Pre-fracture medication use as a predictor of 30-day mortality in hip fracture patients: an analysis of 141,201 patients.

PURPOSE: To evaluate the predictive value of pre-fracture medication usage on 30-day mortality following a hip fracture. METHODS: Information on age, sex, fracture type, time of death and Charlson co-morbidity index (CCI) was collected from the Danish National Patient Registry on all patients above 60 years, sustaining a hip fracture during the period January 1995 to December 2013. Information on drug usage was obtained from the Danish National Prescription Database. Hazard ratios were calculated with 30-day mortality as the outcome. A univariate and 3 multivariate analyses were conducted with increasing adjustments, starting with age, sex and fracture type, adding co-morbidity and dose in the latter. RESULTS: 141,201 patients were included and a total of 12 drugs/drug groups were identified for analysis. Increased mortality was evident in all analyses for antiarrhythmics, beta blockers, proton pump inhibitors, loop diuretics, opioids, acetaminophen and for psycholeptics. For ACE-inhibitors, increased mortality was found in all analyses, except after adjustment for co-morbidity and dose. For thiazide diuretics, a significantly reduced mortality was evident in all but the univariate analyses while NSAIDs and statins were associated with a significantly reduced mortality in all analyses. For calcium channel blockers, an insignificant decrease was found after adjustment for dose. Further analysis showed a dose-response relationship for all drugs except ACE-inhibitors and calcium channel blockers. CONCLUSION: The study shows a correlation between pre-fracture usage of certain drugs and 30 day mortality after a hip fracture.

Re-amputations and mortality after below-knee, through-knee and above-knee amputations.

INTRODUCTION: From January 2013, we changed the surgical strategy in our department and ceased to perform the through-knee amputation (TKA). The primary aim of this study was to investigate re-amputation rates ≤ 90 days after non-traumatic major lower-extremity amputations performed before and after this change of practice. Furthermore, we reported mortality before and after the change of practice. METHODS: All non-traumatic major lower-extremity amputations performed in a single centre in two study periods (before and after the change of practice); 2009-2012 (cohort A) and 2014-2015 (cohort B) were included. Re-amputations and all-cause mortality ≤ 90 days after the index amputations were analysed. RESULTS: Cohort A: Included 180 amputations with 27 below-knee amputations (BKA), 68 TKAs and 85 above-knee amputations (AKA). 86.7% of patients were American Society of Anesthesiologists (ASA) score 3-5. The re-amputation rate ≤ 90 days was 29.6% (95% confidence interval (CI): 12.7-47.3%) after BKA, 33.8% (95% CI: 22.7-45.3%) after TKA, 9.4% (95% CI: 2.9-15.1%) after AKA and 21.6% (95% CI: 15.6-27.6%) overall. The overall mortality ≤ 90 days was 35.2% (95% CI: 26.2-44.2%). Cohort B: Included 116 amputations with 21 BKA and 95 AKA. 92.7% of patients were ASA score 3-5. The re-amputation rate ≤ 90 days was 19.1% (95% CI: 7.7-40.0%) after BKA, 2.1% (95% CI: 0.6-7.4%) after AKA and 5.2% (95% CI: 2.4-10.8%) overall. The overall mortality ≤ 90 days was 32.8% (95% CI: 26.2-44.2%). CONCLUSIONS: The overall re-amputation rate ≤ 90 days following major lower-extremity amputation decreased significantly from 22% to 5% after cessation of the TKA procedures, but mortality remained unchanged. FUNDING: none. TRIAL REGISTRATION: not relevant.

No Effect of Acupuncture as Adjunctive Therapy for Patients with Total Knee Replacement: A Randomized Controlled Trial.

