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Background: Neck of Femur (NOF) fractures are a common injury in comorbid elderly patients which are associated with increased rates of morbidity and mortality following fracture. Because of their injury, patients can experience reductions in quality of life and independent living leading to transfer to nursing home or dependent levels of care. Numerous factors are associated with either complications or reductions in survival following fractured NOF. From the VISION cohort there is evidence that troponin elevation in the post-operative period following a diverse range of non-cardiac surgical procedures may lead to an increased risk of mortality in the absence of classical ischaemic or cardiac symptoms. The aim of this systematic review and meta-analysis is to validate the utility of perioperative troponin elevation as a prognostic indicator for mortality and cardiac morbidity in those with fractured NOF., Methods: The PRISMA guidelines for the conduct of meta-analyses were followed. An electronic search was conducted of the EMBASE, MEDLINE (Ovid) and Biosis databases. Studies were included for analysis if they stratified outcomes by perioperative troponin elevation in surgically managed fractured NOF and reported sufficient data on troponin elevation and mortality following surgery. Primary and secondary outcomes assessed were all-cause post-operative mortality and a composite measure of cardiac complications (myocardial infarction, cardiac failure and arrhythmia) respectively., Results: Eleven studies met inclusion criteria giving a total of 1363 patients. Overall, 497 patients (36.5%) experienced an elevation in troponin levels following surgery. Perioperative troponin elevation was significantly associated with all-cause mortality (OR 2.6; 95% CI 1.5 - 4.6; p <0.001) and cardiac complications (OR 7.4; 95% CI 3.5 - 15.8; p <0.001). Patient factors significantly associated with troponin elevation included pre-existing coronary artery disease, cardiac failure, hypertension, previous stroke and previous myocardial infarction., Conclusion: Perioperative troponin elevation is significantly associated with increased mortality and post-operative cardiac complications following fractured NOF and may be a useful prognostic indicator in these patients. Future research should further stratify patients by the magnitude of troponin elevation and further refine the risk factors., Competing Interests: Declaration of Competing Interest The senior author (NJL) has previously received honoraria, travel and accommodation expenses unrelated to the subject of this paper from Merck, Sharp and Dohme. No authors received any benefits for this study that would constitute a conflict of interest., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Fractures of the proximal femur are a significant cause of mortality and morbidity in the elderly population. Yet predictive marker of unfavourable prognosis are still lacking. Calcium phosphate product is a marker of osteo-renal dysregulation. This study investigated the role of serum calcium phosphate product (SCPP) levels as a prognostic parameter for outcome in those patients., Patients and Methods: A total of 3577 consecutive patients with diagnosed fractures of the proximal femur were included in our study (72.5% females). SCPP was divided into tertiles: <1.92mmol(2)/l(2), 1.93-2.38mmol(2)/l(2) and >2.39mmol(2)/l(2). Data collection was performed prospectively and statistical evaluation was performed retrospectively., Results: Mean follow up in our study group was 11.0±0.3 months. The mean age of our study group was 79.0 years (SEM ±14 years). To facilitate analysis, patients were divided in two groups: ≤84 years (64.4%) and ≥85 years (35.6%), and mortality <12 months was 12.4% (n=445). In our study population higher SCPP levels ad admission were associated with a markedly elevated mortality. In a multivariate logistic regression model adjusted for age and sex, plasma creatinine and haemoglobin at admission caused a 1.3 (CI: 1.01-1.6) for SCPP 1.93-2.38mmol(2)/l(2), and a 1.6 (CI: 1.2-2.0) for SPP >2.39mmol(2)/l(2) fold increase in overall mortality compared to patients with baseline SCPP levels (<1.92mmol(2)/l(2)) as reference category., Conclusion: Those findings in our study population with 3577 patients over a period of 20 years proved to be, that serum Ca levels may be a good predictor for mortality in patients with fracture of the proximal femur. Further studies are required to evaluate whether these high risk patients might benefit from specific therapeutic measurements. This prognostic factor may help to increase the outcome of elderly patients with a fracture of the proximal femur., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Current management of undisplaced hip fractures is based on internal fixation. Reported revision rates of 12-17% for this procedure negatively impact on patient morbidity and mortality. The aim of this novel study is to examine if the nutritional status of these patients is associated with failure of internal fixation., Patients and Methods: A consecutive series of 111 undisplaced intracapsular hip fractures treated with cannulated screw was identified. These were retrospectively reviewed including routine admission serum investigations (lymphocyte count and albumin levels). Radiological investigations were used to assess fracture classification, posterior-tilt angle, fixation adequacy, screw configuration and failure (avascular-necrosis, non-union and screw cut-out)., Results: 16% of fixations failed (18 patients). Patients with fixation-failure had a significantly lower albumin (35g/l vs. 40g/l, p=0.02) and lymphocyte count (0.7×10(9)l vs. 1.4×10(9)l, p≤0.001) than non-failure patients. Lymphocyte count, albumin level and posterior-tilt angle were independent predicators of failure on binary logistic regression analysis. We suggest that routine laboratory tests can be used to identify patients at greatest risk of failure of internal fixation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Single dose Gentamicin (240 mg) has been shown to reduce postoperative wound infection in patients with fractured neck of femur when used in a combined antibiotic regimen. However, concerns have arisen about the risk of acute kidney injury (AKI) in these patients., Objective: To determine if the use of prophylactic Gentamicin is associated with AKI in fractured neck of femur patients., Methods: A historical cohort study. Pre- and post-operative creatinine mmol/l of 100 successive fractured neck of femur patients admitted from September 2010 were compared to a control of 100 age, sex and procedure matched individuals operated upon before the introduction of prophylactic Gentamicin (2005). AKI was defined as an increase in serum creatinine by over 50% of base line. Statistical significance was regarded as p<0.05., Results: A significant rise in creatinine levels was observed in both control (p=0.005) and study groups (p=0.001). There was neither a significant difference in peak creatinine between groups (p=0.87) nor in rates of AKI (p=0.568) between the 2 groups., Conclusion: Single preoperative doses of Gentamicin (240 mg) have no detrimental impact on renal function in this group. There is, however, a significant rise in creatinine following fractured neck of femur surgery, independent of Gentamicin., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

