Secondary osteoporosis prevention: three-year outcomes from a Fracture Liaison Service in elderly hip fracture patients.

BACKGROUND: Hip fractures are the most serious fragility fractures due to their associated disability, higher hospitalization costs and high mortality rates. Fracture Liaison Service (FLS) programs have enhanced the management of osteoporosis-related fractures and have shown their clinical effectiveness. AIMS: To analyze the effect of the implementation of a FLS model of care over the survival and mortality rates following a hip fracture. METHODS: We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture before and after the implementation of the FLS in our center (between January 2016 and December 2019). Patients were followed for three years after the index date. Mortality, complications and refracture rates were compared between the two groups using a Multivariate Cox proportional hazard model. RESULTS: A total of 1366 patients were included in this study (353 before FLS implementation and 1013 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (79.3% vs 12.5%; p < 0.01) and there was an increase in adherence to treatment (51.7% vs 30.2%; p < 0.01). A total of 413 (40.8%) patients after FLS implementation and 141 (39.9%) individuals before (p = 0.47) died during the three-years follow-up period. A second fracture occurred in 101 (10.0%) patients after FLS implementation and 37 (10.5%) individuals before (p = 0.78). Patients after the implementation of the FLS protocol had a lower all cause one-year mortality [adjusted Hazard Ratio (HR) 0.74 (0.57-0.94)] and a decreased risk of suffering a second osteoporotic fracture [adjusted HR 0.54 (0.39-0.75) in males and adjusted HR 0.46 (0.30-0.71) in females]. CONCLUSIONS: The implementation of a FLS protocol was associated with a lower all-cause one-year mortality rate and a higher survivorship in elderly hip fracture patients. However, no three-year mortality rate differences were observed between the two groups. We also found a reduction in the complication and second-fracture rates.

Balancing fracture risk versus risk of mortality before fracture among women aged 80 years or older.

BACKGROUND: Most fractures occur in women aged ≥80 years but competing mortality unrelated to fracture may limit the benefit of osteoporosis drug therapy for some women in late life. Our primary aim was to develop separate prediction models for non-spine fracture (NSF) and mortality before fracture to identify subsets of women with varying fracture versus mortality risks. METHODS: Separate prediction models were developed for NSF and mortality before NSF for 4895 women aged ≥80 years enrolled in the Study of Osteoporotic Fractures (SOF) or the Health Aging and Body Composition (HABC) study. Proportional hazards models modified to account for competing mortality were used to identify candidate risk factors for each outcome. Predictors associated with NSF or mortality (p < 0.2) were included in separate competing risk models to estimate the cumulative incidence of NSF and mortality before NSF during 5 years of follow-up. This process was repeated to develop separate prediction models for hip fracture and mortality before hip fracture. RESULTS: Significant predictors of NSF (race, total hip BMD, grip strength, prior fracture, falls, and use of selective serotonin reuptake inhibitors, benzodiazepines, or oral/transdermal estrogen) differed from predictors of mortality before NSF (age, walking speed, multimorbidity, weight change, shrinking, smoking, self-rated health, dementia, and use of warfarin). Within nine subsets of women defined by tertiles of risk, 5-year outcomes varied from 28% NSF and 8% mortality in the high-risk NSF/low-risk mortality subset, to 9% NSF and 22% mortality in the low-risk NSF/high-risk mortality subset. Similar results were seen for predictors of hip fracture and mortality before hip fracture. CONCLUSION: Considerable variation in 5-year competing mortality risk is present among women in late life with similar 5-year NSF risk. Both fracture risk and life expectancy should inform shared clinical decision-making regarding initiation or continuation of osteoporosis drug therapy for women aged ≥80 years.

Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Mortality following fragility hip fracture in China: a record linkage study.