Objective: Acupuncture is a low risk option in pain management following total knee replacement as an alternative to opioid analgesics. Therefore, the benefit of acupuncture as adjunct to an exercise program was investigated. Furthermore, the modifying effect of previous benefit from acupuncture was explored. Design: Three weeks postoperatively, eligible patients were randomized to acupuncture and exercises or exercises alone. Setting: An outpatient rehabilitation centre in the municipality of Copenhagen, Denmark. Subjects: A total of 172 patients were included. Methods: Main outcome was proportion of patients that reported a clinically important change in pain at night following each treatment. Secondary outcomes were change in disability measured after termination of the course of treatment and at three months follow-up. Also consumption of medication and walking distance after termination of the course of treatment were assessed. Results: No additional benefit of acupuncture was found on any of the main outcomes. Between-group differences were non-significant in proportions of patients with a clinically important reduction of night pain (Relative Risk: 0.98; 95% Confidence Interval (CI): 0.86-1.11) or evening pain (Relative Risk: 0.94; 95% CI: 0.81-1.0. Conclusions: Our results do not support the addition of acupuncture to routine rehabilitation. Previous benefit from acupuncture was not able to identify those likely to respond to acupuncture. Future studies to investigate whether subgroups of patients would benefit from acupuncture are needed.

Orthogeriatric Service Reduces Mortality in Patients With Hip Fracture.

INTRODUCTION: Orthogeriatric service has been shown to improve outcomes in patients with hip fracture. The purpose of this study is to evaluate the effect of orthogeriatrics at Bispebjerg University Hospital, Denmark. The primary outcome is mortality inhospital and after 1, 3, and 12 months for patients with hip fracture. The secondary outcome is mortality for home dwellers and nursing home inhabitants. MATERIALS AND METHODS: This is a retrospective clinical cohort study with an historic control group including all patients with hip fracture admitted from 2007 to 2011. Patients with hip fracture are registered in a local database, and data are retrieved retrospectively using the Danish Civil Registration Number. RESULTS: We included 993 patients in the intervention group and 989 patients in the control group. A univariate analysis showed only significantly decreased mortality inhospital 6.3% vs 3.1% (P = .009) after orthogeriatrics. However, when adjusting for age, gender, and American Society of Anaesthesiologists (ASA) score in a multivariate analysis, including all patients with hip fracture, we find significantly reduced mortality inhospital (odds ratio [OR] 0.35), after 30 [OR 0.66] and 90 days [OR 0.72] and 1 year [OR 0.79]). When using a univariate analysis for home-dwelling patients, we found significantly reduced mortality inhospital (8.3-2.0%, P < .0001), after 30 days (12.2-6.8%, P = .004) and 90 days (20.5-13.0%, P = .002). One-year mortality was not significant. Patients from nursing homes had no significant decreasing mortality at any point of time in the univariate analysis. CONCLUSION: We have shown significant decreases for inhospital, 30 day, 90 day, and 1-year mortality after implementation of orthogeriatric service at Bispebjerg Hospital when adjusting for age, gender, and ASA score. Future trials should include frail patients with other fracture types who can benefit from orthogeriatrics.

Daily number of fractures is associated with road temperature in an urban area.

INTRODUCTION: Different factors related to winter are known to influence the fracture incidence, but little is known about the effect of road surface temperature. This study examines the association between road surface temperature and the daily number of fractures in an urban area during two winters. MATERIAL AND METHODS: Retrospective data collection was conducted on all patients treated at Bispebjerg Hospital, Denmark, for a humeral, ankle, distal radius or hip fracture during the periods October to April 2009/2010 and 2010/2011. Patients were grouped according to age into the following categories: < 15, 15-30, 30-45, 45-60 and > 60 years. Data on road surface temperature (Tp.) were obtained from The Danish Road Directorate and grouped into the following categories: Days with Tp. > 0 °C, Tp. < 0 °C, Tp. > -5 °C, Tp. < -5 °C and ice alert (IA). RESULTS: A total of 4,892 patients (4,938 fractures) were treated during the study periods. The daily number of distal radius, humeral and ankle fractures increased significantly with decreasing road surface temperature and the presence of IA. For hip fractures no significant association was found. Decreasing temperature was associated with a significant decrease in the daily number of fractures for patients < 15 years, whereas patients > 30 years experienced a significant increase. CONCLUSION: Decreasing road temperature results in increased numbers of all fractures except hip fractures. Low temperatures is a risk factor for patients > 30 years and a protective factor for patients < 15 years. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Preoperative factors associated with red blood cell transfusion in hip fracture patients.

INTRODUCTION: Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients. METHOD: The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database. RESULTS: Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion. CONCLUSION: Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.

