Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland.

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type. OBJECTIVE: Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland. METHODS: A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years. RESULTS: We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m2, age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m2, ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities. CONCLUSIONS: Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Positive Effects of a Sufficient Pre-fracture Serum Vitamin D Level on the Long-Term Survival of Hip Fracture Patients in Finland: A Minimum 11-Year Follow-Up.

BACKGROUND: Several studies have shown that the mortality of elderly hip fracture patients is higher than that in the general population, and is higher in male than in female hip fracture patients. OBJECTIVE: The objective of this study was to investigate factors affecting overall mortality at a minimum of 11 years following a new hip fracture. METHODS: The sex, age, pre-fracture serum 25-hydroxyvitamin D level, American Society of Anesthesiologists physical status classification (ASA class), 1- to 12-month mortality, and 2- to 11-year mortality of hip fracture patients were collected. The use of anti-osteoporotic medication and prescribed calcium and vitamin D supplements during the first 3 post-operative years were checked. The survival of the patients was analyzed using both the Bayesian multivariate analysis and the life table method. RESULTS: The mean age of females at the time of the index hip fracture was 80.5 years and of males was 73 years. The protective factors were age <80 years; ASA class 1-2; serum 25-hydroxyvitamin level ≥ 50 nmol/L; post-fracture use of calcium and vitamin D supplementation; post-fracture concomitant use of calcium and vitamin D supplementation and anti-osteoporotic drugs; and male sex. The excess mortality was higher among women than men. Survival was highest among patients with a vitamin D level of ≥ 50 nmol/L. Post-fracture concomitant use of calcium and vitamin D and anti-osteoporotic drugs was positively associated with survival. CONCLUSION: Our results indicate a positive relationship between a sufficient pre-fracture vitamin D serum concentration (≥ 50 nmol/L) and survival, and a potential relationship between reduced mortality and the concomitant post-fracture use of prescribed calcium plus vitamin D supplementation and anti-osteoporotic medication.

A long-term follow-up of 221 hip fracture patients in southeastern Finland: analysis of survival and prior or subsequent fractures.

UNLABELLED: To analyze the type and effect of prior and subsequent fractures in a hip fracture cohort. MATERIALS AND METHODS: Hip fracture patients (n=221) were followed for a mean of 8 years and all prior and subsequent fractures were studied. Incidence of the first fracture and subsequent fractures according to sex, age group, and time between the first and the index hip fracture were measured. The absolute fracture risk was measured in the study subjects and in the age groups <75 years and ≥75 years. Patients' survival was analyzed with the life-table method. RESULTS: One third of the hip fracture patients had sustained previous fractures. In men, these were mostly ankle or hip fractures, and in women, wrist fractures. Of the subjects, 24% suffered a subsequent fracture, which in both sexes was usually a second hip fracture. At the end of the 8-year follow-up, 74% of the patients had died. The observed absolute fracture risk was 7% at one year and 24% at 5 years. In women, excess mortality was lowest during the first 4.8 years after the index hip fracture among patients with one fracture. However, it was highest among women with two fractures. In men, excess mortality was lowest among those with two fractures and highest among those with ≥3 fractures. There were no differences between the genders in sustaining subsequent fractures. CONCLUSIONS: The fracture risk subsequent to hip fracture was similar in both genders. Patients with prior hip fractures had the worst survival rate.

Second hip fracture and patients' medication after the first hip fracture: a follow-up of 221 hip fracture patients in Finland.