Mortality risk declined over time. Patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China. PURPOSE: Hip fractures in older adults often lead to an elevated risk of death. However, few studies investigated mortality risk following hip fracture in mainland China. This retrospective cohort study aimed to evaluate the crude mortality and excess mortality after fragility hip fractures in Lishui residents aged 50 years and older. METHODS: Patients having a fragility hip fracture between October 2013 and August 2019 were identified from the Lishui District Inpatient Data Collection and followed up until August 2020. Death information was ascertained from the linked death registry records. We calculated the follow-up mortality rate and corresponding 95% confidence intervals (CIs) as well as the standard mortality ratios (SMRs) in comparison with the mortality rates of Lishui residents. RESULTS: During the study period, a total of 808 patients (63.4% females) with an average age of 75 years were admitted for fragility hip fractures. The 1st, 2nd, and 3rd year follow-up mortality rates were 16.51, 6.06, and 5.03 per 100 person-year, respectively. The SMRs were 8.46 (6.94, 9.97), 5.74 (4.86, 6.63), and 4.63 (3.98, 5.27) for the 1st, 2nd, and 3rd year following fragility hip fracture. CONCLUSION: Although mortality risk declined over time, patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China.

'Skeletal Age' for mapping the impact of fracture on mortality.

Background: Fragility fracture is associated with an increased risk of mortality, but mortality is not part of doctor-patient communication. Here, we introduce a new concept called 'Skeletal Age' as the age of an individual's skeleton resulting from a fragility fracture to convey the combined risk of fracture and fracture-associated mortality for an individual. Methods: We used the Danish National Hospital Discharge Register which includes the whole-country data of 1,667,339 adults in Denmark born on or before January 1, 1950, who were followed up to December 31, 2016 for incident low-trauma fracture and mortality. Skeletal age is defined as the sum of chronological age and the number of years of life lost (YLL) associated with a fracture. Cox's proportional hazards model was employed to determine the hazard of mortality associated with a specific fracture for a given risk profile, and the hazard was then transformed into YLL using the Gompertz law of mortality. Results: During the median follow-up period of 16 years, there had been 307,870 fractures and 122,744 post-fracture deaths. A fracture was associated with between 1 and 7 years of life lost, with the loss being greater in men than women. Hip fractures incurred the greatest loss of life years. For instance, a 60-year-old individual with a hip fracture is estimated to have a skeletal age of 66 for men and 65 for women. Skeletal Age was estimated for each age and fracture site stratified by gender. Conclusions: We propose 'Skeletal Age' as a new metric to assess the impact of a fragility fracture on an individual's life expectancy. This approach will enhance doctor-patient risk communication about the risks associated with osteoporosis. Funding: National Health and Medical Research Council in Australia and Amgen Competitive Grant Program 2019.

Osteoporosis is a 'silent disease' which often has no immediate symptoms but gradually weakens bones and makes them more likely to break. A bone fracture caused by osteoporosis in people over the age of 50 is linked to long-term health decline and in some cases, even early death. However, poor communication of the mortality risk to patients has led to a low uptake of treatment, resulting in a crisis of osteoporosis management. The impact of a fracture on life expectancy is typically conveyed to patients and the public in terms of probability (how likely something is to occur) or the relative risk of death compared to other groups. However, statements such as "Your risk of death over the next 10 years is 5% if you have suffered from a bone fracture" can be difficult to comprehend and can lead to patients underestimating the gravity of the risk. With the aim of devising a new way of conveying risks to patients, Tran et al. analyzed the relationship between fracture and lifespan in over 1.6 million individuals who were 50 years of age or older. The findings showed that one fracture was associated with losing up to 7 years of life, depending on gender, age and fracture site. Based on this finding, Tran et al. proposed the idea of 'skeletal age' as a new metric for quantifying the impact of a fracture on life expectancy. Skeletal age is the sum of the chronological age of a patient and the estimated number of years of life lost following a fracture. For example, a 60-year-old man with a hip fracture is predicted to lose an estimated 6 years of life, resulting in a skeletal age of around 66. Therefore, this individual has the same life expectancy as a 66-year-old person that has not experienced a fracture. Skeletal age can also be used to quantify the benefit of osteoporosis treatments. Some approved treatments substantially reduce the likelihood of post-fracture death and translating this into skeletal age could help communicate this to patients. For instance, telling patients that "This treatment will reduce your skeletal age by 2 years" is easier to understand than "This treatment will reduce your risk of death by 25%". Given the current crisis of osteoporosis management, adopting skeletal age as a new measure of how the skeleton declines after a fracture could enhance doctor-patient communication regarding treatment options and fracture risk assessment. Tran et al. are now developing an online tool called 'BONEcheck.org' to enable health care professionals and the public to calculate skeletal age. Future work should investigate the effectiveness of this new metric in conveying risk to patients, compared with current methods.