Metaanalysis of risk factors for mortality in patients with hip fracture.

INTRODUCTION: The aim of this meta-analysis is to assess the association of three different clinical score systems with the mortality in hip fracture patients. METHODS: A literature search was conducted on November 13, 2011 using PubMed and Embase. The search yielded 315 publications which were reviewed on the basis of the inclusion criteria. RESULTS: Thirteen studies were included for further processing. The following clinical score systems were found to be of prognostic value for mortality in hip fracture patients: a high American Society of Anesthesiologists (ASA) score of three or above (odds ratio (OR): 3.07; 95% confidence interval (CI): 2.78-3.38; p < 0.00001, 15,625 study participants included), a Charlson Comorbidity Index (CCI) score of one or more (OR: 2.05; 95% CI: 1.79-2.34; p < 0.00001, 13,570 study participants included) and dementia (assessed with Mini Mental State Examination or obtained from journal extraction) (OR: 2.73; 95% CI: 1.64-4.57; p = 0.0001; 1,782 study participants included). CONCLUSION: The present meta-analysis showed that the ASA score, the CCI score and assessment of preexisting dementia are useful in predicting the mortality of hip fracture patients.

Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview.

BACKGROUND AND PURPOSE: Widely different metal ion concentrations in blood and serum have been reported with metal-on-metal (MoM) implants. We reviewed the literature on blood and serum ion concentrations of chromium (Cr) and cobalt (Co) following various MoM hip arthroplasties. METHODS: Studies were searched for in the Medline database, Embase, and the Cochrane Database of Systematic Reviews. Highest mean or median ion concentrations of Cr and Co after a minimum of 1 year of follow-up were extracted and grouped according to sample- and articulation type, and average values were calculated. RESULTS: 43 studies were included and 16 different MoM implants were identified. For the different types of bearings, average ion concentrations and range were calculated from the mean or median ion concentration. The average Cr concentration ranged between 0.5 and 2.5 µg/L in blood and between 0.8 and 5.1 µg/L in serum. For Co, the range was 0.7-3.4 µg/L in blood and 0.3-7.5 µg/L in serum. INTERPRETATION: When the average blood ion concentrations calculated for the different implants, together with the concentrations measured in the individual studies, were compared with the upper acceptable limit for Cr and Co in blood, no clear pattern was recognized. Furthermore, we were unable to detect any clear difference in ion concentrations between different types of implants (THA and resurfacing).

[Collaboration between geriatricians and orthopaedic surgeons on elderly patients]. / Samarbejde mellem geriatri og ortopædkirurgi hos ældre patienter.

Close collaboration between geriatricians and orthopaedic surgeons on elderly patients with hip fractures reduces mortality, the number of complications, and the length of hospital stay and increases the functional abilities of the patients. In some Danish hospitals the two groups of doctors work closely together, in others there are few or no geriatricians.

Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays? A retrospective study of 38,020 patients.

BACKGROUND AND PURPOSE: Hip fractures are associated with high mortality, but the cause of this is still not entirely clear. We investigated the effect of surgical delay, weekends, holidays, and time of day admission on mortality in hip fracture patients. PATIENTS AND METHODS: Using data from the Danish National Indicator Project, we identified 38,020 patients admitted from 2003 to 2010. Logistic regression analysis was used to study the association between sex, age, weekend or holiday admission, night-time admission, time to surgery, and ASA score on the one hand and mortality on the other. RESULTS: The risk of death in hospital increased with surgical delay (odds ratio (OR) = 1.3 per 24 h of delay), ASA score (OR (per point added) = 2.3), sex (OR for men 2.2), and age (OR (per 5 years) = 1.4). The mortality rate for patients admitted during weekends or public holidays, or at night, was similar to that found for those admitted during working days. INTERPRETATION: Minimizing surgical delay is the most important factor in reducing mortality in hip fracture patients.

Secondary hyperparathyroidism and mortality in hip fracture patients compared to a control group from general practice.