A prospective randomised controlled trial was performed to establish the effect of oral iron supplementation on haemoglobin level at 4 weeks post-operative in elderly patients with fractured neck of femur undergoing surgical treatment. We single blindly randomised 68 patients into two groups. Thirty-four patients in the treatment group were compared with 32 in the control group. The treatment group received 200mg of oral iron tablets 3 times a day for 4 weeks in the post-operative period compared to nothing for the control group. The groups were comparable in all other aspects. The iron treatment resulted in significantly increased haemoglobin value at 4 weeks; 0.76 g% higher than the control group (95% CI of +0.01 to +1.51) which is statistically significant (P<0.05). There was no major complication. We recommend oral iron supplementation in elderly anaemic patients with hip fracture in the post-operative period.

Introduction: This study aims prospectively to assess perioperative measurement of Troponin T, a marker of myocardial injury, as a predictor of morbidity and mortality in patients undergoing surgery for fractured neck of femur., Method: All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03 ng/mL was considered to be raised. Adverse outcome measures were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay., Results: One hundred and twenty-nine patients presented with femoral neck fractures. 108 patients were included after application of the exclusion criteria. 42 (39%) showed a Troponin rise. Of these, 25 sustained one or more outcome complications versus seven with no rise (p<0.001). The mean hospital stay was 25.7 days for patients with elevated Troponin, 18.3 days in the normal group (p<0.012). There were nine deaths in the raised Troponin group, and five with no rise (p<0.05)., Discussion: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 39% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many patients appear to be having silent events, causing significant morbidity. We recommend Troponin measurement in all patients to identify this risk and allow appropriate optimisation measures.

Although it is widely accepted that aspirin will increase the risk of intra- and post-operative bleeding, clinical studies have not consistently supported this assumption. We aimed to assess the effect of pre-operative aspirin on blood loss and transfusion requirements in patients undergoing emergency fixation of femoral neck fractures. A prospective case-control study was undertaken in patients presenting with femoral neck fractures. Parameters recorded included intra-operative blood loss, post-operative blood loss, transfusion requirements and peri-operative reduction in haemoglobin concentration. Of 89 patients presenting with femoral neck fractures 32 were on long-term aspirin therapy. Pre-operative aspirin ingestion did not significantly affect peri-operative blood loss, or change in haemoglobin concentration or haematocrit. However those patients taking aspirin pre-operatively had a significantly lower haemoglobin concentration and haematocrit and were more likely to be anaemic at presentation than those who were not receiving aspirin. Patients taking aspirin were also more likely to receive blood transfusion post-operatively.

