Background: Hip fractures are associated with high mortality and reduced quality of life. Studies have reported a high body mass index (BMI) as being positively associated with survival when linked to old age and some chronic diseases. This phenomenon is called the “obesity paradox.” The association between BMI and survival after hip fracture has not been thoroughly studied in large samples, nor has to what extent the association is altered by comorbidities, sex, and age. The objective of this study was to investigate the association of BMI with survival after hip fracture and with the probability of returning to living at home after hip fracture. Methods: This cohort study was based on data from a prospectively maintained national registry of patients with hip fracture. A total of 17,756 patients ≥65 years of age who were treated for hip fracture during the period of 2013 to 2016, and followed until the end of 2017, were included. BMI was clinically assessed at hospital admission, comorbidity was measured with the American Society of Anesthesiologists (ASA) score, and the date of death was retrieved from a national database. Self-reported data on living arrangements were assessed on admission and 4 months after fracture. Multivariable regression models were used to estimate the associations. Results: Despite ASA scores being similar among all BMI groups, obese patients had the highest 1-year survival and patients with a BMI of <22 kg/m2 had the lowest. Adjustment for potential confounders strengthened the associations. For the chance of returning to living at home, no advantage was seen for obese patients, but patients with a BMI of <22 kg/m2 had clearly worse odds compared with patients who were of normal weight, overweight, or obese. Conclusions: The obesity paradox appears to be true for hip fracture patients aged 65 and older. Attention should be given to patients with malnutrition and underweight status rather than to those with overweight status or obesity when developing the orthogeriatric care. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background and purposeRecent studies have demonstrated a high incidence of postoperative periprosthetic femoral fracture (PPF) in elderly patients treated with 2 commonly used cemented, polished tapered stems. We compared the prevalence and incidence rate of PPF in a consecutive cohort of octagenerians with femoral neck fractures (FNFs) treated with either a collarless, polished tapered (CPT) stem or an anatomic matte stem (Lubinus SP2).Patients and methodsIn a multicenter, prospective cohort study, we included 979 hips in patients aged 80 years and above (72% females, median age 86 (80–102) years) with a femoral neck fracture as indication for surgery. 69% of the patients were classified as ASA class 3 or 4. Hip-related complications and repeat surgery were assessed at a median follow-up of 20 (0–24) months postoperatively.Results22 hips (2.2%) sustained a PPF at a median of 7 (0–22) months postoperatively; 14 (64%) were Vancouver B2 fractures. 7 of the 22 surgically treated fractures required revision surgery, mainly due to deep infection. The cumulative incidence of PPFs was 3.8% in the CPT group, as compared with 0.2% in the SP2 group (p < 0.001). The risk ratio (RR) was 16 (95% CI: 2–120) using the SP2 group as denominator.InterpretationThe CPT stem was associated with a higher risk of PPF than the SP2 stem. We suggest that the tapered CPT stem should not be used for the treatment of femoral neck fractures in patients over 80 years.

Background and purposeDisplaced femoral neck fractures (FNFs) are associated with high rates of mortality during the first postoperative year. The Sernbo score (based on age, habitat, mobility, and mental state) can be used to stratify patients into groups with different 1-year mortality. We assessed this predictive ability in patients with a displaced FNF treated with a hemiarthroplasty or a total hip arthroplasty.Patients and methods292 patients (median age 83 (65–99) years, 68% female) with a displaced FNF were included in this prospective cohort study. To predict 1-year mortality, we used a multivariate logistic regression analysis including comorbidities and perioperative management. A receiver operating characteristic (ROC) analysis was used to evaluate the predictive ability of the Sernbo score, which was subsequently divided in a new manner into a low, intermediate, or high risk of death during the first year.ResultsAt 1-year follow-up, the overall mortality rate was 24%, and in Sernbo’s low-, intermediate-, and high-risk groups it was 5%, 22%, and 51%, respectively. The Sernbo score was the only statistically significant predictor of 1-year mortality: odds ratio for the intermediate-risk group was 4.2 (95% Cl: 1.5–12) and for the high-risk group it was 15 (95% CI: 5–40). The ROC analysis showed a fair predictive ability of the Sernbo score, with an area under the curve (AUC) of 0.79 (95% CI: 0.73–0.83). Using a cutoff of less than 11 points on the score gave a sensitivity of 61% and a specificity of 83%.InterpretationThe Sernbo score identifies patients who are at high risk of dying in the first postoperative year. This scoring system could be used to better tailor perioperative care and treatment in patients with displaced FNF.

The short-term success-rate of DAIR was unexpectedly favourable in this fragile patient population; the results being on par with that after PJI in osteoarthritis patients. The need for repeated bandage changes postoperatively indicates an increased risk for PJI and should prompt early surgical intervention.