INTRODUCTION: Previously, little attention has been paid as to how disturbances in the parathyroid hormone (PTH)-calcium-vitamin D-axis, such as secondary hyperparathyroidism (SHPT), relate to mortality amongst hip fracture patients. This study aimed to (1) determine if SHPT is associated with mortality in this group of patients, (2) investigate the association between serum (s-) PTH, s-total calcium, s-25-hydroxyvitamin D (s-25(OH)D) and mortality and (3) determine the prevalence of SHPT amongst hip fracture patients and a control group. METHOD: The study included 562 hip fracture patients (HF) (age ≥ 70 years) admitted to a Danish university hospital. The hip fracture patients were prospectively enrolled in a dedicated hip fracture database. Each hip fracture patient was exactly matched according to age and sex with two controls randomly chosen from a control population of 21,778 subjects who had s-PTH, s-total calcium and s-25(OH)D measured at the Copenhagen General Practitioners Laboratory after referral from their general practitioner. The control group (Con) thus consisted of 1124 subjects. RESULTS: General 1-year mortality: Con-female 8.4%, Con-male 15.3%, HF-female 24.6%, HF-male 33.3%, p<0.0001 (log rank). SHPT AND RELATED 1-YEAR MORTALITY: Con-no SHPT 8.9%, Con-SHPT 16.8%, HF-no SHPT 22.7%, HF-SHPT 34.9%, p<0.0001 (log rank). The mortality rates were higher for controls with SHPT (OR 2.06, 95% CI: 1.32-3.23), hip fracture patients without SHPT (OR 3.00, 95% CI: 2.14-4.20) and hip fracture patients with SHPT (OR 5.46, 95% CI: 3.32-8.97) compared to the controls without SHPT. PREVALENCE OF SHPT: Con 16%, HF 20%, p=0.09 (Chi-square). CONCLUSIONS: Our study clearly shows that SHPT is significantly associated with mortality in both hip fracture patients and the control group. In the multivariate Cox regression analysis, s-PTH and s-total calcium were both significantly associated with mortality, whereas s-25(OH)D was not associated with mortality in this analysis. Our study furthermore indicates that SHPT is almost equally prevalent amongst the hip fracture patients and the control group.

Routine blood tests as predictors of mortality in hip fracture patients.

OBJECTIVE: The aim of this study was to assess the evidence for the association between different biochemical markers at admission and mortality through a meta-analysis. DATA SOURCES: PubMed-, Embase-, Cochran Library and the Web of Knowledge were searched for cohort studies. STUDY SELECTION: Eligible studies were observational studies with a study population larger than 150 subjects, a mean age above 60 years and a study duration below 730 days. DATA EXTRACTION: Characteristics of studies and outcomes of all-cause mortality were extracted from the retrieved articles. Data were pooled across studies for the individual biomarker using random- or fixed-effect analysis. DATA SYNTHESIS: 15 eligible studies of 5 different markers on mortality were studied. The following markers were found to be of prognostic value on mortality in hip fracture patients: low haemoglobin (odds ratio, 2.78; 95% confidence interval, 2.17-3.55; P<0.00001, 3148 subjects included), low total lymphocyte count, TLC (odds ratio, 2.60; 95% confidence interval, 1.61-4.20; P<0.00001, 1689 subjects included), low albumin (odds ratio, 1.83; 95% confidence interval, 1.31-2.56; P=0.0004, 1680 subjects included), low albumin/low TLC (odds ratio, 3.00; 95% confidence interval, 1.81-4.99; P<0.0001, 704 subjects included), low albumin/high TLC (odds ratio, 3.39; 95% confidence interval, 1.83-6.29; P=0.0001, 704 subjects included), high creatinine (odds ratio, 1.58; 95% confidence interval, 1.25-1.99; P=0.0001, 3761 subjects included), and high PTH (odds ratio, 15.43; 95% confidence interval, 3.60-66.14; P=0.0002, 525 subjects included). CONCLUSION: Biochemical markers at admission are valid predictors of mortality in hip fracture patients.

Value of routine blood tests for prediction of mortality risk in hip fracture patients.

