Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population. INTRODUCTION: Knowledge on younger patients with hip fractures is limited. Common preconceptions are that they suffer fractures due to high-energy trauma, alcohol or substance use disorder but not associated to osteoporosis. We aimed to descriptively analyze the characteristics of young and middle-aged patients with hip fractures and examine bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) at the time of the fracture. METHODS: A prospective multicenter cohort study on adult patients with hip fractures below age 60 collected detailed information on patient characteristics regarding demographics, trauma mechanism, previous fractures, comorbidity and medication, and lifestyle factors. DXA results were compared to population-based reference data. RESULTS: The cohort contains 91 women and 127 men, median age 53 (IQR 47-57). Most fractures, 83%, occurred in patients aged 45-59. Two-thirds of all fractures resulted from low-energy trauma. Half of the patients had prior fractures after age 20. Thirty-four percent were healthy, 31% had one previous disease, and 35% had multiple comorbidities. Use of medication associated with increased fracture risk was 32%. Smoking was prevalent in 42%, harmful alcohol use reported by 29%, and signs of drug-related problems by 8%. Osteoporosis according to WHO criteria was found in 31%, osteopenia in 57%, and normal BMD in 12%. CONCLUSION: In patients with hip fractures below age 60, risk factors for osteoporosis and fractures were numerous. Moreover, the prevalence of osteoporosis was markedly higher than in the general population. We suggest that young and middle-aged patients with hip fractures undergo a thorough health investigation including DXA, regardless of trauma mechanism.

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.

Objectively Measured Physical Activity and Its Association with Functional Independence, Quality of Life and In-Hospital Course of Recovery in Elderly Patients with Proximal Femur Fractures: A Prospective Cohort Study.

BACKGROUND: Physical activity in elderly patients is crucial for recovery from proximal femoral fractures. Considering the limited possibilities for objective measurement, we aimed to evaluate the use of an accelerometer in this population to determine activity's association with functional independence, quality of life, and course of recovery. METHODS: 52 patients undergoing operative treatment for proximal femur fractures (81.3 ± 7.5 years) were included in a prospective cohort study. 12 patients with fall but without fracture of the lower extremities (80.8 ± 9.5 years) served as control. An Axivity AX3 tracker continuously recorded signal vector magnitudes during the hospital stay. Additionally, 2 ± 1 and 8 ± 3 days (time point 1 and 2) after operation EuroQol-5D and Barthel-20 indices were evaluated. RESULTS: Physical activity increased in all patients with time. Multiple regression analyses revealed that a high Barthel-20 before fracture, a low age, a high body mass index, high albumin, and low C-reactive protein levels were independent predictors for high physical activity at time point 1 (p < 0.05). Physical activity correlated significantly with EuroQol-5D and Barthel-20 at time point 1 and 2 (p < 0.02). Furthermore, physical activity at time point 1 predicted EuroQol-5D, physical activity, and Barthel-20 at time point 2 (p < 0.01). A multiple regression demonstrated equal physical activity in patients with or without a hip fracture. CONCLUSIONS: Accelerometer signals correlate with postoperative physical activity, Barthel-20 and quality of life in elderly patients. Physical activity is thereby positively influenced by a high prefall functional independence and a good nutrition status. A timely and adequate operation provided, there is no difference between patients with or without a fracture. This trial is registered with DRKS 00011934 on 10th April 2017.

Failure of short versus long cephalomedullary nail after intertrochanteric fractures.

The aim of study is to examine the frequency of reoperation and difference in failures for short cephalomedullary nail (SN) and long cephalomedullary nail (LN).We included patients with an intertrochanteric fracture treated with Gamma nail (Stryker®). All radiographs were reviewed, TAD and diastasis were measured, and type of failure registered.216 patients were included, 95 short nails and 121 long nails. We found 12 reoperations, 5 in the SN group and 7 in the LN group. Most common failure was cut out. Our study showed no difference in frequency of reoperations or type of failures.

The effect of a heel-unloading orthosis in short-term treatment of calcaneus fractures on physical function, quality of life and return to work - study protocol for a randomized controlled trial.