Análisis de los factores de riesgo de mortalidad al año en pacientes con fractura de cadera osteoporótica en España: un estudio observacional prospectivo / Analysis of risk factors for mortality at one year in patients with osteoporotic hip fracture in Spain: a prospective observational study

Objetivo: Analizar los factores de riesgo que inciden en la mortalidad al año de las fracturas de cadera osteoporóticas en España. Materiales y métodos: Fue un estudio observacional prospectivo. Los pacientes con fractura de cadera que fueron intervenidos quirúrgicamente en el Hospital Universitario Virgen Macarena de Sevilla, España del1 de enero de 2017 al 31 de diciembre de 2017. Se recopiló la información requerida a través de registros de historia clínica y seguimiento. Se realizó un análisis de factor único para descartar los factores con p<0,1, y luego estos factores se incluyeron en el análisis de regresión de Cox para averiguar los factores de riesgo independientes para la mortalidad posoperatoria al año. Resultados: Se incluyeron un total de 426 participantes, 107 hombres (25,1%) y 319 mujeres (74,9%). Durante el seguimiento de un año fallecieron 81 casos (19,0%). Hubo 7 factores de riesgo independientes relacionados con la tasa de mortalidad al año de las fracturas de cadera osteoporóticas en España: Los factores de riesgo inmodificables incluyeron los niveles de actividad previos a la lesión, ASA grado 4 y enfermedad pulmonar combina-da. Los factores de riesgo prevenibles incluyeron complicaciones respiratorias, complicaciones cardiovasculares, complicaciones cerebrovasculares, y trombosis venosa. Conclusión: La tasa de mortalidad de las fracturas de cadera osteoporóticas en España es relativamente alta, pero mediante la prevención activa de las complicaciones postoperatorias, la tasa de mortalidad puede disminuir. (AU)

Objetive: Aanalyze the risk factors that affect the one-year mortality of osteoporotic hip fractures in Spain. Materials and methods: This was a prospective observational study. Participants came from patients with hip fractures who underwent surgery at the Virgen Macarena University Hospital in Seville, Spain from January 1, 2017 to December 31, 2017. The required infor-mation was collected through medical history re-cords and follow-up. A single factor analysis was performed to screen out the factors with p<0.1, and then these factors were brought into the Cox regression analysis to find out the independent risk factors for the one-year postoperative mortality. Results: A total of 426 participants were included, 107 males (25.1%) and 319 females (74.9%). During the one-year follow-up, 81 cases (19.0%) died. There were 7 independent risk factors related to the one-year mortality rate of osteoporotic hip fractures in Spain: Unchangeable risk factors in-cluded pre-injury activity levels, ASA grade 4 , and combined lung disease. Preventable risk factors included respiratory complications, cardiovascu-lar complications cerebrovascular complications, and venous thrombosis. Conclusion: The mortality rate of osteoporotic hip frac-tures in Spain is relatively high, but through active prevention of postoperative complications, the mortality rate may decrease. (AU)

Mortality related to and functional outcomes of upper cervical spine fractures in the elderly.

BACKGROUND: Although the mortality related to hip fracture and osteoporotic vertebral fracture have been reported, few studies have examined the mortality related to atlas and/or axis fractures. The aim of this study was to assess the association between mortality and atlas and/or axis fractures retrospectively and to elucidate the efficacy of surgical treatment. METHODS: A total of 33 elderly patients who were treated for atlas and/or axis fractures at our institution between January 2012 and December 2018 were included in this study. These patients were divided into two groups: surgical treatment and conservative treatment. Fracture types, comorbidities, neurological status, treatment types, and walking ability at follow-up were reviewed. Mortality was assessed using medical records or via phone interviews. RESULTS: The mean age at injury was 79.9 ± 8.0 years, and the mean follow-up period was 2.3 years. The overall mortality rates at 1 and 5 years were 21.4% and 48.4%, respectively. During the observation period, 12 (36%) patients died. Twenty-two patients were treated conservatively (14 were treated with a cervical collar, 8 were treated with a halo vest). Surgical procedures included occipital-cervical fixation, osteosynthesis of C2 fractures, C1-2 fixation, and C1-4 fixation using a posterior approach. Surgical treatment correlated with better survival rates. There was no significant difference between the two groups in terms of ambulatory ability and functional recovery. CONCLUSION: Upper cervical spine fractures appear to have a worse prognosis compared to hip and osteoporotic vertebral fractures. This study indicates the efficacy of surgical treatment for upper cervical spine fractures in the elderly for improving survival prognosis.