The national Finnish guidelines for medical treatment of hip fracture patients are: anti-osteoporotic drugs and the daily concomitant use of calcium plus vitamin D supplements. We investigated the incidence, the fracture type and the side of all second hip fractures among 221 consecutive hip fracture patients who were followed up for 5 years. The medication of the patients and the time interval between the first and second hip fracture were analyzed. Of the patients 12% (26/221) sustained a second hip fracture. The type of fracture was in most cases (76%) the same as in the first case, more often in trochanteric and subtrochanteric fractures than in cervical fractures. The mean interval between the fractures was 4±4.2 years (±S.D.); 3.2±3.5 years in men and 4.4±4.4 years in women. The number of patients using polypharmacy (5 or more drugs daily) was 9/25 (36%) at the time of the first hip fracture and 17/25 (68%) at the time of the second hip fracture. The use of at least one psychotropic drug regularly rose from 9/25 (36%) to 16 (64%) between the two fractures. Concomitant use of calcium plus vitamin D and anti-osteoporotic drugs was insufficient among the patients. More effort should be focused on the secondary prevention following the first hip fracture.

Post-fracture prescribed calcium and vitamin D supplements alone or, in females, with concomitant anti-osteoporotic drugs is associated with lower mortality in elderly hip fracture patients: a prospective analysis.

BACKGROUND: Several studies have shown excess mortality among hip fracture patients compared with the normal population of the same age. Finnish guidelines for medical treatment of hip fracture patients recommend anti-osteoporosis medication and the daily concomitant use of prescribed calcium and vitamin D supplements. However, whether post-fracture use of calcium and vitamin D supplements is associated with survival in such patients has not been evaluated. OBJECTIVE: To study the association between survival in hip fracture patients and patients' sex and age, pre-fracture vitamin D status, American Society of Anesthesiologists - Physical Status (ASA-PS) class, type of fracture and post-fracture use of prescribed calcium plus vitamin D and anti-osteoporotic medication. METHODS: The study population was 221 hip fracture patients primarily treated in acute care for a new hip fracture in 2003-4 in two Finnish hospitals. After a median of 27.5 months from the fracture, a questionnaire was sent to all patients who were still alive at the time (n = 137). The patients were queried about their use of prescribed calcium plus vitamin D supplementation and of anti-osteoporotic drugs. The follow-up time for use of anti-osteoporotic medication and prescribed calcium and vitamin D was 19.5-36 months (median 27.5 months). Data on the use of prescribed calcium plus vitamin D supplementation and anti-osteoporotic drugs were checked against information on reimbursement of drug prescriptions held by the Finnish Social Insurance Institution. A total of 4 years' (48 months') survival data for all patients in the study population was also obtained, with the dates of patient deaths being checked against Official National and Regional population statistics. Patient survival was analysed using both the Bayesian multivariate analysis and the life table method. RESULTS: In the multivariate analysis, the combination of variables that best explained post-fracture survival was as follows: age <80 years; ASA-PS class 1-2 (ASA-PS class 1 and 2 data were combined in calculations); post-fracture use of prescribed calcium plus vitamin D supplements concomitantly with anti-osteoporotic drugs; post-fracture use of prescribed calcium plus vitamin D supplements; post-fracture use of anti-osteoporotic drugs only; and type of fracture (femoral neck or subtrochanteric). This model correctly predicted 74% of cases. At 36 months, we observed a 36% reduction in deaths in females who used prescribed calcium plus vitamin D supplementation and a corresponding 43% reduction in males. Survival of females who used anti-osteoporotic drugs concomitantly was even greater (43% reduction in deaths) over the entire follow-up period. Excess mortality was highest in females and males who used neither anti-osteoporotic drugs nor prescribed calcium and vitamin D. CONCLUSION: Our results indicate a potential relationship between reduced mortality and post-fracture use of prescribed calcium plus vitamin D supplementation and, in females, concomitant use of anti-osteoporotic drugs. However, further investigations are needed to understand the reason for the reduction in the risk of death. Population-based, randomized, placebo-controlled trials with total mortality as the main endpoint should be conducted to verify our results.

Undertreatment of osteoporosis following hip fracture in the elderly.