BACKGROUND: There are no standardized therapy guidelines for rehabilitation of calcaneus fractures. While there is consensus on non or partial weight-bearing, the use of supporting devices such as specific foot ankle orthosis is still a matter of debate. Recently, a heel-unloading orthosis ("Settner shoe") was introduced for aftercare of these fractures, allowing walking by shifting the load to the middle-foot and forefoot. This orthosis enables early mobilization of patients suffering from either one-sided or two-sided fractures. The Settner shoe can be applied in non-operative therapy and after surgery. Specifically in calcaneus fractures, early regain of physical activity has been highlighted as one of the key factors for quality of life and the ability to return to work. Thus, we hypothesize that mobilization with the Settner shoe results in improved quality of life and greater physical activity within the first 3 months. METHODS: This is going to be analyzed by a randomized controlled study comparing treatment with and without this specific orthosis. The secondary outcome measure is the time point of return to work in patients aged between 18 and 60 years, with calcaneus fracture. Furthermore, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 3-dimensional gait analysis, and the Euroqol-5 dimension-3 level (EQ-5D-3 L) questionnaire for quality of life are assessed. DISCUSSION: This is the first trial applying a standardized rehabilitation protocol in patients with calcaneus fractures, aiming to improve the non-operative part of treatment by use of an orthosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03572816 . Registered on 27 July 2018.

Validation of Activity Tracking Procedures in Elderly Patients after Operative Treatment of Proximal Femur Fractures.

BACKGROUND: Early postoperative physical activity in elderly patients suffering from proximal femoral fractures may reduce mortality. We hypothesized that activity trackers can reliably and objectively monitor the in-hospital mobilization, correlating with functional independence and quality of life. METHODS: Three different tracker types (Fitbit™ flex, Misfit™ Shine, and Axivity AX3) at three locations (wrist, ankle, and femur) recorded steps and signal vector magnitudes (SVM) in 22 patients. They were 81 ± 8 years old, were equally distributed between the sexes, and had an ASA score of 2.5 ± 0.6. Single protocoled activity events (n = 191) were clinically categorized into 4 levels and correlated with the monitored signals. Additionally, 2 ± 1 and 8 ± 3 days after the operation, the EuroQol-5D and the Barthel-20 index supplemented this data. RESULTS: All measurements at the wrist (Fitbit, Misfit) resulted in unacceptable accuracy; however, sensitivity and specificity reached around 90% using the Misfit at the ankle. Applying this combination, the correlation between real and measured steps (R2 = 0.99) and the category discrimination were statistically significant (p < 0.002). A discriminant analysis featured the calculation of four activity levels based on SVM measurements using the Axivity tracker at the femur. A cluster analysis showed a 100% agreement between the clinically observed and the calculated activity levels. The amount of active minutes or periods and both the EuroQol-5D and the Barthel-20 indices significantly increased between the analyzed time points after the operation. However, only the Barthel-20 was associated with the measured activity levels (p < 0.01). CONCLUSION: The Misfit and the Axivity trackers can reliably monitor activity in elderly patients after operative treatment of proximal femur fractures. However, the wear location is decisive. Objectively measured activity correlated with functional independence and quality of life.

Introduction of national guidelines for restrictive blood transfusion threshold for hip fracture patients--a consecutive cohort study based on complete follow-up in national databases.

BACKGROUND: Randomized controlled trials have demonstrated that a restrictive red blood cell (RBC) transfusion strategy lowers transfusion frequency without affecting mortality. However, the external validity of these trials has not been tested in a large cohort. The purpose was to estimate the effect of introducing a National Clinical Guideline (NCG) for a restrictive hemoglobin transfusion threshold on transfusion frequency and mortality in hip fracture patients > 65 years old. METHODS: A consecutive cohort study of hip fracture patients > 65 years old residing in the southern region of Denmark was conducted using prospectively gathered data from registers during two separate 1-year time periods. The first period from October 1, 2012, to September 30, 2013, included 1494 patients and used a liberal transfusion threshold, whereas the second period from October 1, 2015, to September 30, 2016, including 1414 participants used a restrictive threshold from the NCG. Participant data for age, sex, body mass index, Charlson Comorbidity Index, time to surgery, and death were retrieved from the Danish Interdisciplinary Registry of Hip Fractures and were merged with RBC transfusion and medication data extracted from the Danish Transfusion and Odense Pharmacoepidemiological Databases, respectively. Cox proportional hazards models were used to test relative mortality risk for the restrictive group compared with the liberal group at 30 and 90 days. RESULTS: Overall RBC transfusions decreased from 42 to 30% (p < 0.001). The 30-day mortality rate (95% CI) was 9% (8;11) in the restrictive group and 13% (11;14) in the liberal group (p < 0.008), whereas the adjusted relative mortality risk was 0.72 (0.57;0.91). The 90-day mortality rate was 15% (13;17) in the restrictive group and 19% (17;21) in the liberal group, whereas the adjusted relative mortality risk was 0.78 (0.65;0.94). CONCLUSION: These data suggest that the introduction of an NCG on restrictive blood transfusion leads to lower transfusion frequency in hip fracture patients > 65 years old. Even though this reduction is associated with decreased mortality at both 30 and 90 days, it may be explained by other issues than restrictive transfusion strategy. There has been an improvement in the mortality of hip fracture patients in Denmark, and we suggest that a restrictive transfusion strategy does not lead to increased mortality.