to 4% of those who did not lose their pre-fracture CAS. Correspondingly, 9.2% versus 6.2% developed a community-treated infection. The risk of 30-day post-discharge infection increased with increasing loss of any CAS points. The adjusted HRs for patients who had lost their pre-fracture CAS status, compared to patients who did not, was 1.34 (CI: 1.16-1.54) for hospital-treated infection, 1.35 (CI: 1.09 - 1.67) for pneumonia and 1.36 (CI: 1.21-1.52) for community-treated infection.

CONCLUSION

In this large national cohort study, we found that loss of pre-fracture basic mobility status upon hospital discharge was strongly associated with 30-day post-discharge risk of developing infection. These findings suggest a clinical importance of carefully focusing on regaining the pre-fracture basic mobility before discharging the patient.

Hospital variation in the risk of infection after hip fracture surgery: a population-based cohort study including 29,598 patients from 2012-2017

Background and purpose - Understanding the key drivers of hospital variation in postoperative infections after hip fracture surgery is important for directing quality improvements. Therefore, we investigated variation in the risk of any infection, and subgroups of infections including pneumonia and sepsis after hip fracture surgery.Methods - In this nationwide population-based cohort study, all Danish patients aged ≥ 65 undergoing surgery for an incident hip fracture from 2012 to 2017 were included. Risk of postoperative infections, based on data from hospital registration (hospital-treated infections) and antibiotic dispensing (community-treated infections), were calculated using multilevel Poisson regression analysis. Hospital variation was evaluated by intra-class coefficient (ICC) and median risk ratio (MRR).Results - The risk of hospital-treated infection was 15%. The risk of community-treated infection was 24%. The adjusted risk varied between hospitals from 7.8-25% for hospital-treated infection and 16-34% for community-treated infection. The ICC indicated that 19% of the adjusted variance was due to hospital level for hospital-treated infection. The ICC for community-treated infections was 13%. The MRR showed a 2-fold increased risk for the average patient acquiring a hospital-treated infection at the highest risk hospital compared with the lowest risk hospital. For community-treated infection, the MRR was 1.4.Interpretation - Our results suggest that 20% of infections could be reduced by applying the top performing hospitals' approach. Nearly a 5th of the variation was at the hospital level. This suggests a more standardized approach to avoid postoperative infection after hip fracture surgery.Hip fracture is a leading cause of hospital admission among the elderly. The 30-day mortality following hip fracture surgery has been approximately 10% during the last few years in Denmark (Pedersen et al. 2017). Higher mortality after hip fracture has been associated with a range of hospital factors (Kristensen et al. 2016, Sheehan et al. 2016) and patient factors in observational studies (Roche et al. 2005). Furthermore, variation in 30-day mortality after hip fracture surgery has been observed between Danish hospitals, but not fully explained (Kristensen et al. 2019).

Is tranexamic acid use in patients with a hip fracture safe?

AIMS

To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events.

METHODS

This is a consecutive cohort study with prospectively collected registry data. Patients with a hip fracture in the Region of Southern Denmark were included over a two-year time period (2015 to 2017) with the first year constituting a control group. In the second year, perioperative TXA was introduced as an intervention. Outcome was transfusion frequency, 30-day and 90-day mortality, and thromboembolic events. The latter was defined as any diagnosis or death due to arterial or venous thrombosis. The results are presented as relative risk (RR) and hazard ratio (HR) with 95% confidence intervals (CIs).

RESULTS

A total of 3,097 patients were included: 1,558 in the control group and 1,539 in the TXA group.31% (n = 477) of patients had transfusions in the control group compared to 27% (n = 405) in the TXA group yielding an adjusted RR of 0.83 (95% CI 0.75 to 0.91). TXA was not associated with increased 30-day mortality with an adjusted HR of 1.10 (95% CI 0.88 to 1.39) compared to the control group as well as no association with increased risk of 90-day mortality with a per protocol adjusted HR of 1.24 (95% CI 0.93 to 1.66). TXA was associated with a lower risk of thromboembolic events after 30 days (RR 0.63 (95% CI 0.42 to 0.93)) and 90 days (RR 0.72 (95% CI 0.52 to 0.99)). A subanalysis on haemoglobin demonstrated a median 17.7 g/L (interquartile range (IQR) 11.3 to 27.3) decrease in the control group compared to 17.7 g/L (IQR 9.7 to 25.8) in the per protocol TXA group (p = 0.060 on group level difference).

CONCLUSION

TXA use in patients with a hip fracture, was not associated with an increased risk of mortality but was associated with lower transfusion rate and reduced thromboembolic events. Thus, we conclude that it is safe to use TXA in this patient group. Cite this article: Bone Joint J 2021;103-B(3):449-455.