The national Finnish guidelines for medical treatment of hip fracture patients are: osteoporosis medication and the daily concomitant use of vitamin D and calcium supplements. We investigated the post-fracture medical therapy for osteoporosis and the calcium and vitamin D therapy among hip fracture patients in two Finnish hospitals. The pre-fracture osteoporosis medication and use of calcium and vitamin D supplements of the patients were inquired on admission. The patient-specific use of osteoporosis medication and of prescribed calcium and vitamin D therapy during the follow-up time were checked from The Finnish Social Insurance Institution. At the end of the follow-up, those who were alive were inquired about the use of medication at the time. Eight percent of the 223 patients used osteoporosis medication and 8% used prescribed calcium and vitamin D supplements before the fracture. During the follow-up, the figures were 39% (52/133) and 53% (70/133), respectively, and at the end of the follow-up, correspondingly, 25% (29/114) and 44% (50/114). The follow-up time was 19.5-35 months. The post-fracture medical therapy for osteoporosis was insufficient. More effort should be focused on the secondary prevention following hip fracture in order to ensure the recommended treatment of osteoporosis.

Use of benzodiazepines and benzodiazepine-related drugs among 223 patients with an acute hip fracture in Finland: Comparison of benzodiazepine findings in medical records and laboratory assays.

BACKGROUND AND OBJECTIVE: CNS drugs are a risk factor for falls and fractures among older people. Our aim was to describe the use of benzodiazepines and benzodiazepine-related drugs among patients admitted to two Finnish hospitals as a result of an acute hip fracture, and to analyse the concordance of benzodiazepine findings from different data sources. PATIENTS AND METHODS: We studied the use of benzodiazepines and benzodiazepine-related drugs by (i) asking the patient or his/her relatives about his/her use of hypnotics; (ii) checking the patient's medical records; and (iii) analysing for the presence of benzodiazepines in serum and urine. Blood and urine samples were taken at admission. Detection of benzodiazepines in serum and urine was achieved by the fluorescence polarisation method. Concordance in benzodiazepine findings between medical records and laboratory results was estimated by calculating the degree of agreement (kappa) and described graphically using a Venn diagram. RESULTS: A total of 223 patients were enrolled in the study. Of these, 71% were women. The mean age of women was 80.5 years (SD: 10) and of men, 73 years (SD: 12) [p < 0.0001]. Thirty percent of the patients reported that they used hypnotics. Benzodiazepine in serum or urine was detected in 83 (37%) patients. Over half of the patients coming from residential homes (53%) and institutions (54%) were benzodiazepine-positive. For home dwellers the proportion of patients that were benzodiazepine-positive was 29%. In 48% (40/83) of the benzodiazepine-positive patients, the type of benzodiazepine could not be identified because of a lack of drug records regarding benzodiazepines. A total of 113 (51%) patients used benzodiazepines or benzodiazepine-related drugs when both laboratory results and medical drug records were taken into account. Thirty-nine percent of these patients were home dwellers, 69% came from residential care and 76% from institutional care. The concordance between medical records and laboratory results expressed as overlap area was 32% in men and 59% in women, 38% in community-dwelling patients, 63% in residential home patients, and 68% in patients from institutions. CONCLUSION: Half of patients with an acute hip fracture used benzodiazepines or benzodiazepine-related drugs. The highest prevalences were found in institutional and residential care where it should be well known that the use of CNS drugs increases the risk of hip fracture. Concordance of benzodiazepine findings was moderate in all patients and poorest among men. Concordance was poorer among home dwellers than among those living in residential homes and institutions. Analysing benzodiazepine in serum seems to be the most reliable method for ascertaining benzodiazepine exposure. This laboratory test could be performed routinely when the elderly patient is admitted to hospital because of a fall or, at least, in case of hip fracture. Then, if needed, the patient should be informed about the risks of benzodiazepine use, and further falls and fractures could be prevented.

Half of the patients with an acute hip fracture suffer from hypovitaminosis D: a prospective study in southeastern Finland.

