Pre-operative Anemia and Hyponatremia Increase the Risk of Mortality in Elderly Hip Fractures

Document Type : RESEARCH PAPER


1 Department of Orthopedic Surgery, AIIMS, New Delhi, India

2 Department of Orthopedic Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India



Objectives: Pre-operative assessment is routinely performed for all hip fractures, and include a thorough 
clinical examination and multiple pre-operative tests. While abnormalities are often detected in many 
tests, they have varied effect on mortality. The purpose of the study was to assess the prevalence and 
impact of these abnormal tests and comorbidities.
Methods: This was a prospective study of 283 consecutive hip fracture patients aged above 50 years admitted in a 
major trauma hospital from February 2019 to December 2019. The prevalence of abnormalities in the following tests 
were assessed: chest x-ray, electrocardiogram, complete blood count, serum electrolytes, renal function test, 
prothrombin time/international normalized ratio, and serum bilirubin. Also, presence of comorbidities were recorded. 
Mortality within 90 days of admission was assessed.
Results: 91.5% (N= 259/283) of the patients had at least one abnormal investigation. The most common abnormal 
investigation was anemia (70.3%, N= 199/283), followed by deranged sodium (36.4%, N= 103/283). 17.7% (N= 
50/283) of the patients had at least one new comorbidity diagnosed after admission. The most common newly 
diagnosed comorbidity was hypertension (10.6%, N= 30/283). Anemia (p=0.044), deranged sodium (p=0.002), 
raised urea (p=0.018), raised creatinine (p=0.002), renal disease (p=0.015), neurological diseases (p=0.024), and 
charlson comorbidity index (p=0.004) were associated with increased mortality in multivariate analysis.
Conclusion: Pre-operative hemoglobin, sodium, urea, and creatinine were the most important tests influencing 
mortality, and derangements of these should therefore be carefully evaluated and managed. Hip fracture care 
pathways should focus on correction of these abnormalities.
 Level of evidence: II


