Difference in Mortality Rate by Type of Anticoagulant in Elderly Patients with Cardiovascular Disease after Hip Fractures

Five states of reduction in OTA/AO A1.3 intertrochanteric fractures of the femur a biomechanical study

OBJECTIVE

This study aims to analyze the differences in mechanical stability of OTA/AO 31A1.3 intertrochanteric fractures under various reduction conditions.

METHODS

Twenty standard synbone artificial femur test bones were selected for the OTA/AO 31A1.3 intertrochanteric fracture model. The models were divided into five groups according to their reduction state: positive support, neutral support, negative support, varus fixation, and valgus fixation, with four specimens in each group. All models were fixed using PFNA intramedullary fixation and subjected to static axial compression tests. The subsidence displacement of the proximal femur under different loads and the axial stiffness of the model were measured to verify the mechanical stability of the OTA/AO 31A1.3 intertrochanteric fracture under different reduction conditions.

RESULTS

After the static axial compression test, the proximal femoral subsidence displacement in the positive support and neutral support groups was lower than that in the negative support, valgus fixation, and varus fixation groups (p < 0.001). The axial stiffness of the model was highest in the positive support group. Significant differences in subsidence displacement and axial stiffness were found between the groups (p < 0.001). The positive support group demonstrated the best mechanical stability, while the varus fixation group showed the poorest performance.

CONCLUSION

Positive support of the medial cortex can be regarded as the best reduction state for OTA/AO 31A1.3 intertrochanteric fractures, suggesting that this approach should be preferred during surgery to enhance mechanical stability and improve clinical outcomes. Conversely, varus fixation should be avoided due to its inferior stability.

Effect of Chronic Kidney Disease on All-Cause Mortality After Hip Fracture Surgery: A Retrospective Cohort Study

In this retrospective cohort study, we investigated: (1) The impact of comorbid chronic kidney disease (CKD) on postoperative mortality in patients with a hip fracture; (2) mortality variations by dialysis type, potentially indicating CKD stage; (3) the efficacy of different hip fracture surgical methods in reducing mortality for patients with CKD. This study included 25,760 patients from the Korean National Health Insurance Service-Senior cohort (2002-2019) who underwent hip fracture surgery. Participants were categorized as CKD and Non-CKD. Mortality rate was determined using a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) through a Cox proportional-hazard model. During follow-up, we ascertained that 978 patients (3.8%) had CKD preoperatively. Compared to the Non-CKD group, the mortality risk (HR) in the CKD group was 2.17 times higher (95% confidence interval [CI], 1.99-2.37). In sensitivity analysis, the mortality risk of in patients who received peritoneal dialysis and hemodialysis was 6.21 (95% CI, 3.90-9.87) and 3.62 times (95% CI, 3.11-4.20) higher than that of patients who received conservative care. Mortality risk varied by surgical method: hip hemiarthroplasty (HR, 2.11; 95% CI, 1.86-2.40), open reduction and internal fixation (HR, 2.21; 95% CI, 1.94-2.51), total hip replacement (HR, 2.27; 95% CI, 1.60-3.24), and closed reduction and percutaneous fixation (HR, 3.08; 95% CI, 1.88-5.06). Older patients with CKD undergoing hip fracture surgery had elevated mortality risk, necessitating comprehensive pre- and postoperative assessments and management.

The Rising Problem of Hip Fractures in Geriatric Patients-Analysis of Surgical Influences on the Outcome

BACKGROUND

Hip fractures in geriatric patients often have a poor outcome in terms of mortality, mobility as well as independence. Different surgical influence factors are known that improve the outcome.

METHODS

In this observational cohort study, 281 patients of a geriatric trauma unit were analyzed prospectively. Demographic factors, as well as data regarding the trauma mechanism and perioperative treatment, were recorded. The nutritional status was also analyzed. The follow-up was set to 120 days.

RESULTS

The key conclusion of this study is that a high ASA classification, the use of anticoagulatory medicine and malnutrition are significantly associated with higher mortality together with worse independence (p < 0.05). There is no significant difference in outcome concerning the time to surgery within the first 24 h.

CONCLUSIONS

Malnutrition seems to be an important risk factor for an adverse outcome of geriatric patients and therefore warrants a focus in multidisciplinary treatment. The risk factor ASA cannot be improved during the pre-surgery phase, but requires intensified care by a multidisciplinary team specialized in orthogeriatrics.

Influencing factors on morbidity and mortality in intertrochanteric fractures

We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.

Hip arthroplasty for patients with chronic renal failure on dialysis

An increasing number of chronic renal failure patients are experiencing hip joint disorders. This study aimed to analyze the outcomes of hip arthroplasty in chronic renal failure patients undergoing dialysis. Of 2364 hips that underwent hip arthroplasty during 2003-2017, 37 were retrospectively examined. Radiological and clinical outcomes of hip arthroplasty, and development of local and general complications during follow-up and their associations with dialysis duration were analyzed. The mean patient age, follow-up duration, and bone mineral density T-score were 60.6 years, 36.6 months, and - 2.62, respectively. Osteoporosis was noted in 20 cases. Most patients who underwent total hip arthroplasty with a cementless acetabular cup implant exhibited excellent radiological outcomes. There were no changes in femoral stem alignment, subsidence, osteolysis, and loosening. Thirty-three patients had an excellent or good Harris hip score. Complications developed in 18 patients within 1 year postoperatively. General complications developed in 12 patients at > 1 year postoperatively; no patient experienced local complications. In conclusion, hip arthroplasty for chronic renal failure patients on dialysis yielded excellent radiological and satisfactory clinical outcomes but may be associated with postoperative complications. Careful preoperative treatment planning and overall postoperative management are required to reduce the complication risk.