Risk factors for new chronic opioid use after hip fracture surgery: a Danish nationwide cohort study from 2005 to 2016 using the Danish multidisciplinary hip fracture registry

OBJECTIVE

To examine the risk factors for new chronic opioid use in elderly patients who underwent hip fracture surgery.

DESIGN

Prospective population-based cohort study.

SETTING AND PARTICIPANTS

Using Danish nationwide health registries, we identified all opioid non-user patients aged ≥65 years who had undergone hip fracture surgery from 2005 to 2016 and were alive within the first year following surgery.

MAIN OUTCOME MEASURES

New chronic opioid use defined by the dispensing of at least two prescription opioids within two of the last three quarters during the first year following surgery.

RESULTS

We identified 37 202 opioid non-user patients who underwent hip fracture surgery. Of these, 5497 (15%) developed new chronic opioid user within 1 year of surgery. Risk factors for new chronic opioid use were Body Mass Index (BMI) of <18.5 (adjusted OR (aOR) 1.22, 95% CI 1.09 to 1.36), BMI of 25.0-29.9 (aOR 1.12, 95% CI 1.04 to 1.21) and BMI of ≥30 (aOR 1.57, 95% CI 1.40 to 1.76) with BMI 18.6-24.9 as reference, a pertrochanteric/subtrochanteric fracture (aOR 1.27, 95% CI 1.20 to 1.34) with femoral neck fracture as reference, preoperative use (vs no-use) of non-steroidal anti-inflammatory drug (aOR 1.68, 95% CI 1.55 to 1.83), selective serotonin reuptake inhibitor (aOR 1.42, 95% CI 1.32 to 1.53), antidepressants (aOR 1.36, 95% CI 1.24 to 1.49), antipsychotics (aOR 1.21, 95% CI 1.07 to 1.35), corticosteroids (aOR 1.54, 95% CI 1.35 to 1.76), statins (aOR 1.09, 95% CI 1.02 to 1.18), antibiotics (aOR 1.32, 95% CI 1.22 to 1.42), antiosteoporosis drugs (aOR 1.33, 95% CI 1.19 to 1.49) and anticoagulatives (aOR 1.24, 95% CI 1.17 to 1.32). Presence of cardiovascular comorbidities, diabetes, gastrointestinal diseases, dementia, chronic obstructive pulmonary disease or renal diseases was further identified as a risk factor.

CONCLUSION

In this large nationwide cohort study, we identified several risk factors associated with new chronic opioid use after hip fracture surgery among patients who were alive within the first year following surgery. Although not all factors are modifiable preoperative, this will allow clinicians to appropriately counsel patients preoperatively and tailor postoperative treatment.

The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients

Objectives Long-term opioid use after hip fracture surgery has been demonstrated in previously opioid-naïve elderly patients. It is unknown if the opioid type redeemed after hip surgery is associated with long-term opioid use. The aim of this study was to examine the association between the opioid type redeemed within the first three months after hip fracture surgery and opioid use 3-12 months after the surgery. Methods A nationwide population-based cohort study was conducted using data from Danish health registries (2005-2015). Previously opioid-naïve patients registered in the Danish Multidisciplinary Hip Fracture Registry, aged ≥65 years, who redeemed ≥1 opioid prescription within three months after the surgery, were included. Long-term opioid use was defined as ≥1 redeemed prescription within each of three three-month periods within the year after hip fracture surgery. The proportion with long-term opioid use after surgery, conditioned on nine-month survival, was calculated according to opioid types within three months after surgery. Adjusted odds ratios (aOR) for different opioid types were computed by logistic regression analyses with 95% confidence intervals (CI) using morphine as reference. Subgroup analyses were performed according to age, comorbidity and calendar time before and after 2010. Results The study included 26,790 elderly, opioid-naïve patients with opioid use within three months after hip fracture surgery. Of these patients, 21% died within nine months after the surgery. Among the 21,255 patients alive nine months after surgery, 15% became long-term opioid users. Certain opioid types used within the first three months after surgery were associated with long-term opioid use compared to morphine (9%), including oxycodone (14%, aOR; 1.76, 95% CI 1.52-2.03), fentanyl (29%, aOR; 4.37, 95% CI 3.12-6.12), codeine (13%, aOR; 1.55, 95% CI 1.14-2.09), tramadol (13%, aOR; 1.56, 95% CI 1.35-1.80), buprenorphine (33%, aOR; 5.37, 95% CI 4.14-6.94), and >1 opioid type (27%, aOR; 3.83, 95% CI 3.31-4.44). The proportion of long-term opioid users decreased from 18% before 2010 to 13% after 2010. Conclusions The findings suggest that use of certain opioid types after hip fracture surgery is more associated with long-term opioid use than morphine and the proportion initiating long-term opioid use decreased after 2010. The findings suggest that some elderly, opioid-naïve patients appear to be presented with untreated pain conditions when seen in the hospital for a hip fracture surgery. Decisions regarding the opioid type prescribed after hospitalization for hip fracture surgery may be linked to different indication for pain treatment, emphasizing the likelihood of careful and conscientious opioid prescribing behavior.