BACKGROUND: There is a 5- to 8-fold increased risk of mortality during the first 3 months after a hip fracture. Several risk factors are known. We studied the predictive value (for mortality) of routine blood tests taken on admission. METHODS: 792 hip fracture patients were included prospectively; blood tests were taken on admission. Follow-up data on mortality were obtained from the civil registration system. Patients were divided into 2 groups based on whether they had survived at least 90 days after the hip fracture. To estimate which laboratory tests could be used to predict outcome, we used receiver operation characteristic (ROC) curves. RESULTS: 3-month mortality could be predicted with 69% accuracy from the level of plasma creatinine in standard admission blood tests. The mortality in patients with elevated levels of creatinine was almost 3-fold that of the patients with normal creatinine. Mortality was also associated with age, low blood hemoglobin, high plasma potassium, and low plasma albumin levels. INTERPRETATION: Our findings could be of use in identifying patients who might benefit from increased attention perioperatively.

A comprehensive hip fracture program reduces complication rates and mortality.

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1-year mortality before and after introduction of a comprehensive multidisciplinary fast-track treatment and care program for hip fracture patients (the optimized program). DESIGN: Retrospective chart review with historical control. SETTING: Orthopedic ward (110 beds) at a university hospital (700 beds). PARTICIPANTS: Five hundred thirty-five consecutive patients aged 40 and older (94%>or=60) hospitalized for hip fracture between January 1, 2003, and March 31, 2004. Three hundred and thirty-six patients (70.3%) were community dwellers before the fracture and 159 (29.7%) were admitted from nursing homes. INTERVENTION: The fast-track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a more-systematic approach to nutrition, fluid and oxygen therapy, and urinary retention. RESULTS: In the intervention group, the rate of any in-hospital postoperative complication was reduced from 33% to 20% (odds ratio=0.61, 95% confidence interval=0.4-0.9; P=.002). Rates of confusion (P=.02), pneumonia (P=.03), and urinary tract infection (P<.001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group (P<.001). For community dwellers, 12-month mortality was 23% in the control group versus 12% in the intervention group (P=.02). Overall 12-month mortality was 29% in the control group and 23% in the intervention group (P=.2). CONCLUSION: The optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality. Randomized clinical trials are needed to confirm these results and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.

[Registration of prehabilitation prior to surgery]. / Registrering af praehabilitering inden planlagt operation.

Four to eight week prehabilitation programs for smokers and harmful drinkers were included in the national guidelines in 2001. In October 2007 a guarantee for surgery within one month of waiting time came into effect in Denmark. The present Danish patient administration system already contains room for registration of prehabilitation prior to surgery. Using one specific code for prehabilitation at the surgical department and another for prehabilitation at other departments will enable correct registration. Thereby, it is possible to differentiate between ordinary waiting time before surgery and time for prehabilitation.

White blood cell scintigraphy for differentiation of infection and aseptic loosening: a retrospective study of 76 painful hip prostheses.

BACKGROUND: Diagnosis of an infected arthroplasty is often difficult. Fever, abnormal physical findings, radiographic changes, findings at bone scintigraphy, an elevated erythrocyte sedimentation rate, CRP, and leucocytosis are not specific enough. We evaluated the diagnostic value of white blood cell scintigraphy. METHODS: We retrospectively reviewed 76 cases (66 patients) admitted for white blood cell scintigraphy with a clinical suspicion of infection in a hip prosthesis during the period 1995-2003. The leukocytes were labeled with (99m)Tc-HMPAO or with (111)In-oxin. Anterior and posterior views were taken of both hip joints at 3 different time points after injection: 1 h, 3 h, and 22 h. Infection was verified by means of bacteriological cultures, histopathological findings, intraoperative frozen sections, and follow-up (up to 3.5 years). RESULTS: Of 76 scintigraphies, 51 were negative and 25 were positive. There were 81% true positive, 94% true negative, 6% false positive, and 19% false negative outcomes. INTERPRETATION: White blood cell scintigraphy with additional late imaging is an effective tool for differentiation between loosening and infection in painful hip arthroplasty.

Introduction of new guidelines for emergency patients: motivational counselling among smokers.

