Outcomes after hip fractures sustained in hospital: A propensity-score matched cohort study

AimsThe aim of this study was to compare outcomes following hip fracture for patients who sustained their fracture whilst in hospital (inpatients) with those who sustained their fracture in the community (outpatients).Patients and MethodsData on all hip fracture admissions aged 65 years or over between 1^st May 2007 and 31^st March 2018 was analysed from a prospectively collected hip fracture database. Patient demographics, co-morbidities, and discharge information were analysed. Outcome measures included mortality (inpatient, 30-day and one year), surgical site infection (SSI) rate and mean length of stay (LOS). Baseline characteristics were used to generate propensity-match scores for each patient, with inpatients matched to outpatients in a 1:1 ratio. Outcomes were compared after matching.Results7,592 patients were included in the study. 338 were identified as having an inpatient hip fracture. There was a significantly greater level of comorbidity in the inpatient group at baseline. After propensity-score matching, there were 229 patients in the inpatient group and 222 in the outpatient group, with no significant difference in baseline co-morbidities. In this propensity score matched cohort, 30-day mortality was significantly higher in the inpatient group (16%) compared to the outpatient group (10%), P = 0.049. 1-year mortality was also significantly higher in the inpatient group (44%) compared to the outpatient group (34%), P = 0.03. There was no significant difference in inpatient mortality, mean LOS and SSI rates between the two groups.ConclusionPatients who suffer a hip fracture whilst in hospital have significantly poorer outcomes than those who suffer a hip fracture whilst an outpatient, even after adjusting for co-morbidities. Dedicated guidelines are needed for this particularly vulnerable group.     

Patient-reported outcomes in hip resurfacing versus conventional total hip arthroplasty: a register-based matched cohort study of 726 patients

Background and purpose — The theoretical mechanical advantages of metal-on-metal hip resurfacing (MoM-HR) compared with conventional total hip arthroplasty (THA) have been questioned. Studies including measures of patient-reported function, physical activity, or health-related quality of life have been sparse. We compared patient-reported outcomes in MoM-HR patients with a matched group of patients with conventional THA at 7 years post-surgery.

Patients and methods — Patients and patient data were retrieved from the Swedish Hip Arthroplasty Register. The case group, consisting of 363 patients with MoM-HR, was matched 1:1 with a control group, consisting of patients with a conventional THA. Patients were sent a postal patient-reported outcome measures (PROM) questionnaire including the Hip Disability and Osteoarthritis Outcome Score (HOOS), EQ-5D, and VAS pain. We used multivariable linear regression analyses to investigate the influence of prosthesis type.

Results — 569 patients (78%) returned the questionnaire with complete responses (299 MoM-HRs and 270 conventional THAs). MoM-HR was associated with better scores in HOOS function of daily living (4 percentage units) and HOOS function in sport and recreation (8 percentage units) subscales. Type of prosthesis did not influence HOOS quality of life, HOOS pain, HOOS symptoms, EQ-5D index, hip pain, or satisfaction as measured with visual analog scales.

Interpretation — At mean 7 years post-surgery, patients with hip resurfacing had somewhat better self-reported hip function than patients with conventional THA. The largest difference between groups was seen in the presumed most demanding subscale, i.e., function in sport and recreation.     

Hip arthroplasty after extracapsular hip fracture: a matched pair cohort analysis

Eighteen patients with a prior intertrochanteric or basicervical hip fracture had a total or bipolar hip arthroplasty. The clinical and radiographic results of these patients were compared to a control group of patients (matched for age, gender, associated diagnoses, and length of follow-up) who had a primary total hip arthroplasty. There was a significant increase in intraoperative blood loss, operative time, and number of units of blood transfused in the fracture group compared to the primary arthroplasty group. The mean preoperative Harris hip scores were not significantly different between the two groups, but the postoperative scores were significantly lower for the fracture group (p < .001). There was no notable difference in the rates of radiographic loosening or heterotopic ossification between the two groups. The results of this study suggest that patients should be counseled preoperatively that the functional outcome of hip arthroplasty after internal fixation of extracapsular hip fractures is decreased compared to control patients with a primary total hip arthroplasty.     

