Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study

PurposeThe COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3–4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture.MethodsA multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for “fragility hip fractures” were included in the study. Patients’ 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27.ResultsA total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865–3.978).ConclusionHip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of “long-COVID” and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.     

Concurrent fractures of the hip and wrist: A matched analysis of elderly patients

Introduction

Osteoporotic fractures involving the hip and wrist are common in the elderly. The incidence of coincident hip and wrist fractures in the same patient is small but may represent a unique subpopulation of elderly with osteoporotic fragility fractures and little information has been published about these patients.

Materials and methods

We performed a retrospective review studying a series of 33 elderly patients who were admitted with concurrent hip and wrist fractures and matched them with patients of similar age, race, gender and co-morbidities with isolated hip fractures analysing their pre-morbid functional status, degree of osteoporosis by the Singh's index, length of stay and re-admission rate.

Results

In our cohort of 33 matched pairs, location of fall in the study group consisted of 21 at home and 26 in the control group. The median duration of stay in hospital was 23 days versus 18 days in the control group. Bone density assessment of our study group revealed 18 patients with severe osteoporosis with Singh's index and 21 severe osteoporosis in the control group. The 1-year re-admission rate for the patients in the study group was 7 and 12 in the control group. Ambulatory status at discharge in the study group was 12 and in the control group 21.

Discussion and conclusion

Our study population demonstrated a higher proportion of community ambulators with fewer 1-year re-admission rates and a high cervical:trochanteric ratio of 2.7, all of which signify that they belong to a physiologically younger and more active cohort than our control group of isolated hip fractures. Patients with concurrent hip and wrist fractures were not significantly more osteoporotic, and showed a trend toward longer stay in hospital and incurred a higher cost of stay. The confluent upper limb injury was the likely reason for their post-discharge impaired ambulatory status. The most common location of injury in both groups of patients is at home.     

Relationship of body mass index with main limb fragility fractures in postmenopausal women

Body mass index (BMI) has been found to be related to the risk of osteoporotic hip fractures in women, regardless of bone mineral density (BMD). The same relationship is under debate for other limb fragility fractures. Very few studies have investigated the comparison of fracture risk among BMI categories, classified according to the WHO criteria, despite the potential usefulness of such information for clinical purposes. To address these issues we studied 2,235 postmenopausal women including those with fragility fractures of the hip (187), ankle (108), wrist (226) and humerus (85). Statistical analyses were performed by logistic regression by treating the fracture status as the dependent variable and age, age at menopause, femoral neck BMD and BMI as covariates. BMI was tested as a continuous or categorical variable. As a continuous variable, increased BMI had a protective effect against hip fracture: OR 0.949 (95% CI, 0.900–0.999), but carried a higher risk of humerus fracture: OR 1.077 (95% CI, 1.017–1.141). Among the BMI categories, only leanness: OR 3.819 (95% CI, 2.035–7.168) and obesity: OR 3.481 (95% CI, 1.815–6.678) showed a significantly higher fracture risk for hip and humerus fractures, respectively. There was no relationship between ankle and wrist fractures and BMI. In conclusion, decreasing BMI increases the risk for hip fracture, whereas increasing BMI increases the risk for humerus fractures. Leanness-related low BMD and obesity-related body instability might explain the different BMI relationships with these two types of fracture.     

Socioeconomic disparities in the utilization of spine augmentation for patients with osteoporotic fractures: an analysis of National Inpatient Sample from 2011 to 2015

BACKGROUND CONTENTVertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty.PURPOSEThe purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures.METHODSWith the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value <.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage.RESULTSWe identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58–0.70, p<.001), Hispanic patients (OR=0.79, 95% CI: 0.73–0.86, p<.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70–0.89, p<.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53–0.66, p<.001), private insurance (OR=0.90, 95% CI: 0.85–0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47–0.69, p<.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70–1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71–0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58–0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare.CONCLUSIONSOur study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.     

Total hip replacement after femoral neck fractures in elderly patients : Results of 8,577 fractures reported to the Norwegian Arthroplasty Register

Background?A total hip arthroplasty (THA) is often used as treatment for failed osteosynthesis of femoral neck fractures and is now also used for acute femoral neck fractures. To investigate the results of THA after femoral neck fractures, we used data from the Norwegian Arthroplasty Register (NAR).

