Predictors of hip fractures and mortality in long-term care homes in Saskatchewan: Does vitamin D supplementation play a role?

High rates of hip fracture (HF) in long-term care (LTC) lead to increased hospitalization and greater risk of death. Supplementation of residents with vitamin D3 (vitD) has been recommended, but may be infrequently acted upon. Using a prospective cohort design, we explored use of vitD at doses ≥800 IU for hip fractures (HF) and for mortality among permanent LTC residents in Saskatchewan between 2008 and 2012, using provincial administrative health databases (N = 23178). We used stepwise backward regression with Cox proportional hazard multivariate analysis for time to first HF or to death upon entry into LTC (excluding the first three months), the association of daily vitD (determined during the first three months), age, sex, age*sex interaction, prior HF, osteoporosis diagnosis and Charlson Comormidity Score (CCS) was determined. Users of VitD were more likely older, women and those with previous HF. For HF, no significant impact of vitD or CCS was found. Models for mortality, stratified by sex, showed in women only, that vitD use resulted in a significant inverse association with time to death [HR (0.91(0.87-0.96)]; for men it was 0.94(0.88-1.01). The impact of VitD supplementation in LTC deserves further investigation, however, the mechanisms for its effect on mortality remain unclear.

Effects of nutritional intervention upon bone turnover in elderly hip fracture patients. Randomized controlled trial.

BACKGROUND AND AIM: Hip fracture patients are at great risk of malnutrition, but documentation of the effect of nutrition supplementation in this group is sparse and inconclusive. The aim of this study was to examine if personalized nutrition advice combined with vitamin K1, Ca and vitamin D could improve bone turnover 4 months after hip fracture. DESIGN: This is a preplanned sub study of a randomized controlled trial of orthogeriatric care. The intervention group received orthogeriatric care, including nutrition advice and supplementation. The control group received usual care at the orthopedic ward. Blood was drawn for measurements of a number of vitamins and of bone turnover markers upon admission and at four months follow up. RESULTS: 71 patients (31 in the intervention group and 40 controls) had available data at 4 months as well as at baseline. After four months, vitamin K1 and 25(OH)D were higher in the intervention group compared with controls; vitamin K1: 1.0 ± 1.2 vs 0.6 ± 0.6 ng/ml, p = 0.09, 25(OH)D: 60 ± 29 vs 43 ± 22 nmol/L, p = 0.01 when adjusted for baseline differences. In a secondary, unadjusted analysis, comprising all patients with available four months data (n = 136), the differences were statistically significant for vitamin K1 as well as 25(OH)D (p = 0.03 and p < 0.001, respectively). There was a non-significant increase in 25(OH)D in the intervention group from baseline to 4 months follow up, and a significant decrease in the control group. There was no difference in bone turnover markers between the two groups at 4 months follow up. A substantial loss of weight and physical function was found in both groups. CONCLUSIONS: The supplementation of 25(OH)D and vitamin K1 improved serum concentrations of these vitamins, but this did not translate into any improvement in the bone turnover markers. The RCT is registered in ClinicalTrials.govNCT01009268 and NCT01738776.

Effects of essential amino acid supplementation and rehabilitation on functioning in hip fracture patients: a pilot randomized controlled trial.

BACKGROUND: Physical exercise and nutrition seem to have a key role in the management of hip fracture patients. AIM: To evaluate the impact of a 2-month rehabilitative protocol combined with dietetic counseling, with or without essential amino acid supplementation, on functioning in hip fracture patients. METHODS: In this pilot randomized controlled study, we recruited patients aged more than 65 years, at 3 months after hip fracture. We randomly assigned the participants into two groups (A and B). Both groups performed a physical exercise rehabilitative programme (five sessions of 40 min/week for 2 weeks, followed by a home-based exercise protocol) and received a dietetic counseling; only group A was supplemented with two sachets of 4 g/day of essential amino acids (Aminotrofic®). We evaluated at baseline and after 2 months of intervention (T1): hand grip strength, Timed Up and Go, and Iowa Level of Assistance scale (ILOA). RESULTS: The 32 hip fracture patients (mean aged 79.03 ± 7.80 years) were allocated into two groups: group A (n = 16) and group B (n = 16). All the participants showed significant differences in all outcomes at T1 (p < 0.017). Sarcopenic patients in group A (n = 10) showed statistically significant differences in all the primary outcomes at T1 (p < 0.017), whereas sarcopenic patients in group B (n = 13) showed a significant reduction of ILOA only. In non-sarcopenic patients, we found no differences at T1 in all outcome measures. DISCUSSION: Hip fractures are a complex multifactorial condition of the elderly that determines devastating effects on functioning and independence. CONCLUSION: A multidisciplinary rehabilitative and nutritional intervention seems to be effective on functioning in hip fracture patients, in particular sarcopenic ones.

Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial.

Background: Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS). Methods: Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein-enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested. Results: One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4-185 days) in the intervention group versus control 35.5 days (3-183 days; plogrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68-1.41). Hospital LOS: 12.0 days (4-56 days) versus 11.0 days (3-115 days; p = .19; adjHR: 0.75; 95% CI: 0.53-1.06) and LOS in rehabilitation clinics: 19.5 days (0-174 days) versus 18.5 days (0-168 days; p = .82; adjHR: 1.04; 95% CI: 0.73-1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found. Conclusions: Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Influencia de la vitamina D sobre la microestructura y propiedades biomecánicas de pacientes con fractura de cadera / Influence of vitamin D on biomechanical microstructure and properties of patients with hip fracture

Introducción: Valorar niveles séricos de 25-hidroxivitamina D -25(OH)D-, hormonas con influencia sobre el metabolismo óseo (parathormona -PTH- y factor de crecimiento insulínico -IGF-I-), marcadores de remodelado óseo (MRO) (telopéptido carboxilo-terminal del colágeno tipo I -β-CTX- y propéptido aminoterminal del procolágeno tipo I -PINP-), densidad mineral ósea (DMO), microestructura y biomecánica de cuello de fémur, en pacientes con fractura de cadera osteoporótica (OP) vs. pacientes artrósicos (OA). Material y métodos: Estudio observacional transversal de 29 pacientes OP y 14 OA, edad ≥50 años. Cuantificamos niveles séricos hormonales y MRO (inmunoensayo), DMO de cadera (DXA), microestructura (micro-CT) y biomecánica (ensayos de compresión uniaxial, sistema IGFA). Análisis estadístico (SPSS 20.0.) Resultados: Los pacientes OP presentaron niveles inferiores de 25(OH)D (p=0,02) y DMO de cadera (p<0,05), y superiores de PTH (p=0,029) y de β-CTX (p=0,04). Los niveles de 25(OH)D se correlacionaron positivamente con IGF-I (p=0,04) y negativamente con β-CTX (p=0,003). Los valores de PTH se correlacionaron negativamente con DMO de cadera (p=0,0005) y positivamente con la separación trabecular (Tb.Th) (p=0,006). Los pacientes con niveles de 25(OH)D <20 ng/mL presentaron niveles mayores de β-CTX (p=0,006), menores de IGF-I (p=0,007) y Tb.Th (p=0,04). Conclusiones: Los niveles de vitamina D son bajos en población anciana, sobre todo en pacientes con fractura de cadera osteoporótica. Además, en estos pacientes existen niveles elevados de PTH y MRO y descendidos de DMO. Los pacientes cuyos niveles de 25(OH)D son inferiores a 20 ng/mL presentan un remodelado óseo más elevado, con menores niveles de IGF-I y alteraciones de la estructura ósea (Tb.Th) que puedan estar en relación con un mayor riesgo de fracturas (AU)