Direct healthcare costs of hip,vertebral, and non-hip,non-vertebral fractures

Limited data exist regarding the cost of non-hip, non-vertebral (NHNV) fractures. Although NHNV fractures may be less expensive than hip and vertebral fractures, they have a higher incidence rate. The objective of this study was to quantify first-year healthcare costs of hip, vertebral, and NHNV fractures. This was a claims-based retrospective analysis using a case-control design among patients with commercial insurance and Medicare employer-based supplemental coverage. Patients were ≥ 50 years old with a closed hip, vertebral, or NHNV fracture between 7/1/2001 and 12/31/2004, and continuous enrollment 6 months prior to and 12 months after the index fracture. Adjusted mean first-year healthcare costs associated with these fractures were determined. Six cohorts were identified. Patients 50–64 years: NHNV (n = 27,424), vertebral (n = 3386) and hip (n = 2423); patients ≥ 65 years: NHNV (n = 40,960), vertebral (n = 11,751) and hip (n = 21,504). The ratio of NHNV to hip fractures was 11:1 in the 50–64 cohort and 2:1 in the ≥ 65 cohort. Adjusted mean first-year costs associated with hip, vertebral, and NHNV fractures were $26,545, $14,977, and $9183 for the 50–64 age cohort, and $15,196, $6701, and $6106 for patients ≥ 65 years. After taking prevalence rate into account, the proportion of the total fracture costs accounted for by NHNV, hip, and vertebral fractures were 66%, 21% and 13% for the 50–64 age cohort, and 36%, 52% and 12% for the ≥ 65 age cohort. Limitations included the exclusion of the uninsured and those covered by Medicaid or military-based insurance programs. The results of this study demonstrate that osteoporotic fractures are associated with significant costs. Although NHNV fractures have a lower per-patient cost than hip or vertebral fractures, their total first-year cost is greater for those 50–64 because of their higher prevalence.     

Timing of surgery for hip fractures in the elderly: A retrospective cohort study

IntroductionAlthough early surgery for elderly patients with hip fracture is recommended in existing clinical guidelines, the results of previous studies are inconsistent. The aim of this study was to compare postoperative outcomes of early and delayed surgery for elderly patients with hip fracture.Materials and MethodsIn this retrospective study using a national inpatient database in Japan, patients aged 65 years or older who underwent surgery for hip fracture between July 2010 and March 2014 were included. Early surgery was defined as surgery on the day or the next day of admission. Assessed outcomes included death within 30 days and hospital-acquired pneumonia.ResultsIn this cohort, 47,073 (22.5%) patients underwent surgery for hip fractures within two days of admission (early surgery group) and 161,805 (77.5%) underwent surgery for hip fractures thereafter (delayed surgery group). Early surgery was significantly associated with lower odds for hospital-acquired pneumonia (odds ratio, 0.42; 95% confidence interval, 0.25–0.69) and pressure ulcers (odds ratio, 0.56, 95%CI: 0.33–0.96, p = 0.035), but was not associated with 30-day mortality (odds ratio, 0.96; 95% confidence interval, 0.49–1.86) or pulmonary embolism (odds ratio, 1.62, 95%CI: 0.58–4.52, p = 0.357).ConclusionsThese results support current guidelines, which recommend early surgery for elderly hip fractures patients.     

No increased mortality after total hip arthroplasty in patients with a history of pediatric hip disease: a matched,population-based cohort study on 4,043 patients