Patients and methods?The results of primary total hip replacements in patients with acute femoral neck fractures (n = 487) and sequelae after femoral neck fractures (n = 8,090) were compared to those of total hip replacements in patients with osteoarthrosis (OA) (n = 55,109). The hips were followed for 0–18 years. The Cox multiple regression model was used to construct adjusted survival curves and to adjust for differences in sex, age, and type of cement among the diagnostic groups. Separate analyses were done on the subgroups of patients who were operated with Charnley prostheses.

Results?The survival rate of the implants after 5 years was 95% for the patients with acute fractures, 96% for the patients with sequelae after fracture, and 97% for the OA patients. With adjustment for age, sex, and type of cement, the patients with acute fractures had an increased risk of revision compared to the OA patients (RR 1.6, 95% CI: 1.0–2.6; p = 0.05) and the sequelae patients had an increased risk of revision (RR 1.3, 95% CI: 1.2–1.5; p < 0.001). Sequelae hips had higher risk of revision due to dislocation (RR 2.0, 95% CI: 1.6–2.4; p < 0.001) and periprosthetic fracture (RR 2.2, 95% CI: 1.5–3.3; p < 0.001), and lower risk of revision due to loosening of the acetabular component (RR 0.72, 95% CI; 0.57–0.93; p = 0.01) compared to the OA patients. The increased risk of revision was most apparent for the first 6 months after primary operation.

Interpretation?THA in fracture patients showed good results, but there was an increased risk of early dislocations and periprosthetic fractures compared to OA patients.     

Characteristics and outcomes of hip fractures in lower limb amputees

IntroductionLower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail.MethodsWe undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients.ResultsTwenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups.DiscussionThe incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation.ConclusionThis study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.     

Mortality and its risk factors in nonagenarians after hip fractures

BackgroundThe purpose of this study was to assess mortality with a minimum of 2-year follow-up, related risk factors for mortality, and functional outcomes after surgical interventions in nonagenarian patients with hip fractures at the latest follow up.MethodsBetween June 2003 and November 2015, 260 nonagenarians (271 hips) with femoral neck and intertrochanteric fractures were included in this retrospective study. Cumulative mortality using the Kaplan-Meier method and risk factors for mortality using Cox proportional-hazards regression model were estimated. As functional outcome, ambulatory ability was assessed before injury and at the latest follow-up.ResultsSix-teen patients (16 hips) were lost to follow-up. The mean age at the time of surgery was 92.2 years (range 90–108 years). Mortality rates were 23.4% (57 of 244 patients) at 1 year and 40.6% (99 of 244 patients) at 2 years. Both genders had elevated standardized mortality ratio at 2-year post-fracture compared to that a 1-year post fracture. Multivariate analysis showed that American Society of Anesthesiologists (OR, 1.371; 95% CI, 1.021–1.843; P = 0.036) and time interval from trauma to operation (OR, 1.043; 95% CI, 1.002–1.086; P = 0.039) were significantly associated with risk of mortality. Of 58 patients alive, 13 patients (22.4%) had the same ambulatory ability before and after injury.ConclusionsThis study demonstrates that mortality is higher in nonagenarians with hip fracture. Risk factors for mortality in nonagenarians with hip fracture are American Society of Anesthesiologists and time interval from trauma to operation. And, nonagenarians with hip fractures have lower rate of maintaining pre-injury ambulatory ability.     

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients

IntroductionThere has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures.Patients and methodsHip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture.Results81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture.Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture.Discussion and conclusionSimultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.     

Factors associated with non-walking 4 months after hip fracture. A prospective study of 23,759 fractures

