The underlying mechanisms of the neuropsychiatric syndrome delirium are still unknown, but neuroinflammation is a central hypothesis. Chitinase-3-like-protein-1 (YKL-40/CHI3L1) is considered a marker of neuroinflammation when measured in cerebrospinal fluid (CSF). The aim of this study was to examine concentrations of CSF YKL-40 in patients with and without delirium, to enhance the understanding of delirium pathophysiology. A total of 545 hip fracture patients were included from two similar cohorts. CSF samples were collected in conjunction with spinal anaesthesia for hip fracture surgery. The patients were screened for delirium both pre- and postoperatively. Those with delirium were further divided into subgroups based on whether they developed it before surgery (prevalent delirium) or after surgery (incident delirium). Among patients without delirium, those who met some, but not all diagnostic criteria, were classified as having subsyndromal delirium. Prefracture cognitive function was assessed, and American Society of Anaesthesiologists physical status score was included as a marker of comorbidity. In total, 257 (47%) of the patients developed delirium. These patients were older and had a higher prevalence of dementia and severe systemic diseases. Among the patients without dementia, those with delirium had higher median concentration of CSF YKL-40 compared with those without delirium (first cohort: 175 versus 132 ng/mL, P = 0.01, second cohort: 243 versus 174 ng/mL, P < 0.001). No association was found among the patients with dementia. The results remained consistent when adjusting for age and comorbidity. No difference in median CSF YKL-40 concentration was found between patients who had delirium at the time of surgery (prevalent delirium) and those who developed it afterwards (incident delirium). Our findings support the hypothesis of neuroinflammation as a mechanism for delirium in patients without dementia.

Abstract Background Studies suggest delirium is associated with neuronal injury, which may further raise mortality risk. Neuronal injury can be assessed by measuring neurofilament light chain (NFL) concentrations in cerebrospinal fluid (CSF). This study aimed to investigate the association of CSF-NfL with delirium and mortality in patients with hip fracture. Methods The study comprised two prospective cohorts of 548 hip fracture patients with per-operative CSF samples. CSF-NfL concentrations were measured using a commercial ELISA. Delirium was assessed daily from admission until the fifth postoperative day and survival censored at one year. The multivariable analyses (Logistic and Cox regression) were adjusted for age, sex, glomerular filtration rate, dementia status, comorbidity, and Activities of Daily Living. Additionally, Cox regression was adjusted for delirium. Results In total, 259 (52%) patients developed delirium. In univariate analysis, CSF-NfL was higher among patients with delirium (2116 pg/ml versus 1366 pg/ml, odds ratio (OR) 2.21, (95% confidence interval (CI) [1.75,2,78], P < 0.001). In adjusted analysis, CSF-NfL was not significant (OR 1.29, [0.92,1.81], P = 0.128) and only remained significantly associated with delirium in the subgroup of patients without dementia (OR 1.84, [1.17, 2.89], P = 0.007). In unadjusted analysis of mortality, CSF-NfL was significantly associated with death at one year (hazard ratio (HR) 1.60, [1.37, 1.87], P < 0.001) but not in adjusted analysis (HR 1.03 [0.84, 1.26], P = 0.736). Conclusions Our findings show that CSF-NfL concentrations were associated with delirium in patients without pre-existing dementia, suggesting possible undiagnosed dementia or, less likely, delirium-related neuronal injury. The CSF-NfL-associated mortality hazard was non-significant after adjustment, mainly for delirium. Thus, the clinical context must be considered when studying CSF-NfL and delirium.

Concerns regarding postoperative complications may delay initiation of anti-osteoporosis treatment after hip fracture. We examined the association between early postoperative Zoledronate administration and acute in-hospital complications, subsequent medical and orthopaedic complications, reoperations, and new fractures within 30 days and one year. In this retrospective observational study, patients aged ≥ 50 years with a new hip fracture were included from two periods: a historical period (HisP) (2012–2013), before implementation of in-patient Zoledronate treatment, and an implementation period (ImpP) (2014–2021), where postoperative Zoledronate was routinely considered. Patients from ImpP not treated with Zoledronate were excluded from comparative analyses. Propensity score matching was used to create comparable treated and untreated groups. Outcomes included acute complications, subsequent medical and orthopaedic complications, reoperations, new fractures, and mortality within 30 days and one year. A total of 1 924 patients were included (68

Subsequent fracture rates and associated mortality were compared before and after the introduction of fracture liaison service (FLS). In 100,198 women and men, FLS was associated with 13