Background and purpose — Patients with pediatric hip diseases are more comorbid than the general population and at risk of premature, secondary osteoarthritis, often leading to total hip arthroplasty (THA). We investigated whether THA confers an increased mortality in this cohort.Patients and methods — We identified 4,043 patients with a history of Legg–Calvé–Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), or developmental dysplasia of the hip (DDH) in the Swedish Hip Arthroplasty Register (SHAR) between 1992 and 2012. For each patient, we matched 5 controls from the general population for age, sex, and place of residence, and acquired information on all participants’ socioeconomic background and comorbidities. Mortality after THA was estimated according to Kaplan–Meier, and Cox proportional hazard models were fitted to estimate adjusted hazard ratios (HRs) for the risk of death.Results — Compared with unexposed individuals, patients exposed to a THA due to pediatric hip disease had lower incomes, lower educational levels, and a higher degree of comorbidity but a statistically non-significant attenuation of 90-day mortality (HR 0.9; 95% CI 0.4–2.0) and a lower risk of overall mortality (HR 0.8; CI 0.7–0.9).Interpretation — Patients exposed to THA due to a history of pediatric hip disease have a slightly lower mortality than unexposed individuals. THA seems not to confer increased mortality risks, even in these specific patients with numerous risk factors.

Altered morphology of the hip joint due to pediatric hip diseases, e.g., Legg–Calvé–Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), or developmental dysplasia of the hip (DDH) is closely linked to early-onset, secondary osteoarthritis (OA) (Jacobsen and Sonne-Holm 2005, Pun 2016) which may lead to total hip arthroplasty (THA) at a young age (Froberg et al. 2011). Thus, the mean age at THA surgery in patients with a history of pediatric hip disease ranges from 38 to 55 years (Traina et al. 2011, Engesaeter et al. 2012), whereas it ranges from 65 to 70 years in patients with primary OA (Engesaeter et al. 2012, Fang et al. 2015, Cnudde et al. 2018). Studies from Nordic countries report that between 4% and 9% of all primary THAs are due to pediatric hip disease (Engesaeter et al. 2012).The long-term outcome and revision rates after THA in patients with previous pediatric hip disease have been studied (Thillemann et al. 2008, Traina et al. 2011), but 90-day mortality and overall mortality after THA in these patients have not yet been investigated. Comorbidities, such as attention deficit hyperactivity disorder (ADHD), depression, cardiovascular disease, hypothyroidism, obesity, and coagulation abnormalities are more common in patients with LCPD and SCFE (Hailer and Nilsson 2014, Perry et al. 2017, Hailer and Hailer 2018, Hailer 2020). In addition, patients with LCPD and SCFE have a higher overall mortality than the general population (Hailer and Nilsson 2014, Hailer 2020). Due to an increased comorbidity burden and possibly increased overall mortality one could therefore fear an increased mortality after THA surgery in these patients.We therefore investigated whether THA surgery in patients with a pediatric hip disease confers an increased 90-day and overall mortality when compared with the general population.     

Direct medical costs attributable to peripheral fractures in Canadian post-menopausal women

Summary

This study determined the cost of treating fractures at osteoporotic sites (except spine fractures) for the year following fracture. While the average cost of treating a hip fracture was the highest of all fractures ($46,664 CAD per fracture), treating other fractures also accounted for significant expenditures ($5,253 to $10,410 CAD per fracture).

Introduction

This study aims to determine the mean direct medical cost of treating fractures at peripheral osteoporotic sites in the year post-fracture (through 2?years post-hip fracture).

Methods

Health administrative databases from the province of Quebec, Canada were used to estimate the cost of treating peripheral fractures at osteoporotic sites for the year following fracture (through 2?years for hip fractures). Included in costs analyses were physician claims, emergency and outpatient clinic costs, hospitalization costs, and subsequent costs for treatment of complications.

Results

A total of 15,827 patients (mean age 72?years) who suffered one fracture at an osteoporotic site had data for analyses. Hip/femur fractures had the highest rate of hospital stays related to fracture (91%) and the highest rate of hospital stays associated with a post-fracture complication (8%). In the year following fracture, the mean (SD) costs (2009 Canadian dollars) of treating acute fractures and post-fracture complications were: hip/femur fracture $46,664 ($43,198), wrist fracture $5,253 ($18,982), and fractures at other peripheral sites $10,410 ($27,641). The average (SD) cost of treating post-fracture complications at the hip/femur in the second year post-fracture was $1,698 ($12,462). Hospitalizations associated with the fracture accounted for 88% of the total cost of fracture treatment.