IntroductionDespite advances in new surgical techniques and improvements in medical care of the last decades a considerable number of patients will not regain their ability to walk after a hip fracture.AimsTo further identify risk factors associated with non-walking 4-months after a hip fracture.Material and methodsRegister-based, longitudinal study with a 4-month follow-up. The collected data from the Swedish hip fracture registry, RIKSHÖFT, contained all hip fracture between 201301–01–2015–12–31 in Sweden. All patients older than 50 years with a non-pathological fracture and who were able to walk before the fracture were included. The association of sex, age, general health, dementia and type of discharge with complete loss of walking after a hip fracture were investigated using a multivariate analysis.ResultsIncluded were 23,759 patients. At the 4-month follow-up, 10% were unable to walk. Twenty-five per cent of patients with dementia lost their ability to walk compared to 7% of those with no cognitive dysfunction. Adjusted odds ratio (OR) for factors associated with loss of walking ability were; discharge to institutionalized care rather than their own home or a rehabilitation unit (OR=1.91; 95% CI=1.67–2.18), dementia (OR=1.80; 95% CI=1.57–2.06), male gender (OR=1.59; 95% CI=1.40–1.81) and ASA score grade III-V (OR=1.37; 95% CI=1.20–1.55) but not age (OR=1.01; 95% CI=1.00–1.02).ConclusionsAn important factor associated with a complete loss of walking ability after a hip fracture is the discharge to institutionalized care. This factor might be influenced either by favouring rehabilitation units or by improving the rehabilitation protocols.     

Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation

BackgroundAs the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients.MethodsAn institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded.Results1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01–1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61–0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37–1.00).ConclusionExtended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued.Level of evidenceLevel III.     

Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population

IntroductionWith the aging of the population the rate of fragility hip fractures increases. While medical recommendations are for hasten surgical treatment, for some older patients burdened with severe comorbidities, this might be risky.AimsTo compare the outcomes of patients treated non-surgically to those of the most fragile patients treated surgically.Patients and methodsA retrospective cohort study, of individuals aged ≥65 yearswho presented with fragility hip fractures between 01.01.2011-30.06.2016, to a primary trauma center. Patients treated surgically were stratified according to their age-adjusted Charlsons' comorbidity index (ACCI) score. Patients in the upper third of ACCI score, representing the more fragile population, were compared to patients treated non-surgically.Results847 patients presented with fragility fractures. 94 (11%) were treated non-surgically and 753 (89%) underwent surgery. Medical reasons were the leading cause for non-surgical treatment (61.7%). Surgically-treated patients were stratified according to their ACCI and 114 patients with ACCI > 9 were chosen for comparison. While both groups were comparable in terms of age, the non-surgical treatment group had more female patients (p. = 0.026) and a smaller proportion of independent walkers (p < 0.001). The ACCI was higher for the surgical treatment group (p < 0.001). In-hospital mortality was similar (14.9% and 18.1% for the operative and non-surgical groups respectively, P. = 0.575). However, one-year mortality was significantly higher for the non-surgical group (48.2% vs. 67.0%, P. = 0.005). The rates of in-hospital complications and 1-year readmissions were similar.ConclusionsOperative treatment for fragility hip fracture reduces long-term mortality rates even in the more fragile patients, compared to non-surgical treatment.     

High energy injury is a risk factor for preoperative venous thromboembolism in the patients with hip fractures: A prospective observational study

BackgroundThe purpose of this study was to identify the incidence of preoperative venous thromboembolism (VTE), and determine if high energy hip fracture affects preoperative VTE occurrence.MethodsThree-hundred nine patients (244 low and 61 high energy injuries) treated between March 2015 and March 2017 were included in this study. Indirect multidetector computed tomographic venography for the detection of preoperative VTE was performed at admission. The incidence of preoperative VTE was compared between high and low energy injury hip fractures. Logistic regression analysis was used to identify independent risk factors for preoperative VTE.ResultsThe overall incidence of preoperative VTE was 18.4% (56 of 305 patients). Preoperative VTE was identified in 17 (27.9%) and 39 (16.0%) patients in the high and low energy injury groups, respectively (p = 0.034). Multivariate logistic regression analysis showed that high energy injury, history of VTE, and myeloproliferative disease were significant predictive factors of preoperative VTE (OR = 2.451; 95% CI = 1.227–4.896, OR = 11.174; 95% CI = 3.500–35.673, OR = 6.936; 95% CI = 1.641–29.321, respectively)ConclusionBecause high energy hip fracture is significantly associated with preoperative VTE occurrence, preoperative evaluation and proper thromboprophylaxis should be performed for patients with a high-energy hip fracture.     