Aims:The aim of this study was to compare the direct lateral approach (DLA) with the anterolateral approach (ALA) and posterior approach (PA) using data on hemiarthroplasties (HAs) reported to the Norwegian Hip Fracture Register. The primary endpoint was reoperations within 12 months post-surgery. Secondary endpoints included mortality, patient-reported outcome measures (PROMs; EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS)), and intraoperative complications. Methods:A total of 39,905 HA patients aged 60 years or older who were operated on using DLA from January 2005 to December 2023 were compared to 2,813 patients operated on with ALA and 5,504 with PA in the same period. Hazard rate ratios (HRRs) for reoperations and mortality were calculated using Cox regression adjusted for age, sex, American Society of Anesthesiologists classification, cognitive status, and fixation method. Patients reported EQ-5D-3L and EQ-VAS 12 months postoperatively. Results:The reoperation rate was 3.7% for DLA, 3.0% for ALA (HRR 0.79 (0.64 to 0.99)), and 5.9% for PA (HRR 1.54 (1.37 to 1.74)). PA was associated with an increased dislocation rate compared to DLA (HRR 3.92 (3.28 to 4.67)). Fewer infections were observed with ALA (1.5%, HRR 0.68 (0.50 to 0.93)) and PA (1.6%, HRR 0.74 (0.59 to 0.92)) compared to DLA (2.2%). Similar 30-day mortality rates were found for all approaches and marginally lower one-year mortality was found for the PA. Patients operated on with the DLA reported significantly lower EQ-5D-3L index score and EQ-VAS at 12 months post-surgery compared to ALA and PA. Fewer intraoperative fractures were found using the PA. Conclusion:This study indicates that PA is associated with a higher reoperation rate after HA compared to the two other approaches. This is primarily due to high dislocation rate, despite a higher infection rate with DLA. EQ-5D-3L and EQ-VAS appear to favour ALA and PA 12 months post-surgery. Based on this study, traditional PA should be avoided in this patient group. ALA seems to be a safe alternative to the DLA.

The study investigated the risk of distal forearm fractures in adult Norwegian residents according to regions of birth. There were significant differences in fracture risk between the region of birth categories. Although the magnitude of the rates was different between the birth categories, similar sex and seasonal risk patterns were observed. Worldwide, distal forearm fractures (DFFs) are the most common fractures in adults. This study compared incidence rates of first DFFs in women and men in Norway by region of birth, age, and season. We included Norwegian residents aged 20 to 79 years with a first DFF between 2010 and 2020 using data from the Norwegian Patient Registry and population estimates from Statistics Norway. Three countries of birth groups were compared: Norwegian-born, Global North (most of Europe, North America, Australia, and New Zealand), and Global South (Asia, Africa, Latin America, Oceania). Compared to Norwegian-born residents in Norway, immigrants from Global North had 16

The aim of this study was to compare the direct lateral approach (DLA) with the anterolateral approach (ALA) and posterior approach (PA) using data on hemiarthroplasties (HAs) reported to the Norwegian Hip Fracture Register. The primary endpoint was reoperations within 12 months post-surgery. Secondary endpoints included mortality, patient-reported outcome measures (PROMs; EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS)), and intraoperative complications. A total of 39,905 HA patients aged 60 years or older who were operated on using DLA from January 2005 to December 2023 were compared to 2,813 patients operated on with ALA and 5,504 with PA in the same period. Hazard rate ratios (HRRs) for reoperations and mortality were calculated using Cox regression adjusted for age, sex, American Society of Anesthesiologists classification, cognitive status, and fixation method. Patients reported EQ-5D-3L and EQ-VAS 12 months postoperatively. The reoperation rate was 3.7% for DLA, 3.0% for ALA (HRR 0.79 (0.64 to 0.99)), and 5.9% for PA (HRR 1.54 (1.37 to 1.74)). PA was associated with an increased dislocation rate compared to DLA (HRR 3.92 (3.28 to 4.67)). Fewer infections were observed with ALA (1.5%, HRR 0.68 (0.50 to 0.93)) and PA (1.6%, HRR 0.74 (0.59 to 0.92)) compared to DLA (2.2%). Similar 30-day mortality rates were found for all approaches and marginally lower one-year mortality was found for the PA. Patients operated on with the DLA reported significantly lower EQ-5D-3L index score and EQ-VAS at 12 months post-surgery compared to ALA and PA. Fewer intraoperative fractures were found using the PA. This study indicates that PA is associated with a higher reoperation rate after HA compared to the two other approaches. This is primarily due to high dislocation rate, despite a higher infection rate with DLA. EQ-5D-3L and EQ-VAS appear to favour ALA and PA 12 months post-surgery. Based on this study, traditional PA should be avoided in this patient group. ALA seems to be a safe alternative to the DLA. Cite this article: Bone Jt Open 2025;6(10):1311–1320.