Conclusions

The treatment of hip fractures accounts for a significant proportion of the costs associated with the treatment of peripheral osteoporotic fractures. Interventions to reduce the incidence of fractures, particularly hip fractures, would result in significant cost savings to the health care system and would preserve quality of life in many patients.     

Reverse total shoulder arthroplasty in wheelchair-dependent patients: a matched cohort study

BackgroundShoulder function in wheelchair-dependent patients is critical for preserving independence and quality of life due to lower extremity impairment. The purpose of this study was to report the revision rate, as well as clinical and radiological outcome in wheelchair-dependent patients treated with reverse total shoulder arthroplasty (RTSA) and to compare them to an ambulating population.MethodsProspectively obtained data of 21 primary RTSAs in 17 wheelchair-dependent patients (5 male, 12 female) with a median age of 72.4 years (range: 49-80) and a minimum follow-up of 2 years were analyzed retrospectively. Revision rate, clinical (Subjective Shoulder Value = SSV, relative Constant-Murley Score = rCS, wheelchair user’s shoulder pain index = WUSPI) and radiological (glenoid loosening, scapular notching, glenoid inclination) outcome, as well as implant-related parameters (baseplate peg length, glenosphere size, bony augmentation), were compared with a 2:1 matching cohort of 42 ambulating patients (10 male, 32 female) with a median age of 72.5 years (range: 56-78).ResultsThe revision rate was 9.5% in both cohorts. In the wheelchair cohort, two shoulders had to be revised due to a complete baseplate dislocation. In the matching cohort, four shoulders had to be revised due to one prosthetic dislocation, one traumatic and one atraumatic scapular spine fracture with glenoid baseplate dislocation, and one fracture of the greater tuberosity. Median preoperative SSV and rCS did not differ significantly between cohorts. Postoperative SSV was also comparable (wheelchair: median 70 (range: 10-99) vs. matching: median 70 (30-100), p = n.s.). Relative CS was significantly lower in the wheelchair cohort (65% vs. 81.4%, P = .004). Median postoperative WUSPI was 35 points (range: 13-40) for difficulty and 0 points for pain (range: 0-29). The highest difficulty and pain were found for ‘hygiene behind the back’ and ‘propulsion of wheelchair up a ramp or on uneven surface’. Glenoid loosening, scapular notching, and postoperative baseplate inclination did not differ significantly between cohorts. In the wheelchair cohort, glenoid autograft augmentation (38.1% vs. 7.1%, P = .002) and implantation of baseplates with longer pegs were performed more often (≥ 25mm: 38.1% vs. 7.1%, P = .004).ConclusionRTSA is a valuable therapeutic option for the treatment of advanced OA or irreparable rotator cuff tears in wheelchair-bound patients with high patient satisfaction. Postoperatively, poorer function and a higher rate of baseplate dislocations might be anticipated compared to ambulating patients.     

Return to work after primary total hip arthroplasty: a nationwide cohort study

Background and purpose — While the number of working-age patients undergoing total hip arthroplasty (THA) is increasing, the effect of the surgery on patients’ return to work (RTW) is not thoroughly studied. We aimed to identify risk factors of RTW after THA among factors related to demographic variables, general health, health risk behaviors, and socioeconomic status.

Patients and methods — We studied 408 employees from the Finnish Public Sector (FPS) cohort (mean age 54 years, 73% women) who underwent THA. Information on demographic and socioeconomic variables, preceding health, and health-risk behaviors was derived from linkage to national health registers and FPS surveys before the operation. The likelihood of return to work was examined using Cox proportional hazard modeling.

Results — 94% of the patients returned to work after THA on average after 3 months (10 days to 1 year) of sickness absence. The observed risk factors of successful return to work were: having < 30 sick leave days during the last year (HR 1.8; 95% CI 1.4–2.3); higher occupational position (HR 2.2; CI 1.6–2.9); and BMI < 30 (HR 1.4; CI 1.1–1.7). Age, sex, preceding health status, and health-risk behaviors were not correlated with RTW after the surgery.