INTRODUCTION: Smoking is the most important risk factor for morbidity and mortality in hospital patients. Patient contact with the healthcare system should include smoking cessation counselling. Emergency admissions are seldom given this opportunity. OBJECTIVE: The aim of the study was to illustrate the implementation of motivational counselling in a department of acute surgery. METHODS: Between May 2003 and January 2004, 200 emergency patients were offered motivational counselling and a 6-week smoking cessation programme. RESULTS: We measured the number of patients who accepted motivational counselling. Of the initial 200 patients, 121 (61%) accepted motivational counselling. The only factor related to the level of motivation was age. The most motivated group had an average age of 45 years, whereas the average age of the least motivated group was 64. There was no correlation between the Fagerstrom score, pack-years, gender, illness, employment, or alcohol consumption and the outcome. Fifty-seven patients agreed to us following them up, of which 10% quit smoking for 6 months; 44% either quit or reduced their smoking for a shorter period of time, and 17% of the continuing smokers requested admission to the smoking cessation programme. CONCLUSION: The majority of smokers acutely admitted to an acute orthopaedic department accepted motivational counselling against smoking, the youngest being the most motivated. It appears possible to implement motivational counselling for smoking cessation in an acute orthopaedic department. It is relevant to consider how, and for which groups, a smoking intervention programme can be offered to acutely admitted patients.

Resistance training in the early postoperative phase reduces hospitalization and leads to muscle hypertrophy in elderly hip surgery patients--a controlled, randomized study.

OBJECTIVES: To better understand how immobilization and surgery affect muscle size and function in the elderly and to identify effective training regimes. DESIGN: A prospective randomized, controlled study. SETTING: Bispebjerg University Hospital, Copenhagen, Denmark. PARTICIPANTS: Thirty-six patients (aged 60-86) scheduled for unilateral hip replacement due to primary hip osteoarthrosis. INTERVENTION: Patients were randomized to standard home-based rehabilitation (1 h/d x 12 weeks), unilateral neuromuscular electrical stimulation of the operated side (1 h/d x 12 weeks), or unilateral resistance training of the operated side (3/wk x 12 weeks). MEASUREMENTS: Hospital length of stay (LOS), quadriceps muscle cross-sectional area (CSA), isokinetic muscle strength, and functional performance. Patients were tested presurgery and 5 and 12 weeks postsurgery. RESULTS: Mean+/-standard error LOS was shorter for the resistance training group (10.0+/-2.4 days, P<.05) than for the standard rehabilitation group (16.0+/-7.2 days). Resistance training, but not electrical stimulation or standard rehabilitation, resulted in increased CSA (12%, P<.05) and muscle strength (22-28%, P<.05). Functional muscle performance increased after resistance training (30%, P<.001) and electrical stimulation (15%, P<.05) but not after standard rehabilitation. CONCLUSION: Postoperative resistance training effectively increased maximal muscle strength, muscle mass, and muscle function more than a standard rehabilitation regime. Furthermore, it markedly reduced LOS in elderly postoperative patients.

Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse.

The ability to develop muscle force rapidly may be a very important factor to prevent a fall and to perform other tasks of daily life. However, information is still lacking on the range of training-induced neuromuscular adaptations in elderly humans recovering from a period of disuse. Therefore, the present study examined the effect of three types of training regimes after unilateral prolonged disuse and subsequent hip-replacement surgery on maximal muscle strength, rapid muscle force [rate of force development (RFD)], muscle activation, and muscle size. Thirty-six subjects (60-86 yr) were randomized to a 12-wk rehabilitation program consisting of either 1) strength training (3 times/wk for 12 wk), 2) electrical muscle stimulation (1 h/day for 12 wk), or 3) standard rehabilitation (1 h/day for 12 wk). The nonoperated side did not receive any intervention and thereby served as a within-subject control. Thirty subjects completed the trial. In the strength-training group, significant increases were observed in maximal isometric muscle strength (24%, P < 0.01), contractile RFD (26-45%, P < 0.05), and contractile impulse (27-32%, P < 0.05). No significant changes were seen in the two other training groups or in the nontrained legs of all three groups. Mean electromyogram signal amplitude of vastus lateralis was larger in the strength-training than in the standard-rehabilitation group at 5 and 12 wk (P < 0.05). In contrast to traditional physiotherapy and electrical stimulation, strength training increased muscle mass, maximal isometric strength, RFD, and muscle activation in elderly men and women recovering from long-term muscle disuse and subsequent hip surgery. The improvement in both muscle mass and neural function is likely to have important functional implications for elderly individuals.