Fracture Liaison Service for Hip Fractures: Is It A Game Changer?

BACKGROUND: Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world. OBJECTIVES: To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture. METHODS: We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6-12 weeks following the fracture to ensure treatment initiation. RESULTS: From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate. CONCLUSIONS: FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center.

Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience.

BACKGROUND: Fragility fractures of the pelvis (FFP) represent an increasing clinical entity. Until today, there are no guidelines for treatment of FFP. In our center, recommendation for operative treatment was given to all patients, who suffered an FFP type III and IV and to patients with an FFP type IIwith unsuccessful non-operative treatment. We performed a retrospective observational study and investigated differences between fracture classes and management alternatives. We hypothetized that operative treatment may reduce mortality. MATERIALS AND METHODS: The medical charts and radiographs of 362 patients were analysed. Patient demographics, FFP-classification, length of hospital stay (LoS), type of treatment, general and surgery-related complications, mortality, Short Form-8 physical component score (SF-8 PCS) and mental component score (SF-8 MCS), Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were documented. RESULTS: 238 patients had FFP type II and 124 FFP type III and IV. 52 patients with FFP type II (21.8%) and 86 patients with FFP type III and IV (69.4%) were treated operatively (p<0.001). Overall mortality did not differ between the fracture classes (p = 0.127) but was significantly lower in the operative group (p<0.001). Median LoS was significantly higher in FFP type III and IV (p<0.001) and in operated patients (p<0.001). There were more in-hospital complications in patients with FFP type III and IV (p = 0.001) and in the operative group (p = 0.006). More patients of the non-operative group were mobile (p<0.001) and independent (p<0.001) at discharge. Half of the patients could not return in their living environment.203 of the 235 surviving patients (86%) answered the questionnaires after a mean follow-up time of 38 months. SF-8 PCS, SF-8 MCS and PMS did not differ between the fracture classes and treatment groups. Pain perception was higher in the operated group (p = 0.013). CONCLUSION: In our study, we observed that operative treatment of FFP provides low mortality rates, although LoS and in-hospital complications were higher in the operative group. At discharge, the non-operative group was more mobile and independent. At follow up, quality of life and mobility were comparable between the groups. Further prospective studies are needed to clarify the impact of operative treatment of FFP on mortality and functional outcome.

Mobility and mortality of 340 patients with fragility fracture of the pelvis.

PURPOSE: To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan. METHODS: We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated. RESULTS: According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%. CONCLUSION: According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.

[Influence of early hip fracture surgery in the elderly on mortality, readmissions, dependence and quality of life.] / Influencia de la cirugía precoz de la fractura de cadera en ancianos en la mortalidad, los reingresos, la dependencia y la calidad de vida.

OBJECTIVE: In spite of technical advances, hip fracture causes high mortality in the elderly. We wanted to know early surgery influence to mortality during admission, one year and after five years, as well as readmissions at one month and one year. We also wanted to know how dependence and Health-Related Quality of Life (HRQOL) evolved in the twelve months of follow-up and what factors were associated with poor patient evolution. METHODS: A prospective observational study was made in patients over 65 years of age treated for osteoporotic hip fracture in a level III hospital between 2010- 2012, with consecutive sampling. We evaluated functionality (Barthel) and quality of life (EuroQol-5D) basal (before fracture), within 30 days, within six and twelve months; readmissions within the 30 days and within one year; and mortality during admission; within one and five years. We used the statistical program SPSS Version 25.0 for the statistical analysis. RESULTS: We followed 327 patients of 82.9 (SD: 6.9) years of means, 258 (78.9%) were women. Fifty-four (45.9%) were treated within 24 hours and 237 (72.5%) within 48 hours. They returned 14 (4.3%) within the 30 days and 44 (13.5%) within the one year. There were 8 deaths during admission (2.4%) and 61 (19.2%) in the first year and 185 (54,6%) within five years. The pre-fracture quality of life was 0.43 median (0.24-0.74), at the month 0.15 (0.07-0.28), at six months 0.26 (0, 13-0.59) and at twelve 0.24 (0.15-0.58). The previous functionality was 85.0 (55.0-100) at the month 35.0 (20.0-60.0) and 60.0 (25.0-85.0) at six and twelve months. There were significant differences between all visits except between six and twelve months. CONCLUSIONS: The patients get worse significantly at the month of surgery and recover in the six months, remaining at twelve, without reaching the baseline value. The results in mortality and readmissions per year are worse for men and older. Early surgery does not reduce mortality, but re-admissions to the year.