Use of proton pump inhibitors and risk of fragility hip fracture in a Mediterranean region

ObjectiveTo determine whether there is an increased risk of hip fracture associated with the use of proton pump inhibitors in a Mediterranean area after adjusting for other potential risk factors.MethodsRetrospective multicenter case–control study carried out in 6 primary health care centers in Catalonia, Spain. Cases were patients aged 50 years and over with a fragility hip fracture registered between January 2007 and December 2010, matched with 2 controls by sex and age. Data collected: use of proton pump inhibitors (type, dosage) in the 5 years previous to the hip fracture, socio-demographic data, body mass index, alcohol and tobacco consumption as well as health conditions and drugs associated with an increase risk of fragility hip fracture.Results358 cases were matched with 698 controls. The mean age was 82 years old in both groups. Women represented 77.1% in the case group and 76.9% in the control group. Crude association between proton pump inhibitors and hip fracture was 1.44 (95% CI, 1.09–1.89) and adjusted OR was 1.24 (95% CI, 0.93–1.65). No association was found with the continuous or discontinuous use of proton pump inhibitors, OR 1.17 (95% CI, 0.77–1.79), and OR of 1.16 (95% CI, 0.85–1.60) respectively. No association was found when restricting the analysis by sex, OR of 1.19 (95% CI, 0.27–5.14) or by age, younger or older than 80 years, OR of 0.72 (95% CI, 0.24–2.15).ConclusionThe use of proton pump inhibitors was not associated with an increased risk of hip fracture after adjusting for other risk factors in a Mediterranean area. This result suggests the existence of protective environmental factors linked to this southern area of Europe that eventually could compensate for the potential harm produced by proton pump inhibitors.     

Urinary tract infection (UTI) at time of geriatric hip fracture surgery increases the risk of experiencing adverse 30-day outcomes

IntroductionPre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients.MethodsThe 2015–2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients ≥65 years of age undergoing surgery due to a traumatic hip fracture were included in the study.ResultsOut of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27–13.1]; p = 0.008), any complication (OR 1.33 [95% CI 1.49–1.63]; p = 0.007), infectious complications (OR 1.71 [95% CI 1.19–2.47]; p = 0.004), non-infectious complications (OR 1.28 [95% CI 1.04–1.58]; p = 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25–3.06]; p = 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57–2.66]; p < 0.001). With regards to infectious complications, presence of a UTI at time of surgery was a significant independent predictor of sepsis (OR 2.44 [95% CI 1.24–4.80]; p = 0.010) and septic shock (OR 4.05 [95% CI 2.03–8.08]; p < 0.001).ConclusionsPatients undergoing hip-fracture surgery with a concurrent UTI at the time of surgery have more adverse 30-day outcomes as compared to hip fracture patients who do not present with a UTI. Despite adjustment for a delay in the time to surgery, the impact of UTI on post-operative outcomes remained significant. While it is difficult to eradicate a UTI in a non-elective population, the findings stress the need for clinical optimization and potential need for early recognition/management of UTI in patients who sustain a hip fracture to minimize the risk of adverse outcomes.     

What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

BackgroundCritical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities.Questions/purposesAre there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs?MethodsThe 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics.ResultsPatients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001).ConclusionPatients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities.Level of EvidenceLevel III, therapeutic study.     

Increased incidence of hip fractures. A population based-study in Finland

In Central Finland, the age-specific incidence of hip fractures did not change between the years 1982-1983 and 1992-1993 though the total number of hip fractures increased by 11% due to population aging. The objective of this study was to define the current hip fracture rates and the characteristics of patients with hip fracture. The population at risk consisted of 240,000 persons living in the Central Finland Health Care District. Hip fracture patients were identified by using the hospital discharge register, the operation lists, and the register of the Department of Anesthesiology. Patients' residential status, weight, and height, date and time of hip fracture, place of accident and mechanism and type of fracture were obtained from medical records. A total of 597 patients, 415 (69.5%) women and 182 (30.5%) men, were admitted to the hospital for treatment of an acute hip fracture in 2002-2003. The mean age of the patients was 79 (SD 13) years. Among patients aged > or =50 years (n = 577), 80.8% of the hip fractures had occurred indoors, 97.6% with a low-energetic mechanism, and 22.7% during the nighttime. The ratio of trochanteric to cervical fractures was 2:3. Between 1992-1993 and 2002-2003, the total number of hip fractures increased by 70%, from 351 to 597. The fracture rates per 1000 person-years in the age group > or =55 years were 2.0 and 3.9 in 1992-1993 and 2.8 and 5.6 in 2002-2003 for men and women, respectively. The corresponding age-adjusted incidence rate ratio (IRR) for men was 1.36 (95% CI: 1.06 to 1.76), P = 0.017, and for women 1.25 (95% CI: 1.07 to 1.47), P = 0.006. Among men, the IRR was highest in the age group 75-84 years, IRR = 1.67 (95% CI: 1.08 to 2.65), while among women, it was highest in the age group > or =85 years, IRR = 1.33 (95% CI: 1.02 to 1.75). The total number of hip fractures almost doubled within 10 years, and the age-adjusted incidence rate increased in both sexes. The accretion of the hip fracture incidence was more than could be explained merely by changes in population size and structure.     