We externally validated the FRISBEE models of 2-year and 5-year fracture risk prediction in 517 women with index fractures. Both models overestimated the fracture risk. Recalibration of the FRISBEE models are needed before use in Norwegian women with recent fractures. PURPOSE:We externally validated the Fracture Risk Brussels Epidemiological Enquiry (FRISBEE) groups' 2-year and 5-year fracture risk models. METHODS:We included women above 50 years with a recent fracture from the consent-based part of the Norwegian Capture the Fracture Initiative study (NoFRACT). They had bone mineral density assessed and filled in a questionnaire including risk factors for fracture at baseline between October 2015 and December 2017. We calculated and validated the 2-year and 5-year fracture risk using the FRISBEE equation models. RESULTS:Of 517 women aged 65.5 ± 8.6 years with fractures, 94 (18%), 55 (11%), and 31 (6%) sustained a subsequent fracture of any type, major osteoporotic fractures (MOF), or central fracture, during 4.7 ± 1.3 years mean follow-up. The area under the receiver-operating curve (AUC) (95% confidence interval (CI)) for any type of fracture, MOF, and central fracture was 0.57 (0.51-0.63), 0.57 (0.46-0.67), and 0.65 (0.53-0.77), respectively, for the FRISBEE 2-year risk models and 0.57 (0.51-0.64), 0.58 (0.50-0.67), and 0.67 (0.57-0.76) for the FRISBEE 5-year risk models. The calibration slopes (with 95% CI) that compared observed vs. predicted probabilities for fracture across deciles of risk for any type of fracture, MOF, and central fracture were all low: 0.34 (0.02-0.64), 0.33 (- 0.09-0.74), and 0.61 (0.16-1.06), in the FRISBEE 2-year models, and 0.54 (0.13-0.95), 0.43 (0.05-0.80), and 0.69 (0.31-1.08), in the FRISBEE 5-year models. CONCLUSION:Overall, the FRISBEE models overestimated both 2-year and 5-year fracture risk. Recalibration is needed before these models can be used in Norwegian women with recent fractures.

Alterations in brain energy metabolism have long been proposed as one of several neurobiological processes contributing to delirium. This is supported by previous findings of altered CSF lactate and neuron-specific enolase concentrations and decreased glucose uptake on brain-PET in patients with delirium. Despite this, there are limited data on metabolic alterations found in CSF samples, and targeted metabolic profiling of CSF metabolites involved in energy metabolism has not been performed. The aim of the study was to investigate whether metabolites related to energy metabolism in the serum and CSF of patients with hip fracture are associated with delirium. The study cohort included 406 patients with a mean age of 81 years (standard deviation 10 years), acutely admitted to hospital for surgical repair of a hip fracture. Delirium was assessed daily until the fifth postoperative day. CSF was collected from all 406 participants at the onset of spinal anaesthesia, and serum samples were drawn concurrently from 213 participants. Glucose and lactate in CSF were measured using amperometry, whereas plasma glucose was measured in the clinical laboratory using enzymatic photometry. Serum and CSF concentrations of the branched-chain amino acids, 3-hydroxyisobutyric acid, acetoacetate and β-hydroxybutyrate were measured using gas chromatography-tandem mass spectrometry (GC-MS/MS). In total, 224 (55%) patients developed delirium pre- or postoperatively. Ketone body concentrations (acetoacetate, β-hydroxybutyrate) and branched-chain amino acids were significantly elevated in the CSF but not in serum among patients with delirium, despite no group differences in glucose concentrations. The level of 3-hydroxyisobutyric acid was significantly elevated in both CSF and serum. An elevation of CSF lactate during delirium was explained by age and comorbidity. Our data suggest that altered glucose utilization and a shift to ketone body metabolism occurs in the brain during delirium.

Oslo in Norway has had the highest incidence of hip fractures in the world. The incidence in Oslo has been thoroughly described every decade since the late 1970s. The incidence in Oslo has previously been higher compared to the rest of Norway but has now decreased to a level below the country average. The purpose of this study was to report the incidence of hip fractures in Oslo in 2019 and compare it with the incidence rates from the previous four decades. Patients residing in Oslo in 2019 with a new hip fracture identified by searching the Oslo hospital’s patient administrative systems and protocols from the operating theaters. The diagnosis was verified through medical records and/or radiographs. To compare with previous studies, the direct standardization method was used with the population of Oslo in 2019 as the standard. A total of 758 hip fractures, 70

