Use of direct-acting anticoagulants (DOACs) delays surgery and is associated with increased mortality in hip fracture patients.

PURPOSE: Treatment with direct-acting oral anticoagulants (DOACs) is increasing among hip-fracture patients, with accompanying safety concerns regarding spinal anesthesia (SA). The aim of this study was to investigate if DOAC use is associated with increased waiting time before surgery, increased mortality, or other adverse events. METHODS: Registry data on surgically treated hip-fracture cases at a single hospital between 2015 and 2021 were analyzed. Multivariable regression analyses were performed with DOAC-status and choice of anesthesia as exposures, and waiting time, length of stay, transfusion, and mortality as outcomes. RESULTS: 2885 cases were included, 467 patients (16%) were using DOACs. DOAC users were older (86.3 vs. 82.2 years, p < 0.001), had a higher Charlson Comorbidity Index (2.1 vs. 1.5, p < 0.001) and had longer median time to surgery than non-DOAC cases (36 h vs 17 h, p < 0.001). General anesthesia (GA) was used in 19.3% of DOAC patients and in 3.0% of non-DOAC patients. DOAC-patients had an increased risk of one-month mortality (Adjusted Odds Ratio (AOR) 1.6 (1.1-2.3)) and one-year mortality (AOR 1.4 (1.1-1.8)). There were no differences in risk of blood transfusion. Patients on DOAC operated under GA had a lower risk of one-year mortality (AOR 0.5 (0.3-0.9)), but a similar one-month mortality to DOAC-patients operated under SA. CONCLUSION: DOAC users had a longer waiting time to surgery, indicating postponement of surgery due to concerns of the safety of SA. The clinical practice should be changed to allow earlier surgery for DOAC patients.

Distinct Subsets of Noncoding RNAs Are Strongly Associated With BMD and Fracture, Studied in Weight-Bearing and Non-Weight-Bearing Human Bone.

We investigated mechanisms resulting in low bone mineral density (BMD) and susceptibility to fracture by comparing noncoding RNAs (ncRNAs) in biopsies of non-weight-bearing (NWB) iliac (n = 84) and weight bearing (WB) femoral (n = 18) postmenopausal bone across BMDs varying from normal (T-score > -1.0) to osteoporotic (T-score ≤ -2.5). Global bone ncRNA concentrations were determined by PCR and microchip analyses. Association with BMD or fracture, adjusted by age and body mass index, were calculated using linear and logistic regression and least absolute shrinkage and selection operator (Lasso) analysis. At 10% false discovery rate (FDR), 75 iliac bone ncRNAs and 94 femoral bone ncRNAs were associated with total hip BMD. Eight of the ncRNAs were common for the two sites, but five of them (miR-484, miR-328-3p, miR-27a-5p, miR-28-3p, and miR-409-3p) correlated positively to BMD in femoral bone, but negatively in iliac bone. Of predicted pathways recognized in bone metabolism, ECM-receptor interaction and proteoglycans in cancer emerged at both sites, whereas fatty acid metabolism and focal adhesion were only identified in iliac bone. Lasso analysis and cross-validations identified sets of nine bone ncRNAs correlating strongly with adjusted total hip BMD in both femoral and iliac bone. Twenty-eight iliac ncRNAs were associated with risk of fracture (FDR < 0.1). The small nucleolar RNAs, RNU44 and RNU48, have a function in stabilization of ribosomal RNAs (rRNAs), and their association with fracture and BMD suggest that aberrant processing of rRNAs may be involved in development of osteoporosis. Cis-eQTL (expressed quantitative trait loci) analysis of the iliac bone biopsies identified two loci associated with microRNAs (miRNAs), one previously identified in a heel-BMD genomewide association study (GWAS). In this comprehensive investigation of the skeletal genetic background in postmenopausal women, we identified functional bone ncRNAs associated to fracture and BMD, representing distinct subsets in WB and NWB skeletal sites. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Posterior versus lateral approach for hemiarthroplasty after femoral neck fracture: Early complications in a prospective cohort of 583 patients.