Simultaneous hip and upper limb fracture in the elderly: incidence, features and management considerations

We performed a retrospective analysis of all patients admitted to a single unit over 4 years with fractured neck of femur. Of the 760 patients admitted over this period of time 36 (4.7%) were found to also have a fracture of the upper limb. The associated upper limb fractures were distal radius (n=28), olecranon (n=2) and neck of humerus (n=5) and fifth metacarpal (n=1), with the same ratio of intracapsular to extracapsular fractures as the whole group. The female to male ratio in the isolated hip fracture group was 2.4:1 and for the combined fractures group was 8:1 (difference P=0.014). The mean patient age was 77.3 years for isolated hip fractures and 83.9 for the combined group (P=0.037). The mean total length of stay in hospital for isolated hip fracture was 15.6 days and for combined fractures was 20.4 days (P=0.010). We have demonstrated that combined upper limb and neck of femur fractures occur in a population that is older and predominantly female. They are associated with a significant increase in hospital stay and increased difficulties in mobilisation as a consequence of the combined fractures. It is therefore important to recognise this specific subgroup of patients presenting with hip fractures in order to ensure that they receive adequate treatment and rehabilitation and that the use of valuable health care resources are optimised.     

Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study

Several epidemiological studies have identified clinical factors that predict the risk of hip fractures in elderly women independently of the level of bone mineral density (BMD), such as low body weight, history of fractures, and clinical risk factors for falls. Their relevance in predicting all fragility fractures in all postmenopausal women, including younger ones, is unknown. The objective of this study was to identify independent predictors of all osteoporosis-related fractures in healthy postmenopausal women. We prospectively followed for 5.3 +/- 1.1 years a cohort of 672 healthy postmenopausal women (mean age 59.1 +/- 9.8 years). Information on social and professional conditions, demographic data, current and past medical history, fracture history, medication use, alcohol consumption, caffeine consumption, daily calcium intake, cigarette smoking, family history of fracture, and past and recent physical activity was obtained. Anthropometric and total hip bone mineral density measurements were made. Incident falls and fractures were ascertained every year. We observed 81 osteoporotic fractures (annual incidence, 21 per 1000 women/year). The final model consisted of seven independent predictors of incident osteoporotic fractures: age > or = 65 years, odds ratio estimate (OR), 1.90 [95% confidence interval (CI) 1.04-3.46], past falls, OR, 1.76 (CI 1.00-3.09), total hip bone mineral density (BMD) < or = 0.736 g/cm(2), OR, 3.15 (CI 1.75-5.66), left grip strength < or = 0.60 bar, OR, 2.05 (CI 1.15-3.64), maternal history of fracture, OR, 1.77 (CI 1.01-3.09), low physical activity, OR, 2.08 (CI 1.17-3.69), and personal history of fragility fracture, OR, 3.33 (CI 1.75-5.66). In contrast, body weight, weight loss, height loss, smoking, neuromuscular coordination assessed by three tests, and hormone replacement therapy were not independent predictors of all fragility fractures after adjustment for all variables. We found that some--but not all--previously reported clinical risk factors for skeletal fragility predicted all fragility fractures independently of BMD in healthy postmenopausal women, although they differed somewhat from those predicting specifically hip fractures in elderly women. These risk factors appear to reflect quality of bone structure (previous fragility fracture), lifestyle habits (physical activity), muscle function and health status (grip strength), heredity (maternal history of fracture), falls, and aging. Measurements of these variables should be included in the clinical assessment of the risk of osteoporotic fractures in postmenopausal women.