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.

Effect Modification on Death by Age and Sex in Elderly Hip Fracture

BACKGROUND

This study compared the effects of hip fractures on mortality according to sex and age in a nationwide cohort of elderly patients with hip fractures and controls.

METHODS

Patients with hip fractures and matched controls were selected from the National Health Insurance Service-Senior cohort. Time-dependent propensity score matching was estimated from a Cox proportional hazards model with January 1, 2005, as the baseline and hip fracture as an event. Patients were matched by age and sex to participants at risk of developing a hip fracture at time zero. The effect size is presented as hazard ratio (HR) using a Cox proportional hazards model with a robust variance estimator that accounts for clustering within the matched pairs.

RESULTS

Altogether, 14,283 patients with incident hip fractures and 28,566 matched controls were identified. The HR of male sex in hip fractures was 1.31 (95% confidence interval [CI], 1.22-1.40; Pinteraction<0.01). Moreover, the HR of age group in hip fractures was 0.73 (95% CI, 0.66-0.80; Pinteraction<0.01) between the 65 to 74 and 75 to 84 years groups, 0.76 (95% CI, 0.71-0.81; Pinteraction<0.01) between the 75 to 84 and ≥85 years groups, and 0.55 (95% CI, 0.50-0.61; Pinteraction<0.01) between the 65 to 74 and ≥85 years groups.

CONCLUSIONS

Male sex increases the risk of death in elderly patients with hip fractures versus matched controls, but the increased risk of death with age in hip fractures was decreased compared to that in matched controls.

Prevalence of sarcopenia and mortality rate in older adults with hip fracture

BACKGROUND

Several international study groups adopted appendicular skeletal muscle mass (ASM) index adjusted by (1) height squared, (2) weight, and (3) body mass index (BMI) in the diagnosis of sarcopenia. However, different prevalence rates of sarcopenia by each index and clinical implications were not well known. The purpose of this study was to compare the differences in (1) the percentage of sarcopenia in hip fracture patients and (2) the relative mortality rate according to the sarcopenia criteria of three ASM indices.

METHODS

Between January 2009 and December 2020, 1003 older adult hip fracture patients at a tertiary institution were eligible and retrospectively reviewed for this study. Based on the ASM measured on dual-energy X-ray absorptiometry, three indices were calculated, and sarcopenia was diagnosed. The proportion of sarcopenia was evaluated according to each index. One, two, and five-year mortality rates were compared between each sarcopenia group and a normal musculature group, based on ASM criteria.

RESULTS

The proportion of sarcopenia patients differed according to three ASM indices. The proportion of sarcopenic patients by ASM/height² index was higher than those of the other two indices in both male and female hip fracture patients. In male patients, 61% were sarcopenic by ASM/height² index, 37% by ASM/weight index, and 44% by ASM/BMI index. In female patients, 26%, 11%, and 14% were sarcopenic, respectively. Among the three indices, only ASM/height² had significant correlations with all 1-, 2-, and 5-year mortality rates.

CONCLUSIONS AND IMPLICATIONS

The prevalence of sarcopenia in hip fracture patients differed substantially according to ASM indices. Sarcopenic hip fracture patients had a higher mortality rate than those with normal musculature. The 1-year, 2-year, and 5-year mortality rates were discriminated by ASM/height² criteria in both men and women. Future prospective studies in a larger cohort are warranted.

Population-based Analysis for Risk of Suicide Death in Elderly Patients after Osteoporotic Fracture: a Nested Case-Control Study

BACKGROUND

The purpose of study was to investigate the incidence rate of suicide in elderly patients with osteoporotic fractures in a nested case-control model and to analyze the change in the risk of suicide death over time after each osteoporotic fracture.

METHODS

We used the National Health Insurance Service-Senior cohort of South Korea. Suicide cases and controls were matched based on sex and age at the index date. Controls were randomly selected at a 1:5 ratio from the set of individuals who were at risk of becoming a case at the time when suicide cases were selected. Conditional logistic regression analysis was performed to evaluate the association between each type of osteoporotic fracture and the risk of suicide death.

RESULTS

Three thousand seventy suicide cases and 15,350 controls were identified. Patients with hip fracture showed an increased risk of suicide death within 1 year of fracture (adjusted odds ratio [aOR] = 2.64; 95% confidence interval [CI], 1.57-4.46; P < 0.001) compared to controls. However, the increased risk of suicide death in patients with hip fracture lasted up to 2 years (aOR = 1.59; 95% CI, 1.04-2.41; P = 0.031). Spine fracture increased the risk of suicide deaths for all observation periods. There was no evidence that humerus fracture increased the risk of suicide death during the observational period. Radius fracture increased only the risk of suicide death within 2 years of fracture (aOR = 1.43; 95% CI, 0.74-2.77; P = 0.282).