Introduction: To assess serum levels of 25-hydroxyvitamin D-25 (OH) D-hormones with influence on bone metabolism (parathormone -PTH- and insulin-like growth factor (IGF)-I), bone remodeling markers (BRM) (carboxy-terminal telopeptide of collagen type I-β-CTX- and amino-peptide pro-peptide of procollagen type I -PINP), bone mineral density (BMD), microstructure and biomechanics of the femoral neck, in patients with osteoporotic hip fracture (OH) versus arthritic patients (OA). Material and methods: A cross-sectional observational study of 29 OH and 14 OA, age ≥50 years. We quantified hormonal serum levels and BRM (immunoassay), hip BMD (DXA), microstructure (micro-CT) and biomechanics (uniaxial compression tests, IGFA system). Analysis (SPSS 20.0.) Results: OH patients had lower levels of 25(OH)D (p=0.02) and hip BMD (p<0.05), and higher PTH (p=0.029) and β-CTX (p=0.04). Levels of 25(OH)D correlated positively with IGF-I (p=0.04) and negatively with β-CTX (p=0.003). The PTH values were correlated negatively with hip BMD (p=0.0005) and positively with trabecular thickness (TbTh) (p=0.006). Patients with 25(OH)D <20 ng/mL presented higher levels of β-CTX (p=0.006), lower IGF-I (p=0.007) and TbTh (p=0.04). Conclusions: Vitamin D levels are low in the elderly population, especially in patients with osteoporotic hip fracture. These patients also presented raised levels of PTH and BRM and descended from BMD. Patients whose 25(OH)D levels are below 20 ng/mL present higher bone remodeling, with lower levels of IGF-I and alterations of the bone structure (TbTh) that may be linked to a greater risk of fractures (AU)

Effectiveness of nutritional supplementation on sarcopenia and recovery in hip fracture patients. A multi-centre randomized trial.

BACKGROUND AND OBJECTIVES: Functional deterioration and reduced mobility in elderly patients with a hip fracture are associated with a loss of both muscle mass and function (sarcopenia). The aim of this study was to assess whether oral nutritional supplementation (ONS) improves muscle mass and nutritional markers (BMI, proteins) in elderly patients with hip fracture. METHODS: Patients aged 65 years and over with hip fractures admitted to either of two rehabilitation facilities were included. Patients with diabetes, with Barthel index scores <40 prior to the fracture or with pathological fractures were excluded. A random-numbers generator was used to randomly allocate patients to the intervention group (IG) or the control group (CG). Those in the IG received a standard diet plus ONS in the form of two bottles a day of ß-hydroxy-ß-methylbutyrate (HMB), while those in the CG received a standard diet only. The intervention was not blinded. In order to assess changes in body mass index (BMI), anthropometric parameters were recorded at both admission and discharge. Patients' functional situation was evaluated using the Barthel index (BI) and the Functional Ambulation Categories (FAC) score. Muscle mass was assessed using bioelectrical impedance analysis, which allowed us to calculate appendicular lean mass (aLM). The outcome variable was the difference between aLM upon discharge, minus aLM upon admission (Δ-aLM). RESULTS: Of the 107 randomised patients (IG n55, CG n52), 49 finished the study in the IG and 43 in the CG. BMI and aLM were stable in IG patients, whilst these parametres decreased in the CG. A significant difference was observed between the two groups (p<0.001, and p=0.020 respectively). The predictive factors for Δ-aLM were ONS (p=0.006), FAC prior to fracture (p<0.001) and BI prior to fracture (p=0.007). The concentration of proteins (p=0.007) and vitamin D (p.001) had increased more in the IG than in the CG. CONCLUSION: A diet enriched in HMB improves muscle mass, prevents the onset of sarcopenia and is associated with functional improvement in elderly patients with hip fractures. Orally administered nutritional supplements can help to prevent the onset of sarcopenic obesity. TRIAL REGISTRATION: www.clinicaltrials.gov identifier: NCT01404195, registered 22 July 2011, HYPERPROT-GER Study.

Tratamiento de la anemia perioperatoria de la fractura de cadera / Treatment of perioperative anemia in hip fracture

No disponible

Effect of oral taurine on morbidity and mortality in elderly hip fracture patients: a randomized trial.