Calcitonin gene-related peptides (CGRP) is a 37 amino acids peptide that has a proliferative effect on human endothelial cells, and is therefore important for the formation of new vessels and wound healing. As indicated by in vitro and animal studies, CGRP is also a potent vasodilator for cutaneous, cerebral, coronary vessels, a bronchoconstrictor and endocrine regulator. Systemic CGRP increase in patients with soft tissue injuries, chronic illness and sepsis, indicates that CGRP may yet be an important peptides in chronic illness. Although CGRP is a potent vasodilator, systemic vascular resistance does not increase in some patients with high CGRP levels. We questioned whether any changes occur in systemic CGRP levels in patients with one of the most common types of bone fractures especially in the elderly. In order to evaluate further the role of this peptide in these patients, a vasoconstictor (Endothelin-1 [ET]) and another sensory neuropeptide (Substance P [SP]) were measured within 24 h of injury. A sample was obtained on admission (day 1) and within 24 h post admission (day 2) in patients with fracture neck of femur (mean age 77.6, +/- 10 years, n = 20) and compared with healthy controls (51, +/- 26.8 years, n = 20). Peptides and hormones were measured by ELISA techniques. Mean (ng/l) CGRP was elevated in patients (day 1 [314 +/- 195] and day2 [209.2 +/- 150]); compared to controls (68.2 +/-31) P<0.005. Endothelin was non-significantly higher in day-2 (day 1 [28.5 +/-31], day2 [37.4 +/-38], controls [24.2 +/-21]) P = NS. SP maintained higher levels within 24 h after injury (day 1 [85.7 +/- 94], and day2 [80.9 +/- 91.8]) compared to controls, P< 0.05. Furthermore, Elastase (a decisive marker for inflammation and infectious complications) was found to be higher in patients being pronounced in day 2 than in day 1 (day 1 [200 +/-136], day2 [139 +/-118]). Creatine kinase and myoglobin were measured and found to be notably higher in patients. These peptides may be yet another group of cytokines playing significant role in immunologic, inflammatory complications or wound healing in this group of patients., (Copyright 2000 Harcourt Publishers Ltd.)

The blood transfusion requirements of a consecutive series of 249 unselected patients with femoral neck fracture were studied retrospectively. A total of 339 Units of blood were transfused (a mean of 1.36 Units per patient). Blood transfusion occurred in 132 patients (53.0%), with each receiving a mean of 2.57 Units. Patients aged 80 years and above as a group were transfused significantly more blood than those aged less than 80 years: 1.64 vs 0.94 Units, X2 = 12.09, p < 0.001. Patients with intertrochanteric fractures were transfused significantly more blood than those with intracapsular fractures (1.74 vs 1.00 Units: X2 = 13.4, p < 0.001).

59 elderly patients (mean age 82) with femoral neck fractures were randomised into two groups. 27 patients received daily an oral nutrition supplement (250 ml, 20 g protein, 254 kcal) for a mean of 32 days; 32 patients acted as controls. On admission most patients had nutritional deficiencies. Despite being offered adequate quantities, nutritional requirements were not met during the hospital stay. Clinical outcome was significantly better in the supplemented group (56% favourable course vs 13% in controls) during the stay in the convalescent hospital. The rates of complications and deaths were also significantly lower in supplemented patients (44% vs 87%). 6 months after the fracture the rates of complications and mortality were significantly lower in supplemented patients (40% vs 74%). The median duration of hospital stay was significantly shorter in the supplemented group (24 vs 40 days). Thus the clinical outcome of elderly patients with femoral neck fracture can be improved by once daily dietary oral supplementation.

A survey of 128 patients with femoral neck fractures has emphasised the difference in physical condition and clinical behaviour between those with cervical fractures and those with trochanteric fractures. The latter group of patients manifest advanced biological ageing and present a greater health care problem. Maintenance of mobility in the elderly may alleviate this situation.

In a retrospective study of patients with hip fractures, the preoperative lymphocyte counts of 62 patients who had died before discharge were compared with those of 64 patients who had survived for at least 6 months. It was found that the lymphocyte count was below the normal range (1.5-4.0 x 10(9)/l) in 82 per cent of those patients who died but only 36 per cent of those who survived. This difference is highly significant (P less than 0.001). It is suggested that the total lymphocyte count is valuable as an easily estimated prognostic index to identify the subgroup of patients who are at increased risk of dying from this injury.