CONCLUSION

There were noticeable differences in both degree and duration of increased suicide risks depending on the type of osteoporotic fracture. Mental stress and suicide risk in elderly patients after osteoporotic fracture should be assessed differently depending on the types of fracture.

Risk factors for subsequent vertebral fractures following a previous hip fracture

INTRODUCTION

The purpose of our study was to evaluate the incidence and to identify risk factors of subsequent vertebral fractures after hip fractures, and to determine whether the subsequent vertebral fracture increases the mortality rate of elderly hip fracture patients.

MATERIALS AND METHODS

From January 2009 to July 2016, 1,554 patients were diagnosed as having a hip fracture and were treated surgically at our institution. Among them, 1121 patients age > 50 years at the time of injury and were followed up for 1 year or longer after the hip fracture surgery. In these patients, radiographs of the hip and spine were taken at each follow-up. We reviewed medical records and radiographs of these patients. Among the 1121 patients, 107 patients (9.5%) had subsequent vertebral fractures after the hip fracture during entire follow-up periods.

RESULTS

In multivariable analysis, previous history of vertebral fracture [odds ratio (OR), 2.62; p < 0.001], medication possession rate (MPR) of osteoporosis treatment < 80% (OR, 1.92; p = 0.014), and a lower lumbar bone mineral density (BMD) (OR, 2.58; p = 0.001) appeared as risk factors for subsequent vertebral fractures.

CONCLUSION

However, the subsequent vertebral fractures did not affect the mortality after the hip fractures. Age ≥ 70 years [hazard ration (HR) 2.70; p = .039], body mass index < 18.5 kg/m² (HR, 2.57; p =0 .048), and Charlson comorbidity index ≥ 2 (HR, 2.04; p =0.036) were risk factors of the death. Timely management is warranted to prevent subsequent vertebral fractures in hip fracture patients with risk factors.

Effect of oral anticoagulant use on surgical delay and mortality in hip fracture

AIMS

Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality).

RESULTS

A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA.

CONCLUSION

Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222-233.

Effect of Pneumonia on All-cause Mortality after Elderly Hip Fracture: a Korean Nationwide Cohort Study

BACKGROUND

The purposes of this study were 1) to investigate the incidence of pneumonia during hospitalization in elderly hip fracture patients, 2) to evaluate the effect of pneumonia on 30 day to 1 year mortality and 3) to analyze the impact of age and gender on the mortality rate in the pneumonia patients using a nationwide cohort of Korea.

METHODS

The Korean National Health Insurance Service (NHIS) database included approximately 5.5 million Korean enrollees > 60 years of age. A total of 588,147 participants were randomly selected for senior cohort using 10% simple random sampling. We identified senile (> 65 years old) patients who underwent hip fracture surgery from January 2005 to December 2014 and those who developed pneumonia during hospitalization from the NHIS-Senior cohort. The index date of hip fracture occurrence was defined as the date of admission to the acute care hospital. The last date of follow-up was defined as the date of death or 31 December 2015, whichever came first. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of pneumonia on all-cause mortality.

RESULTS

During the enrollment period, a total of 14,736 patients, who were older than 65 years, underwent hip fracture surgeries. Among them, 1,629 patients (11.05%) developed pneumonia during the hospitalization. The pneumonia incidence was 16.39% (601/3,666) in men patients and 9.29% (1,028/10,042) in women patients. Compared to 13,107 non-pneumonia patients, adjusted relative risk (aRR) of death in pneumonia patients was 2.69 (95% confidence interval [CI], 2.14-3.38; P < 0.001) within postoperative 30-day, 3.40 (95% CI, 3.01-3.83; P < 0.001) within postoperative 90-day, 2.86 (95% CI, 2.61-3.15; P < 0.001) within postoperative 180-day and 2.31 (95% CI, 2.14-2.50; P < 0.001) within postoperative 1-year. According to patient's age, the aRR of death in pneumonia patients was 5.75 (95% CI, 2.89-11.43) in adults aged < 70 years, 5.14 (95% CI, 4.08-6.46) in those aged 70-79 years, 3.29 (95% CI, 2.81-3.86) in those aged 80-89 years and 2.02 (95% CI, 1.52-2.69) in those aged ≥ 90 years. The aRR was 3.63 (95% CI, 3.01-4.38) in men pneumonia patients, and 3.27 (95% CI, 2.80-3.83) in women pneumonia patients.

CONCLUSION

The prevalence of pneumonia in elderly hip fracture patients was 11.05%. Men had higher incidence (16.39%) than women (9.29%). Compared to non-pneumonia patients, the pneumonia patients had higher 30-day to 1-year mortalities with aRR of 2.31 to 3.40. They had increased mortality in all age groups older than 65 years with aRR of 1.52 to 4.08. Both genders of pneumonia patients had higher risk of mortality (aRR, 3.63 in men and 3.27 in women) compared to non-pneumonia patients.