Hip fracture patients represent a large part of the elderly surgical population and face severe postoperative morbidity and excessive mortality compared to adult surgical hip fracture patients. Low antioxidant status and taurine deficiency is common in the elderly, and may negatively affect postoperative outcome. We hypothesized that taurine, an antioxidant, could improve clinical outcome in the elderly hip fracture patient. A double blind randomized, placebo controlled, clinical trial was conducted on elderly hip fracture patients. Supplementation started after admission and before surgery up to the sixth postoperative day. Markers of oxidative status were measured during hospitalization, and postoperative outcome was monitored for one year after surgery. Taurine supplementation did not improve in-hospital morbidity, medical comorbidities during the first year, or mortality during the first year. Taurine supplementation lowered postoperative oxidative stress, as shown by lower urinary 8-hydroxy-2-deoxyguanosine levels (Generalized estimating equations (GEE) analysis average difference over time; regression coefficient (Beta): -0.54; 95% CI: -1.08--0.01; p = 0.04), blunted plasma malondialdehyde response (Beta: 1.58; 95% CI: 0.00-3.15; p = 0.05) and a trend towards lower lactate to pyruvate ratio (Beta: -1.10; 95% CI: -2.33-0.12; p = 0.08). We concluded that peri-operative taurine supplementation attenuated postoperative oxidative stress in elderly hip fracture patients, but did not improve postoperative morbidity and mortality.

Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study.

BACKGROUND & AIMS: Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS: A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS: 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION: We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

Study protocol: High-protein nutritional intervention based on ß-hydroxy-ß-methylbutirate, vitamin D3 and calcium on obese and lean aged patients with hip fractures and sarcopenia. The HIPERPROT-GER study.

INTRODUCTION: Loss of muscle strength is associated with falls, which, in turn, are the main cause of hip fractures in elderly people. The factors that most influence loss of strength in elderly people are a decrease in muscle mass, i.e. sarcopenia, and an increase in fat, i.e. obesity. METHODS: A prospective randomized clinical trial among patients who have undergone an operation for a traumatic hip fracture and who are aged 65 or above will be implemented. We shall compare a control diet against a high-protein diet enriched with ß-hydroxy-ßmethylbutirate, calcium and vitamin D. The diet will be administered during 30 days of hospitalization in the orthopaedic geriatric rehabilitation unit. There will be 50 patients in each arm of the study. The main objective is to assess whether the experimental diet, together with rehabilitation, improves functional recovery, measured on the Barthel index. Secondary objectives are to assess changes in body composition and the prevalence of sarcopenia, obesity and mortality one year after the hip fracture. We shall also assess whether there is a relationship between specific inflammatory markers, sarcopenia and functional recovery. CONCLUSIONS: Ageing is accompanied by changes in body composition that increase the risk of falls and progressive functional loss. These factors are a public health problem because they are highly associated with disability in older people. The present study seeks to gain knowledge of those factors that are most often associated with the onset of disability and those that can be modified through diet.

Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial.

BACKGROUND: malnutrition is an important risk factor for poor outcome in patients recovering after hip fracture surgery. This study aimed to investigate the clinical, nutritional and rehabilitation effects of an oral nutritional supplementation (ONS) in an inpatient rehabilitation setting. METHODS: this was an observer-blinded randomised controlled trial of elderly post-surgical proximal femoral fracture patients. A ready-to-use oral liquid nutritional supplementation (18-24 g protein and 500 kcal per day) in addition to hospital diet was compared with hospital diet only. Both groups received usual rehabilitation therapy and oral calcium and vitamin D supplements. Outcomes were compared at discharge from rehabilitation and after 4 weeks of discharge. The primary outcome parameters were the serum albumin level, the body mass index (BMI), the functional independence measure (FIM) and the elderly mobility scale (EMS). Secondary outcome parameters were frequency of complications, inpatient length of stay, mortality and acute hospital use within 6 months after discharge. RESULTS: a total of 126 patients were recruited, 65 in the supplementation arm and 61 in the control arm. There was a significant difference in change in BMI with a decrease of 0.25 and 0.03 kg/m(2) in the ONS group and 0.72 and 0.49 kg/m(2) in the control group at hospital discharge and follow-up, respectively (P = 0.012). The length of stay in rehabilitation ward was shortened by 3.80 (SE = 1.81, P = 0.04) days favouring the ONS group. The total number of infection episodes was also reduced significantly. No difference was observed in the rate of change of the serum albumin level, the FIM and the EMS. CONCLUSION: clinical and nutritional benefits were seen in this trial but rehabilitation benefits could not be demonstrated.

Integrated nutritional intervention in the elderly after hip fracture. A process evaluation.