Main Subjects

1. Meyer AC, Ek S, Drefahl S, Ahlbom A, Hedström M, Modig K. 
Trends in Hip Fracture Incidence, Recurrence, and Survival 
by Education and Comorbidity: A Swedish Register-based 
Study. Epidemiology. 2021; 32(3):425-433. 
2. Kristensen PK, Hjelholt TJ, Madsen M, Pedersen AB. Current 
Trends in Comorbidity Prevalence and Associated Mortality 
in a Population-Based Cohort of Hip Fracture Patients in 
Denmark. Clin Epidemiol. 2023; 15:839-853. 
3. Frost M, Wraae K, Gudex C, et al. Chronic diseases in elderly 
men: Underreporting and underdiagnosis. Age Ageing. 2012; 
41(2):177-183. doi:10.1093/ageing/afr153.
4. van Dongen SI, van Straaten B, Wolf JRLM, et al. Self-reported 
health, healthcare service use and health-related needs: A 
comparison of older and younger homeless people. Heal Soc 
Care Community. 2019; 27(4):e379-e388. 
5. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse 
prevalence in community settings: a systematic review and 
meta-analysis. Lancet Glob Heal. 2017; 5(2):e147-e156. 
6. Bhan N, Madhira P, Muralidharan A, et al. Health needs, 
access to healthcare, and perceptions of ageing in an 
urbanizing community in India: A qualitative study. BMC 
Geriatr. 2017; 17(1). doi:10.1186/s12877-017-0544-y.
7. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse 
prevalence in community settings: a systematic review and 
meta-analysis. Lancet Glob Heal. 2017; 5(2):e147-e156. 
8. George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra 
R. Injury Mechanisms of Hip Fractures in India. Hip pelvis. 
2021; 33(2):62-70. doi:10.5371/HP.2021.33.2.62.
9. Madsen CM, Jantzen C, Lauritzen JB, Abrahamsen B, 
Jorgensen HL. Hyponatremia and hypernatremia are 
associated with increased 30-day mortality in hip fracture 
patients. Osteoporos Int. 2016; 27(1):397-404. 
10. Zhang L, Yin P, Lv H, et al. Anemia on admission is an 
independent predictor of long-term mortality in hip fracture 
population a prospective study with 2-year follow-up. 
Medicine (Baltimore). 2016; 95(5). 
11. Sanz-Reig J, Salvador Marín J, Ferrández Martínez J, Orozco 
Beltrán D, Martínez López JF, Quesada Rico JA. Prognostic 
factors and predictive model for in-hospital mortality 
following hip fractures in the elderly. Chinese J Traumatol -
English Ed. 2018; 21(3):163-169. 
12. Paruk F, Matthews G, Gregson CL, Cassim B. Hip fractures in 
South Africa: mortality outcomes over 12 months postfracture. Arch Osteoporos. 2020; 15(1):76. 
13. Li S, Sun T, Liu Z. Excess mortality of 1 year in elderly hip 
fracture patients compared with the general population in 
Beijing, China. Arch Osteoporos. 2016; 11(1):35. 
14. George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra 
R. Factors associated with delayed surgery in elderly hip 
fractures in India. Arch Osteoporos. 2021; 16(1). 
15. Groff H, Kheir MM, George J, Azboy I, Higuera CA, Parvizi J. 
Causes of in-hospital mortality after hip fractures in the 
elderly. Hip Int. 2020; 30(2):204-209. 
16. Bernstein J, Roberts FO, Wiesel BB, Ahn J. Preoperative 
testing for hip fracture patient's delays surgery, prolongs 
hospital stays, and rarely dictates care. J Orthop Trauma. 
2016; 30(2):78-80. doi:10.1097/BOT.0000000000000444.
17. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new 
method of classifying prognostic comorbidity in longitudinal 
studies: development and validation. J Chronic Dis. 1987; 
40(5):373-383. doi:10.1016/0021-9681(87)90171-8.
18. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Available 
Published 2011. Accessed October 9, 2020.
19. Ryan G, Nowak L, Melo L, et al. Anemia at Presentation 
Predicts Acute Mortality and Need for Readmission Following 
Geriatric Hip Fracture. JB JS open access. 2020; 5(3). 
20. Guerra MTE, Viana RD, Feil L, Feron ET, Maboni J, Vargas ASG. One-year mortality of elderly patients with hip fracture 
surgically treated at a hospital in Southern Brazil. Rev Bras 
Ortop. 2017; 52(1):17-23. doi:10.1016/j.rboe.2016.11.006.
21. Ayus JC, Fuentes N, Go AS, et al. Chronicity of Uncorrected 
Hyponatremia and Clinical Outcomes in Older Patients 
Undergoing Hip Fracture Repair. Front Med. 2020; 7:263. 
22. Aicale R, Tarantino D, Maffulli N. Prevalence of Hyponatremia 
in Elderly Patients with Hip Fractures: A Two-Year Study. 
Med Princ Pract. 2017; 26(5):451-455. 
23. Kuo SCH, Kuo P-J, Rau C-S, Wu S-C, Hsu S-Y, Hsieh C-H. 
Hyponatremia Is Associated with Worse Outcomes from Fall 
Injuries in the Elderly. Int J Environ Res Public Health. 2017; 
14(5). doi:10.3390/ijerph14050460.
24. Hagino T, Ochiai S, Watanabe Y, et al. Hyponatremia at 
admission is associated with in-hospital death in patients 
with hip fracture. Arch Orthop Trauma Surg. 2013; 
133(4):507-511. doi:10.1007/s00402-013-1693-x.
25. Nigwekar SU, Negri AL, Bajpai D, et al. Chronic prolonged 
hyponatremia and risk of hip fracture in elderly patients with 
chronic kidney disease. Bone. 2019; 127:556-562. 
26. Jamal SA, Arampatzis S, Harrison SL, et al. Hyponatremia and 
fractures: Findings from the MrOS study. J Bone Miner Res. 
2015; 30(6):970-975. doi:10.1002/jbmr.2383.
27. Penrod JD, Litke A, Hawkes WG, et al. The association of race, 
gender, and comorbidity with mortality and function after hip 
fracture. J Gerontol A Biol Sci Med Sci. 2008; 63(8):867-872. 
28. Dhibar D, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada S. 
Predictors and outcome of fragility hip fracture: A 
prospective study from North India. Indian J Endocrinol 
Metab. 2019; 23(3):282. doi:10.4103/ijem.ijem_648_18.
29. Henderson CY, Ryan JP. Predicting mortality following hip 
fracture: an analysis of comorbidities and complications. Ir J 
Med Sci. 2015; 184(3):667-671. doi:10.1007/s11845-015-
30. Härstedt M, Rogmark C, Sutton R, Melander O, Fedorowski A. 
Impact of comorbidity on 6-month hospital readmission and 
mortality after hip fracture surgery. Injury. 2015; 46(4):713-
718. doi:10.1016/j.injury.2014.12.024.
31. Jiang L, Chou ACC, Nadkarni N, et al. Charlson Comorbidity 
Index Predicts 5-Year Survivorship of Surgically Treated Hip 
Fracture Patients. Geriatr Orthop Surg Rehabil. 2018; 
9:2151459318806442. doi:10.1177/2151459318806442.
32. Tang PL, Lin HS, Hsu CJ. Predicting in-hospital mortality for 
dementia patients after hip fracture surgery – A comparison 
between the Charlson Comorbidity Index (CCI) and the 
Elixhauser Comorbidity Index. J Orthop Sci. 2021; 26(3):396-
402. doi:10.1016/j.jos.2020.04.005.
33. Toson B, Harvey LA, Close JCT. The ICD-10 Charlson 
Comorbidity Index predicted mortality but not resource 
utilization following hip fracture. J Clin Epidemiol. 2015; 
68(1):44-51. doi:10.1016/j.jclinepi.2014.09.017.
34. Seyedi HR, Mahdian M, Khosravi G, et al. Prediction of 
mortality in hip fracture patients: Role of routine blood tests. 
Arch Bone Jt Surg. 2015; 3(1):51-55. 
35. Porter CJ, Moppett IK, Juurlink I, Nightingale J, Moran CG, 
Devonald MAJ. Acute and chronic kidney disease in elderly 
patients with hip fracture: Prevalence, risk factors and 
outcome with development and validation of a risk prediction 
model for acute kidney injury. BMC Nephrol. 2017; 18(1). 
36. Rantalaiho I, Gunn J, Kukkonen J, Kaipia A. Acute kidney 
injury following hip fracture. Injury. 2019; 50(12):2268-
2271. doi:10.1016/j.injury.2019.10.008.
37. Zanetti M, De Colle P, Omiciuolo C, et al. Postoperative 
Dehydration Is Associated with Frailty and Decreased 
Survival in Older Patients with Hip Fracture. Nutrients. 2022; 
14(4). doi:10.3390/nu14040820.