OBJETIVO: A pesar de los avances técnicos, la fractura de cadera conlleva una alta mortalidad en ancianos. Con este estudio se deseó conocer cómo influía la cirugía precoz en la mortalidad durante el ingreso, al año y tras cinco años, así como en los reingresos al mes y al año. También se quiso conocer cómo evolucionaban la dependencia y la Calidad de Vida Relacionada con la Salud (CVRS) en los doce meses de seguimiento y qué factores se asociaban a una mala evolución del paciente. METODOS: Se realizó un estudio observacional prospectivo en mayores de 65 años intervenidos por fractura de cadera osteoporótica en un hospital de nivel III, entre 2010 y 2012, con un muestreo consecutivo. Se evaluaron los siguientes factores: funcionalidad (Barthel); calidad de vida (EuroQol-5D) previa, al mes, a los seis y doce meses; reingresos al mes y al año; y mortalidad al ingreso, al año y a los cinco años. El análisis estadístico se realizó con el programa estadístico SPSS Versión 25.0. RESULTADOS: Se siguieron 327 pacientes de 82,9 (SD: 6,9) años de media, de los que 258 (78,9%) fueron mujeres. Se intervinieron 150 (45,9%) en las primeras 24 horas y 237 (72,5%) en las primeras 48 horas. Reingresaron 14 (4,3%) al mes y 44 (13,5%) al año. Hubo 8 muertes intraepisodio (2,4%), 61 (19,2%) al año y 185 (54,6%) a los cinco años. La calidad de vida previa a la fractura fue de 0,43 de mediana (0,24-0,74), 0,15 (0,07-0,28) al mes, 0,26 (0,13-0,59) a los seis meses y 0,24 (0,15-0,58) a los doce meses. La funcionalidad basal fue de 85 (55,0-100), 35 (20,0-60,0) al mes y 60 (25,0-85,0) a los seis y doce meses. Existieron diferencias estadísticamente significativas entre todas las visitas excepto a los seis y doce meses. CONCLUSIONES: Los pacientes empeoran notablemente al mes de la cirugía, recuperándose a los seis meses y manteniéndose a los doce, sin alcanzar el valor basal. Los resultados en mortalidad y reingresos al año son peores para los hombres y los más mayores. La cirugía precoz no disminuye la mortalidad, pero sí los reingresos al año.

Association between post-stroke disability and 5-year hip-fracture risk: The Women's Health Initiative.

BACKGROUND: Hip fractures are a significant post-stroke complication. We examined predictors of hip fracture risk after stroke using data from the Women's Health Initiative (WHI). In particular, we examined the association between post-stroke disability levels and hip fracture risk. METHODS: The WHI is a prospective study of 161,808 postmenopausal women aged 50-79 years. Trained physicians adjudicated stroke events and hip fractures. Our study included stroke survivors from the observational and clinical trial arms who had a Glasgow Outcome Scale of good recovery, moderately disabled, or severely disabled and survived more than 7 days post-stroke. Hip fracture-free status was compared across disability levels. Secondary analysis examined hip fracture risk while accounting for competing risk of death. RESULTS: Average age at time of stroke was 74.6±7.2 years; 84.3% were white. There were 124 hip fractures among 4,640 stroke survivors over a mean follow-up time of 3.1±1.8 years. Mortality rate was 23.3%. Severe disability at discharge (Hazard Ratio (HR): 2.1 (95% Confidence Interval (CI): 1.4-3.2), but not moderate disability (HR: 1.1 (95%CI: 0.7-1.7), was significantly associated with an increased risk of hip fracture compared to good recovery status. This association was attenuated after accounting for mortality. White race, increasing age and higher Fracture Risk Assessment Tool (FRAX)-predicted hip fracture risk (without bone density information) were associated with an increased hip fracture risk. After accounting for mortality, higher FRAX risk and white race remained significant. CONCLUSION: Severe disability after stroke and a higher FRAX risk score were associated with risk of subsequent hip fracture. After accounting for mortality, only the FRAX risk score remained significant. The FRAX risk score appears to identify stroke survivors at high risk of fractures. Our results suggest that stroke units can consider the incorporation of osteoporosis screening into care pathways.