BACKGROUND & AIMS: Within a multicentre randomized controlled trial aimed at improving the nutritional status and increase the speed of recovery of elderly hip fracture patients, we performed a process evaluation to investigate the feasibility of the intervention within the present Dutch health care system. METHODS: Patients in the intervention group received nutritional counseling during 10 contacts. Oral nutritional supplements were advised as needed until three months after hip fracture surgery. The intervention was evaluated with respect to dieticians' adherence to the study protocol, content of nutritional counseling, and patients' adherence to recommendations given. RESULTS: We included 66 patients (mean age of 76, range 55-92 years); 74% women. Eighty-three percent of patients received all 10 contacts as planned, but in 62% of the patients one or more telephone calls had to be replaced by face to face contacts. Nutritional counseling was complete in 91% of contacts. Oral nutritional supplementation was needed for a median period of 76 days; 75% of the patients took the oral nutritional supplements as recommended. CONCLUSIONS: Nutritional counseling in elderly hip fracture patients through face to face contacts and telephone calls is feasible. However, individual tailoring of the intervention is recommended. The majority of hip fracture patients needed >2 months oral nutritional supplements to meet their nutritional requirements. The trial was registered at clincialtrails.gov as NCT00523575.

A trial assessing N-3 as treatment for injury-induced cachexia (ATLANTIC trial): does a moderate dose fish oil intervention improve outcomes in older adults recovering from hip fracture?

BACKGROUND: Proximal femoral fractures are associated with increased morbidity and mortality. Pre-existing malnutrition and weight loss amongst this patient group is of primary concern, with conventional nutrition support being largely ineffective. The inflammatory response post proximal femoral fracture surgery and the subsequent risk of cachexia may explain the inability of conventional high energy high protein management to produce an anabolic response amongst these patients. Omega-3 fatty acids derived from fish oils have been extensively studied for their anti-inflammatory benefits. Due to their anti-inflammatory properties, the benefit of fish oil combined with individualized nutrition support amongst proximal femoral fracture patients post surgery is an attractive potential therapeutic strategy. The aim of the ATLANTIC trial is to assess the potential benefits of an anti-inflammatory dose of fish oil within the context of a 12 week individualised nutrition program, commencing seven days post proximal femoral fracture surgery. METHODS/DESIGN: This randomized controlled, double blinded trial, will recruit 150 community dwelling elderly patients aged ≥65 years, within seven days of surgery for proximal femoral fracture. Participants will be randomly allocated to receive either a 12 week individualized nutrition support program complemented with 20 ml/day anti-inflammatory dose fish oil (~3.6 g eicosapentaenoic acid, ~2.4 g docosahexanoic acid; intervention), or, a 12 week individualized nutrition support program complemented with 20 ml/day low dose fish oil (~0.36 g eicosapentaenoic acid, ~0.24 g docosahexanoic acid; control). DISCUSSION: The ATLANTIC trial is the first of its kind to provide fish oil combined with individualized nutrition therapy as an intervention to address the inflammatory response experienced post proximal femoral fracture surgery amongst elderly patients. The final outcomes of this trial will assist clinicians in the development of effective and alternative treatment methods post proximal femoral fracture surgery which may ultimately result in a reduction in systemic inflammation, loss of weight and lean muscle and improvements in nutritional status, mobility, independence and quality of life among elderly patients. TRIAL REGISTRATION: ACTRN12609000241235.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial.

BACKGROUND: Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness. METHODS: Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture. DISCUSSION: Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011. TRIAL REGISTRATION: ClinicalTrials.gov NCT00523575.

Importance of dietary advice, nutritional supplements and compliance for maintaining body weight and body fat after hip fracture.

