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.

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.

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).

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.

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.