Mortality of high-risk orthopaedic oncology patients during the COVID-19 pandemic: A prospective cohort study.

BACKGROUND AND OBJECTIVES: Should the threshold for orthopaedic oncology surgery during the coronavirus disease-2019 (COVID-19) pandemic be higher, particularly in men aged 70 years and older? This study reports the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during, respiratory complications and 30-day mortality during the COVID-19 pandemic. METHODS: This prospective observational cohort study included 100 consecutive patients. The primary outcome measure was 14-day symptoms and/or SARS-CoV-2 test. The secondary outcome was 30-day postoperative mortality. RESULTS: A total of 100 patients comprising 35 females and 65 males, with a mean age of 52.4 years (range, 16-94 years) included 16 males aged greater than 70 years. The 51% of patients were tested during their admission for SARS-CoV-2; 5% were diagnosed/developed symptoms of SARS-CoV-2 during and until 14 days post-discharge; four were male and one female, mean age 41.2 years (range, 17-75 years), all had primary malignant bone or soft-tissue tumours, four of five had received immunosuppressive therapy pre-operatively. The 30-day mortality was 1% overall and 20% in those with SARS-CoV-2. The pulmonary complication rate was 3% overall. CONCLUSIONS: With appropriate peri-operative measures to prevent viral transmission, major surgery for urgent orthopaedic oncology patients can continue during the COVID-19 pandemic. These results need validating with national data to confirm these conclusions.

The association between Single Nucleotide Polymorphisms of Klotho Gene and Mortality in Elderly Men: The MrOS Sweden Study.

The Klotho (KL) gene is involved in phosphate homeostasis. Polymorphisms in this gene have been reported to be associated with the risk of cardiovascular disease. Here we used computational tools to predict the damage-associated single nucleotide polymorphisms (SNPs) in the human KL gene. We further investigated the association of SNPs in the KL gene and mortality in the Swedish multicenter prospective Osteoporotic Fractures in Men (MrOS) cohort. This study included 2921 men (aged 69-81 years) with mean 4.49 ± 1.03 years follow-up. 18 SNPs in the KL gene were genotyped using Sequenom. These SNPs were identified by in silico tools for the coding and noncoding genome to predict the damaging SNPs. After quality analyses, SNPs were analyzed for mortality risk using two steps approach on logistic regression model screening and then Cox regression model confirmation. Two non-synonymous SNPs rs9536314 and rs9527025 were found to be potentially damaging SNPs that affect KL protein stability and expression. However, these two SNPs were not statistically significantly associated with all-cause mortality (crude Hazard ratio [HR] 1.72, 95% confidence interval [CI] 0.96-3.07 in rs9536314; crude HR 1.82, 95% CI 0.998-3.33 in rs9527025) or cardiovascular mortality (crude HR 1.52, 95% CI 0.56-4.14 in rs9536314; crude HR 1.54, 95% CI 0.55-4.33 in rs9527025) in additive model using Cox regression analysis. In conclusion, these two potentially damaging SNPs (rs9536314 and rs9527025) in the KL gene were not associated with all-cause mortality or cardiovascular mortality in MrOs cohort. Larger scales studies and meta-analysis are needed to confirm the correlation between polymorphisms of the KL gene and mortality.

Risk factors for major adverse cardiovascular events after osteoporotic hip fracture repair surgery.