OBJECTIVE: Poor nutritional status amongst elderly individuals with hip fractures is well documented. Studies have suggested that 30-50 % of patients admitted to orthopaedic departments suffer from protein-energy malnutrition (PEM). DESIGN: An 6 month intervention study. SETTING: The study was conducted in Sweden between February 2005 and October 2006. PARTICIPANTS: Elderly patients with hip fractures (n=32). METHODS: Evaluation of compliance with individual nutritional support and whether body weight and body fat (BF) could be maintained after six months. Evaluation of possible effects of nutritional supplements and dietary advice after hip fracture on BMI, BF, and Mini Nutritional Assessment (MNA). RESULTS: Overall compliance with supplement intake was 73%. After six months, BMI was unchanged. Women's BF had decreased (P < 0.01), although the mean calorie intake with nutritional support was 34 calories per kg body weight/day. Three groups could be identified: one group with increased body weight and BF, one with loss of body weight and BF, and one with increased body weight together with increased TBW and loss of BF. PARTICIPANTS who consumed 0-1 supplements daily lost more weight than those who consumed 2 supplements daily. There was a positive difference (p= < 0.001) for women between MNA values at baseline and after six months. CONCLUSION: In the present study compliance was satisfactory at the group level, and the energy and protein intake increased significantly. BMI was unchanged during the 6 months period. However, the women lost BF during the study period of with some had increasing total body water (TBW). MNA values for women changed in a positive direction.

Does nutritional intervention for patients with hip fractures reduce postoperative complications and improve rehabilitation?

AIMS AND OBJECTIVES: The aims were to investigate whether there were any differences between patients receiving nutritional intervention preoperatively and over five days postoperatively and patients who did not, in terms of postoperative complications, rehabilitation, length of stay and food and liquid intake. BACKGROUND: Patients with hip fractures are often malnourished at admission to hospital and they typically do not receive the energy and calories needed postoperatively. DESIGN: The design was a quasi-experimental, pre- and post-test comparison group design without random group assignment. METHODS: One hundred patients with hip fractures were consecutively included. The control group (n = 50) received regular nutritional support. The intervention group (n = 50) received nutrition according to nutritional guidelines. The outcome measures used were risk of pressure ulcer, pressure ulcers, weight, nosocomial infections, cognitive ability, walking assistance and functional ability, collected preoperatively and five days postoperatively. Each patient's nutrient and liquid intake were assessed daily for five days postoperatively. RESULTS: Significantly fewer (p = 0.043) patients in the intervention group (18%) had pressure ulcers five days postoperatively compared with the control group (36%). Nutrient and liquid intake was significantly higher (p < 0.001) in the intervention group. Median length of stay decreased from nine to seven days (p = 0.137), as did nosocomial infections, from 18-8.7% (p = 0.137). CONCLUSION: Patients with hip fractures receiving nutrition according to nutritional guidelines developed fewer pressure ulcers. This is invaluable to patients' quality of life and a major economic saving for society. RELEVANCE TO CLINICAL PRACTICE: Great benefits can be gained for the patients through modest efforts by nurses and physicians such as nutritional intervention.

Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward.

OBJECTIVE: To examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture. DESIGN: Open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA. SETTING: Thirty-eight bedded acute trauma ward in a teaching hospital. PARTICIPANTS: All but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively. PRIMARY OUTCOME MEASURE: Postoperative mortality in the acute trauma unit. SECONDARY OUTCOME MEASURES: Postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status. RESULTS: DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95% CI 259-440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements. CONCLUSION: Dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients' risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.

Nutritional treatment of bone fracture.

PURPOSE OF REVIEW: Osteoporosis and sarcopenia are nutrition-related risk factors for bone fracture and delayed recuperation from fracture. The purpose of this review was to summarize recent studies that evaluated the effect of the nutritional or anabolic treatment of patients with osteoeporotic, e.g. hip, fractures. RECENT FINDINGS: Four short-term supplementation trials reported trends for improved nutritional and functional status. A high dropout rate and low compliance contributed to negative deductions. The latest Cochrane update on hip fracture aftercare sticks to its previous conclusion that multinutrient feeds reduce the incidence of unfavourable outcomes, i.e. mortality and complications combined. Nandrolone in combination with liquid supplementation improved lean body mass, activities of daily living function and quality of life, effects reported to be partly similar for growth hormone treatment. Bone resorption decreased on 12 months' liquid supplementation in community dwelling osteoporotic individuals. A high protein intake was associated with a lower risk of hip fracture. Calcium and vitamin D supplementation remain the basic prevention for osteoporotic fractures. SUMMARY: Recent supplementation studies appeared to be underpowered or suffered logistic problems, but previous recommendations for multinutrient feeding in hip fracture aftercare remain. Supplementation trials of higher scientific quality are needed, and enteral feeding, anabolic treatment and multimodal approaches need to be evaluated further.