Interpretation — Most employees return to work after total hip arthroplasty. Obese manual workers with prolonged sick leave before the total hip replacement were at increased risk of not returning to work after the surgery.     

Mediterranean diet and incidence of hip fractures in a European cohort

Summary

Prevention of hip fractures is of critical public health importance. In a cohort of adults from eight European countries, evidence was found that increased adherence to Mediterranean diet, measured by a 10-unit dietary score, is associated with reduced hip fracture incidence, particularly among men.

Introduction

Evidence on the role of dietary patterns on hip fracture incidence is scarce. We explored the association of adherence to Mediterranean diet (MD) with hip fracture incidence in a cohort from eight European countries.

Methods

A total of 188,795 eligible participants (48,814 men and 139,981 women) in the European Prospective Investigation into Cancer and nutrition study with mean age 48.6 years (±10.8) were followed for a median of 9 years, and 802 incident hip fractures were recorded. Diet was assessed at baseline through validated dietary instruments. Adherence to MD was evaluated by a MD score (MDs), on a 10-point scale, in which monounsaturated were substituted with unsaturated lipids. Association with hip fracture incidence was assessed through Cox regression with adjustment for potential confounders.

Results

Increased adherence to MD was associated with a 7 % decrease in hip fracture incidence [hazard ratio (HR) per 1-unit increase in the MDs 0.93; 95 % confidence interval (95 % CI)?=?0.89–0.98]. This association was more evident among men and somewhat stronger among older individuals. Using increments close to one standard deviation of daily intake, in the overall sample, high vegetable (HR?=?0.86; 95 % CI?=?0.79–0.94) and high fruit (HR?=?0.89; 95 % CI?=?0.82–0.97) intake was associated with decreased hip fracture incidence, whereas high meat intake (HR?=?1.18; 95 % CI?=?1.06–1.31) with increased incidence. Excessive ethanol consumption (HR high versus moderate?=?1.74; 95 % CI?=?1.32–2.31) was also a risk factor.

Conclusions

In a prospective study of adults, increased adherence to MD appears to protect against hip fracture occurrence, particularly among men.     

Contralateral hip fractures and other osteoporosis-related fractures in hip fracture patients: incidence and risk factors. An observational cohort study of 1,229 patients

Purpose

To report risk factors, 1-year and overall risk for a contralateral hip and other osteoporosis-related fractures in a hip fracture population.

Methods

An observational study on 1,229 consecutive patients of 50?years and older, who sustained a hip fracture between January 2005 and June 2009. Fractures were scored retrospectively for 2005–2008 and prospectively for 2008–2009. Rates of a contralateral hip and other osteoporosis-related fractures were compared between patients with and without a history of a fracture. Previous fractures, gender, age and ASA classification were analysed as possible risk factors.

Results

The absolute risk for a contralateral hip fracture was 13.8?%, for one or more osteoporosis-related fracture(s) 28.6?%. First-, second- and third-year risk for a second hip fracture was 2, 1 and 0?%. Median (IQR) interval between both hip fractures was 18.5 (26.6) months. One-year incidence of other fractures was 6?%. Only age was a risk factor for a contralateral hip fracture, hazard ratio (HR) 1.02 (1.006–1.042, p?=?0.008). Patients with a history of a fracture (33.1?%) did not have a higher incidence of fractures during follow-up (16.7?%) than patients without fractures in their history (14?%). HR for a contralateral hip fracture for the fracture versus the non-fracture group was 1.29 (0.75–2.23, p?=?0.360).

Conclusion

The absolute risk of a contralateral hip fracture after a hip fracture is 13.8?%, the 1-year risk was 2?%, with a short interval between the 2 hip fractures. Age was a risk factor for sustaining a contralateral hip fracture; a fracture in history was not.     

Prediction of hip and other osteoporotic fractures from hip geometry in a large clinical cohort

Summary  

Incident hip fractures and non-hip osteoporotic fractures were studied in 30,953 women during mean 3.7 years of observation. Hip axis length (HAL) and strength index (SI) made a small but statistically significant contribution to hip fracture prediction that was independent of age and hip bone density.