Objective: Evaluate hip fracture (NOF) management in Parkinson’s (PD) against National Institute of Clinical Excellence (NICE) guidelines to identify if adverse outcomes arise from differences in peri-operative management

Background: There is evidence that PD elevates fracture risk [1,2]. People with PD are more likely to fall [1,3] and have osteoporosis [4,5]. Osteoporosis in PD is likely multifactorial: immobility, low body weight, low vitamin D and medication use (especially levodopa through the homocysteine pathway) [6,7,8]. Conflicting evidence exists regarding outcomes post NOF fracture in PD [9,10, 11].

Method: Evaluated: patients with a fractured NOF from Jan 2021 to Dec 2023 (single centre). Cohorts: PD and non-PD (NPD). Data collected: demographics, hip fracture management (NICE best practice) and outcomes (post operative 4AT a brief tool for delirium detection, discharge destination, length of stay and mortality). Any data unavailable was coded as ‘unknown’ and not included in statistical analysis. The audit was registered (ID6239 PRN 12239)

Results: Cohort: 67 PD and 1567 NPD. PD cohort patients were younger (80.9y vs. 83.3y, p=0.004), more likely to be male (43.3% vs. 28.7%, p=0.0153) with a lower pre-operative cognitive score (6.73/10 vs 7.35/10, p=0.0191). A higher proportion of intracapsular fracture in the PD cohort (73.1% vs 55.6%, p= 0.0401). No significant difference between the pre-NOF bone protection rates (16.4% vs 12.7%, p=0.676). There were no statistically significant differences in NOF fracture management between the two groups apart from an unexpected lower rate of pre-operative nerve block in the PD group (49.3% vs 63.6%, p=0.0198). Outcome data showed a higher rate of post-operative delirium (4AT score 2.21/4 vs 1.46/4, p=0.0111), longer length of stay (20.6d vs 15.7d, p=0.001) however there was missing data for mortality (data present 38/67 and 758/1567). Crude 30-day (5.26% vs 10.4%) and 1 year mortality (42.1% vs 33.1%).

Conclusion: No significant differences in the perioperative management between the cohorts were identified, apart from the unexpected difference in nerve block rates. Outcomes, however, were worse in the PD group with a higher rate of delirium, longer length of stay and higher 1 year mortality despite a younger, male cohort. Given there was little modifiable identified in the peri-operative management period resources should be directed towards proactive bone health management.

Table 1a Demographics

Table 1b Demographics

Table 2 NICE guideline

Table 3 outcome post NOF

References: 1. Fink HA, Kuskowski MA, Orwoll ES, et al. Association between Parkinson’s disease and low bone density and falls in older men: the osteoporotic fractures in men study. J Am Geriatr Soc 2005;53(9):1559-64. . Osteoporosis in PD is likely multifactorial, produced by a combination of immobility, decreased muscle strength, low body weight, vitamin D deficiency and medication use (especially levodopa)
2. Zhao Y, Shen L, Ji H-F. Osteoporosis risk and bone mineral density levels in patients with Parkinson’s disease: a meta-analysis. Bone 2013;52(1):498-505.
3. Gnaedinger M, Mellinghoff H-U, Kaelin-Lang A. Parkinson’s disease and the bones. Swiss Med Wkly 2011;141:w13154
4. Ahmed MS, Bahbah E, Shawqi M, et al. Parkinson’s disease and bone health: a pooled analysis of 580470 participant data. Journal of the Neurological Sciences 2017;381:157.
5. Torsney KM, Noyce AJ, Doherty KM, et al. Bone health in Parkinson’s disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2014;85(10):1159-66.
6. Van Den Bos F, Speelman AD, Samson M, et al. Parkinson’s disease and osteoporosis. Age and ageing 2013;42(2):156-62
7. Abou-Raya S, Helmii M, Abou-Raya A. Bone and mineral metabolism in older adults with Parkinson’s disease. Age and Ageing 2009;38(6):675-80.
8. Malochet-Guinamand S, Durif F, Thomas T. Parkinson’s disease: a risk factor for osteoporosis. Joint Bone Spine 2015;82(6):406-10.
9. Nguyen PV, Hjelholt TJ, Heide-Jørgensen U, et al. Postoperative complications, mortality, and quality of in-hospital care among hip fracture patients with Parkinson’s disease. Injury 2022;53(6):2150-57.
10. Harris-Hayes M, Willis AW, Klein SE, et al. Relative mortality in US Medicare beneficiaries with Parkinson disease and hip and pelvic fractures. JBJS 2014;96(4):e27.
11. Bliemel C, Oberkircher L, Eschbach D-A, et al. Impact of Parkinson’s disease on the acute care treatment and medium-term functional outcome in geriatric hip fracture patients. Arch Orthop Trauma Surg 2015;135(11):1519-26.

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