Vitamin D deficiency may be one important contributing risk factor for an osteoporotic fracture among elderly. We analyzed serum 25-hydroxyvitamin D [S-25(OH)D] status in patients with an acute hip fracture in southeastern Finland (61 degrees N). Consecutive patients with a fresh hip fracture (n=223) in two Finnish hospitals during 12 months and 15 months were registered prospectively. S-25(OH)D concentrations (nmol/l) were measured by radioimmunoassay-method. Hypovitaminosis D was defined as S-25(OH)D < 37.5 nmol/l and severe hypovitaminosis D: < 20 nmol/l. The highest threshold of S-25(OH)D in our analysis was > 74 nmol/l. The seasonal variation in S-25(OH)D concentrations was followed. Hypovitaminosis D was found in 53% of the patients. In 9% hypovitaminosis D was severe. Half (50%) of the patients living in their own homes, 55% of those in residential homes, and 61% of institutionalized elderly had hypovitaminosis D. Patients who used both vitamin D and calcium supplement had S-25(OH)D levels between 37.5 nmol/l and 74 nmol/l and > 74 nmol/l more often than non-users (Wx=3.85, p=0.0001). Most (41/61) of the patients who sustained the fracture during the late summer months had S-25(OH)D concentration > or = 37.5 nmol/l, whereas, in winter months the situation was quite the opposite (24/67) (Wx=3.42, p=0.0006). Twenty-two percent (50/223) had S-25(OH)D concentration > 50 nmol/l and four patients > 78 nmol/l. Half of the patients with a hip fracture suffered from hypovitaminosis D. The situation was worst in institutional and residential care, although there are personnel for taking care of vitamin D supplementation. In the late summer, one-third and in late winter two-thirds of the patients suffered from hypovitaminosis D. The geographical location of Finland indicates extensive efforts to increase the use of vitamin D supplements among elderly.

Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw.

OBJECTIVES: To compare the performance of a metallic and a biodegradable screw in the fixation of tibia-fibula syndesmotic ruptures. DESIGN: A randomized, prospective, and blinded study. SETTING: Central hospital, Department of Surgery. PATIENTS: Forty consecutive patients with a clinically verified syndesmotic rupture in association with a malleolar fracture, of whom 38 completed the study. INTERVENTION: After syndesmosis rupture was diagnosed, implant selection was performed intraoperatively by a strict randomization with sealed envelopes. Eighteen patients were treated with a metallic screw, and 20 with a bioabsorbable polylevolactic acid screw. The metallic screws were removed in a second operation at 8 weeks postoperatively. All patients had a treatment-blinded clinical and radiographic control after a mean follow-up of 35 (range 17-51) months. MAIN OUTCOME MEASURES: Return to previous physical activity level, evaluation of ankle stability, range of motion, circumference of the ankle, and a radiographic evaluation of both ankles including a measure of the talocrural, medial joint, and syndesmotic space widths. RESULTS: More patients with a polylevolactic acid screw returned to their previous activity level, and there was less swelling in the ankles of these patients, but joint motion was similar between the groups. The mean values of syndesmotic and medial joint spaces were significantly higher in the radiographs of the operated ankles when compared to the uninjured ankle, but there was not a correlation to the type of screw used. CONCLUSIONS: Polylevolactic acid screws worked as well, or slightly better than, metallic ones in syndesmosis fixation in patients with an ankle fracture.

Simple end-to-end suture versus augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98 patients.

We retrospectively compared the results in 98 patients with an acute Achilles tendon rupture treated with an augmented tendon repair (n = 59) to patients with an end-to-end suture (n = 39) after an average follow-up of 44 (22-69) months. 7 patients were operated on more than 2 weeks after the rupture, all with augmention. The complication rates in the augmention group were 0.1 and in the end-to-end suture group 0.2. We found no differences in subjective outcome or rerupture rate between the groups. In the augmentation group, the rate of complications was higher in those operated on after 2 weeks than in those operated on before. A simple end-to-end suture seems sufficient.