Osteoporotic hip fracture (OHF) is an increasingly frequent age-related pathology, which results in high rates of functional loss and mortality within the first year after surgery. This study assessed whether preoperative levels of brain natriuretic peptide (NT-proBNP) and troponin I were related to early occurrence (30d) of major adverse cardio-vascular events (MACE) after OHF repair surgery. During a 6-month period, perioperative clinical and analytical data from consecutive patients, without known history of cardiovascular disease and undergoing surgery for OHF repair at a single centre, were prospectively collected. MACE was defined as acute myocardial ischaemia or infarction, acute heart failure or cardiovascular death. amongst the 140 patients included, 23 (16.4%) developed postoperative MACE (MACE group) and 117 did not (Control group). Compared to those from control group, patients from MACE group were older, had poorer physical status (ASA III-IV), received preoperative red blood cell transfusion (RBCT) more frequently, presented with lower haemoglobin concentrations and higher NT-proBNP, creatinine and troponin I concentrations. Overall, RBCT requirements and 30d mortality rate were also higher in MACE group. However, in multivariate analysis, only preoperative RBCT, creatinine >1 mg/dL and NT-proBNP >450 pg/mL remained as independent preoperative risks factors for postoperative MACE, while 95% confidence intervals of odds ratios were wide. Though our findings require confirmation in a larger multicentre cohort, identifying risk factors for early postoperative MACE after OHF repair surgery, might facilitate assessing patients' risk prior to and following surgery, and targeting them the appropriate preventive and/or therapeutic interventions.

Racial Disparities Exist in Outcomes After Major Fragility Fractures.

BACKGROUND: Fractures associated with postmenopausal osteoporosis (PMO) are associated with pain, disability, and increased mortality. A recent, nationwide evaluation of racial difference in outcomes after fracture has not been performed. OBJECTIVE: To determine if 1-year death, debility, and destitution rates differ by race. DESIGN: Observational cohort study. SETTING: US Medicare data from 2010 to 2016. PARTICIPANTS: Non-Hispanic black and white women with PMO who have sustained a fragility fracture of interest: hip, pelvis, femur, radius, ulna, humerus, and clinical vertebral. MEASUREMENTS: Outcomes included 1-year: (1) mortality, identified by date of death in Medicare vital status information, (2) debility, identified as new placement in long-term nursing facilities, and (3) destitution, identified as becoming newly eligible for Medicaid. RESULTS: Among black and white women with PMO (n = 4,523,112), we identified 399,000 (8.8%) women who sustained a major fragility fracture. Black women had a higher prevalence of femur (9.0% vs 3.9%; P < .001) and hip (30.7% vs 28.0%; P < .001) fractures and lower prevalence of radius/ulna (14.7% vs 17.0%; P < .001) and clinical vertebral fractures (28.8% vs 33.5%; P < .001) compared with white women. We observed racial differences in the incidence of 1-year outcomes after fracture. After adjusting for age, black women had significantly higher risk of mortality 1 year after femur, hip, humerus, and radius/ulna fractures; significantly higher risk of debility 1 year after femur and hip fractures; and significantly higher risk of destitution for all fractures types. CONCLUSIONS: In a sample of Medicare data from 2010 to 2016, black women with PMO had significantly higher rates of mortality, debility, and destitution after fracture than white women. These findings are a first step toward understanding and reducing disparities in PMO management, fracture prevention, and clinical outcomes after fracture. J Am Geriatr Soc 68:1803-1810, 2020.

Effect of Sarcopenia on Mortality after Percutaneous Vertebral Augmentation Treatment for Osteoporotic Vertebral Compression Fractures in Elderly Patients: A Retrospective Cohort Study.

OBJECTIVE: The aim to evaluate central sarcopenia, as measured by psoas cross-sectional area on admission imaging, is associated with outcomes in patients with vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation treatment. METHODS: We evaluated the records of patients aged >60 years treated with vertebroplasty or kyphoplasty between 2009 and 2018 for osteoporotic VCFs. The Social Security Death Index was used to determine death. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. A multivariate Cox algorithm was applied to recognize factors independently associated with survival. RESULTS: A total of 103 patients were included with an average age of 72.3 years. During the study period, 22 (21.4%) patients were deceased, whereas 81 (78.6%) were alive. The survival rates at 1 month, 6 months, and 1 year after surgery were 99%, 94.1%, and 88.4%, respectively. PLVI measurements ranged from 0.24-1.19 with a mean of 0.59 ± 0.17 and a median of 0.603. A total of 51 patients with a median value of 0.603 were defined as low PLVI group, and 52 patients with a median value of ≥0.603 were defined as the high PLVI group. PLVI was significantly low in patients who died. Age, American Society of Anesthesiologists score, and PLVI value were independently associated with a poor overall survival. CONCLUSIONS: There is a significant correlation between sarcopenia and postoperative mortality after vertebral augmentation procedure in patients with VCFs.