AIM: To compare early complications after the posterior and the direct lateral (transgluteal) approach, when using hemiarthroplasty in the treatment of displaced femoral neck fractures in the elderly. PATIENTS AND METHODS: A prospective clinical study from four Norwegian hospitals, consisting of 583 patients with 1year follow-up. All the hospitals used the same uncemented femoral stem and bipolar heads. Data were collected for gender, age, surgical approach, prosthetic dislocation, postoperative infection, perioperative fracture, duration of surgery, ASA score, diabetes, alcoholism, cognitive failure, BMI, 30-day mortality and 1-year mortality. RESULTS: Mean age was 83 years (SD 7.8) and 434/583 (74%) were female. There were no relevant differences between the treatment groups. A higher risk was found for prosthetic dislocation in the posterior group compared to the lateral group (15/186 (8%) vs. 4/397 (1%); RR=8.0, 95% CI 2.7-23.8, p-value<0.001), both as a one-time event and for the risk of recurrent dislocations (9/186 (5%) vs. 2/395 (0.5%); RR 9.6, 95% CI 2.1-44.0, p-value=0.001). 11/19 patients with dislocation had recurrent dislocations. 10/11 patients with more than one dislocation needed further open surgery. Of those 6/10 needed more than one additional open procedure. Three patients had a resection arthroplasty and one patient had a chronic infection as final result after a dislocation. No other risk factor for dislocation than surgical approach was identified. There were no differences between the approach groups for other complications. CONCLUSION: There was an 8-fold increased risk for prosthetic dislocations after the posterior approach compared to lateral approach. There was a high risk for recurrent prosthetic dislocations and a subsequent risk for further surgeries and a poor end result. The potential advantages of the posterior approach have not been demonstrated after femoral neck fractures and we advise against its continued use.

A restrictive policy for red blood cell transfusion in older hip fracture patients: experiences from a patient register.

BACKGROUND: Allogeneic red blood cell transfusions (ABT) are common in older hip fracture patients. Recent research supports a restrictive transfusion policy. The aim was to study variation in hemoglobin (Hb) concentration, and clinical outcomes in these patients. RESULTS: Cross-sectional study with one-year follow-up in an orthogeriatric unit. Data were obtained from a quality register with demographic and medical information collected by an interdisciplinary team. 106 (22 %) of the 491 patients admitted from September 2011 throughout September 2012 (76 % women, mean age 85 years) received ABT. When given ABT, 80 % had Hb <80 g/l and mean Hb was 78 g/l. Mean Hb, regardless ABT, showed variation from 125 g/l (±16) on admission to 106 g/l (±17), 101 g/l (±16) and 102 g/l (±14) on 1st, 3rd and 5th postoperative day respectively. Patients with per-/subtrochanteric fractures more often received ABT than those with femur neck fractures (p < 0.001), 70 % of the patients receiving ABT had a per-/subtrochanteric fracture. Patients who received ABT were older, had more chronic diseases and lower mean Hb throughout the hospital stay. Length of stay was longer (median 7 vs. 6 days, p = 0.01), and medical complications more common. In-hospital and 30-day mortalities were similar in patients given ABT and in those who were not, but 1-year mortality was higher among patients who were given ABT (p = 0.008). CONCLUSIONS: Hb had a tendency to fall during the three first days after surgery and seemed to be stabilized on day 5. Patients who received ABT had poorer health, but not significantly higher short-term mortality. This study demonstrates a restrictive transfusion policy.

Effectiveness of gentamicin-containing collagen sponges for prevention of surgical site infection after hip arthroplasty: a multicenter randomized trial.

BACKGROUND: Surgical site infection (SSI) is a feared complication in hip arthroplasty, especially following femoral neck fracture in the elderly, associated with substantially increased morbidity, mortality, and costs. Gentamicin-containing collagen sponges are widely used for prevention of SSIs, but their effectiveness in joint replacement surgery remains unclear. METHODS: We performed a multicenter, randomized trial between February 2011 and July 2013. Eligible patients with femoral neck fracture undergoing hemiarthroplasty were randomly assigned to receive either intravenous antimicrobial prophylaxis alone or with the addition of 2 gentamicin-containing collagen sponges into the hip joint perioperatively. The primary end point was SSI according to the Centers for Disease Control and Prevention criteria within 30 days after surgery. RESULTS: Seven hundred thirty-nine patients were randomly assigned, 684 of whom were included in the modified intention-to-treat analysis. There was no statistical significant difference in SSI between the gentamicin-collagen group (16 of 329 patients [4.9%]) and the control group (19 of 355 patients [5.4%]) (relative risk [RR], 0.91 [95% confidence interval, .48-1.79]; P = .77). No significant differences were observed between the groups in superficial SSI (2 of 329 [0.6%] vs 3 of 355 [0.8%]; P = .99) and deep SSI (14 of 329 [4.3%] vs 16 of 355 [4.5%]; P = .87). There were no significant differences between the groups regarding type of bacteria isolated. CONCLUSIONS: Locally administered gentamicin-collagen sponges did not reduce the incidence of SSI in elderly patients treated with a hemiarthroplasty because of femoral neck fracture. CLINICAL TRIALS REGISTRATION: NCT01287780.