Association of CHA2 DS2 -VASc Score with Stroke, Thromboembolism, and Death in Hip Fracture Patients

OBJECTIVES

Patients undergoing hip fracture surgery have a 10 times increased risk of stroke compared with the general population. We aimed to evaluate the association between the CHA₂ DS₂ -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke/TIA [transient ischemic attack]/systemic embolism (2 points), vascular disease, age 65-74 years, and female sex) score and the risk of stroke, thromboembolism, and all-cause mortality in patients with hip fracture with or without atrial fibrillation (AF).

DESIGN

Nationwide prospective cohort study.

SETTING

Danish hospitals.

PARTICIPANTS

Subjects were all incident hip fracture patients in Denmark age 65 years and older with surgical repair procedures between 2004 and 2016 (n = 78,096). Participants were identified using the Danish Multidisciplinary Hip Fracture Registry.

MEASUREMENTS

We calculated incidence rates, cumulative incidences, and hazard ratios (HRs) with 95% confidence intervals (CIs) by CHA₂ DS₂ -VASc score, stratified on AF history.

RESULTS

The cumulative incidence of ischemic stroke 1 year after hip fracture increased with ascending CHA₂ DS₂ -VASc score, and it was 1.9% for patients with a score of 1 and 8.6% for patients with a score above 5 in the AF group. Corresponding incidences in the non-AF group were 1.6% and 7.6%. Compared with a CHA₂ DS₂ -VASc score of 1, adjusted HRs were 5.53 (95% CI = 1.37-22.24) among AF patients and 4.91 (95% CI = 3.40-7.10) among non-AF patients with a score above 5. A dose-response-like association was observed for all cardiovascular outcomes. All-cause mortality risks and HRs were substantially higher for all CHA₂ DS₂ -VASc scores above 1 in both the AF group and the non-AF group.

CONCLUSION

Among patients with hip fracture, a higher CHA₂ DS₂ -VASc score was associated with increased risk of stroke, thromboembolism, and death. This finding applied both to patients with and without AF. Patients with high CHA₂ DS₂ -VASc scores had almost similar absolute risks for cardiovascular outcomes, irrespective of AF. J Am Geriatr Soc 68:1698-1705, 2020.

The Positive Predictive Value of Hip Fracture Diagnoses and Surgical Procedure Codes in the Danish Multidisciplinary Hip Fracture Registry and the Danish National Patient Registry

Aim

The health-care databases may be a valuable source for epidemiological research in hip fracture surgery, if the diagnoses are valid. We examined the validity of hip fracture diagnoses and surgical procedure codes in the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and the Danish National Patient Registry (DNPR) by calculating the positive predictive value (PPV).

Methods

We identified a random sample of 750 hip fracture patients registered in the DMHFR between 2014 and 2017. Diagnoses have been coded by the 10^th revision of the International Classification of Diseases, while procedures have been coded by the Nordic Medico-Statistical Committee classification in the DNPR and directly transferred to the DMHFR. Using the surgical procedure description from the medical record as gold standard, we estimated the PPV of the hip fracture diagnoses and surgical procedure codes in the DMHFR and the DNPR with 95% confidence interval (CIs).

Results

The PPV was 90% (95% CI: 86%-93%) for fracture of the neck of femur, 92% (95% CI: 87%-95%) for trochanteric fracture, and 83% (95% CI: 78%-88%) for subtrochanteric fracture. Joining trochanteric and subtrochanteric fracture resulted in a PPV of 97% (95% CI: 95%-98%). Procedure codes had a PPV of 100% for primary prosthetic replacement and internal fixation with intramedullary nail, 96% (95% CI: 85%-99%) for internal fixation using screws alone, 91% (95% CI: 84%-96%) for internal fixation using plates and screws, and 89% (95% CI: 83%-94%) for internal fixation with other or combined methods. Stratifying by age group, gender, hospital type and calendar year of surgery showed similar results as the overall PPV estimates.

Conclusion

Our findings indicate a high quality of the hip fracture diagnoses and corresponding procedure codes in the DMHFR and the DNPR, with a majority of PPVs above 90%. Thus, the DMHFR and the DNPR are a valuable data source on hip fracture for epidemiological research.