The one-year mortality rate in elderly patients with osteoporotic fractures of the pelvis.

Osteoporosis is a common condition for elderly people. The incidence of osteoporotic pelvic fractures has been increasing. Osteoporotic pelvic fractures are associated with increased mortality rates. Based on the aim of our study, we found out that one-year mortality rate after a pelvic fracture is high and depends on the fracture type. PURPOSE: The aim of this study was to determine the one-year mortality rate in patients aged 65+ with osteoporotic pelvic fractures depending on the type of fracture according to AO/OTA classification. METHODS: Patients aged 65+ with pelvic insufficiency fractures admitted to a single center between 1 June 2013 and 31 December 2016 were enrolled in the study. The fractures were classified according to AO/OTA classification. The start of the survival time analysis was the date of the injury. The end of the analysis was 31 December 2017 or the date of the patient's death. Mortality rates were assessed with respect to fracture types using Kaplan-Meier curves. The Cox proportional hazards model was applied to assess the dependence of mortality on the fracture type. RESULTS: A total of 105 patients with 95 (90.5%) being female were enrolled in this prospective study. The average age was 80.3 years (95% CI 78.8-81.7). Mean follow-up time was 23.5 months (95% CI 20.7-26.4). According to AO/OTA classification, 30 (28.6%) patients had a type A pelvic fracture, 73 (69.5%) patients-type B fracture, and 2 (1.9%)-type C fracture. Overall, the one-year mortality rate was 23.8% (95% CI 16.8-33.2%). For patients with type A fracture, the one-year mortality rate was 13.3% (95% CI 5.2-31.7%) compared with 27.4% (95% CI 18.6-39.2%) in the group with type B fracture, and this difference was statistically significant (p < 0.001). CONCLUSIONS: We found that within a year after an osteoporotic pelvic fracture, the number of deaths in the patients having type B pelvic fracture was twice higher than in the patients with type A fracture.

Mortality Outcomes of Vertebral Augmentation (Vertebroplasty and/or Balloon Kyphoplasty) for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis.

Background Osteoporotic vertebral compression fractures (OVCFs) are prevalent, with associated morbidity and mortality. Vertebral augmentation (VA), defined as either vertebroplasty and/or balloon kyphoplasty (BKP), is a minimally invasive surgical treatment to reduce pain and further collapse and/or renew vertebral body height by introducing bone cement into fractured vertebrae. Nonsurgical management (NSM) for OVCF carries inherent risks. Purpose To summarize the literature and perform a meta-analysis on the mortality outcomes of patients with OVCF treated with VA compared with those in patients treated with NSM. Materials and Methods A single researcher performed a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines. Online scientific databases were searched in April 2018 for English-language publications. Included studies investigated mortality in patients with OVCF with VA as the primary intervention and NSM as the comparator. A meta-analysis was performed for studies that reported hazard ratios (HRs) and 95% confidence intervals (CIs). HR was used as a summary statistic and was random-effect-models tested. The χ2 test was used to study heterogeneity between trials, and the I2 statistic was calculated to estimate variation across studies. Results Of the 16 included studies, eight reported mortality benefits in VA, seven reported no mortality difference, and one reported mixed results. Seven studies were included in a meta-analysis examining findings in more than 2 million patients with OVCF (VA = 382 070, NSM = 1 707 874). The pooled HR comparing VA to NSM was 0.78 (95% CI: 0.66, 0.92; P = .003), with mortality benefits across 2- and 5-year periods (HR = 0.70, 95% CI: 0.69, 0.71, P < .001; and HR = 0.79, 95% CI: 0.62, 0.9999, P = .05; respectively). Balloon kyphoplasty provided mortality benefits over vertebroplasty, with HRs of 0.77 (95% CI: 0.77, 0.78; P < .001) and 0.87 (95% CI: 0.87, 0.88; P < .001), respectively. Conclusion In a meta-analysis of more than 2 million patients, those with osteoporotic vertebral compression fractures who underwent vertebral augmentation were 22% less likely to die at up to 10 years after treatment than those who received nonsurgical treatment. © RSNA, 2020 See also the editorial by Jennings in this issue.