This study reported the incidence of validated adult distal radius fractures in Oslo, Norway, in 2019. The incidence has been reduced over the last 20 years. However, it is still high compared to other regions in Norway and some of the other Nordic countries. We aimed to report the incidence of distal radius fractures in Oslo in 2019 and compare it to the incidence rates in 1998/1999. Patients aged ≥ 20 years resident in Oslo sustaining a distal radius fracture in 2019 were identified by electronic diagnosis registers, patient protocols, and/or radiology registers. The diagnosis was verified using medical records and/or radiology descriptions. We used the same method as the previous study from Oslo, making the comparison over time more accurate. The age-adjusted incidence rates and the age-standardized incidence rate ratio (IRR) were calculated. The absolute number of fractures decreased from 1490 in 1998/1999 to 1395 in 2019. The IRR for women and men in the age group ≥ 20 years in 2019 compared to 1998/1999 was 0.77 (95

The current study investigated subsequent fracture risk following a forearm fracture in three country of birth categories: Norway, Europe and North America, and other countries. Subsequent fracture risk was modestly higher in Norwegian-born individuals compared to the two other groups. Secondary fracture prevention should be recommended regardless of country background. Fracture risk is higher in patients with a previous fracture, but whether subsequent fracture risk differs by origin of birth is unknown. This study explores subsequent fracture risk in patients with an index forearm fracture according to region of birth. Nationwide data on forearm fractures in patients ≥ 18 years in 2008–2019 were obtained from the Norwegian Patient Registry and Statistics Norway. Index fractures were identified by ICD-10 code S52, whereas subsequent fractures included any ICD-10 fracture code. Data on country of birth were from Statistics Norway and included three regional categories: (1) Norway, (2) other Europe and North America and (3) other countries. Direct age standardization and Cox proportional hazard regression were used to analyse the data. Among 143,476 individuals with an index forearm fracture, 35,361 sustained a subsequent fracture. Norwegian-born forearm fracture patients had the highest subsequent fracture rates (516/10,000 person-years in women and 380 in men). People born outside Europe and North America had the lowest rates (278/10,000 person-years in women and 286 in men). Compared to Norwegian-born individuals, the hazard ratios (HRs) of subsequent fracture in individuals from Europe and North American were 0.93 (95

The purpose of this paper is to describe rates of forearm fractures in adults in Norway 2008–2019. Incidence rate of distal forearm fractures declined over time in both sexes. Forearm fracture constitute a significant health burden and prevention strategies are needed. To assess age- and sex-specific incidence rates, and time trends for forearm fractures in Norway, and compare these with incidence rates in other Nordic countries. Data on all patients aged 20–107 years with forearm fractures treated in Norwegian hospitals from 2008 to 2019 was retrieved from the Norwegian Patient Registry. Fractures were identified based on International Classification of Disease 10th revision code S52. Age- and sex-specific incidence rates and changes in incidence rates were calculated. We identified 181,784 forearm fractures in 45,628,418 person-years. Mean annual forearm fracture incidence rates per 100,000 person-years were 398 (95

INTRODUCTION:Patients with hip fractures are almost always operated with quite extensive surgery and are often frail with a high risk of complications, increased dependency, and death. Orthogeriatric interdisciplinary care has shown better results compared with orthopaedic care alone. The best way of delivering orthogeriatric care, however, is still largely unknown. It is believed that a high degree of integration and shared care is better than on-demand consultative services. We aimed to evaluate two different orthogeriatric models for patients with hip fracture.METHODS:A prospective hip fracture quality database was used to evaluate two coexisting models of care from 2019 to 2021 in our hospital. An 'integrated care model' (ICM) was compared with a 'geriatric consult service' (GCS).RESULTS:516 patients were available for analysis, 360 from ICM and 156 from GCS. Mean age was 84 years. There were 370 (72%) women. American Society of Anesthesiologists class and prefracture cognitive impairment was similar between the groups. There were more patients with femoral neck fractures in the ICM group, and more patients were living independently prefracture. A logistic regression adjusting for the variables above showed that more patients in the ICM group were given a nerve block preoperatively (OR 2.0 (95% CI 1.31 to 2.97); p<0.01), had their urinary catheter removed the first day after surgery (OR 1.9 (95% CI 1.27 to 2.89); p<0.01), were mobilised to standing or seated in a chair beside the bed the first day after surgery (OR 1.5 (95% CI 1.03 to 2.30); p=0.033) and more ICM patients were considered for treatment against osteoporosis (OR 8.58 (95% CI 4.03 to 18.28); p<0.001). There were no significant differences in time to surgery, length of stay, discharge destination or mortality.CONCLUSION:The ICM group performed equally good or better on all quality indicators than the GCS.

In vitro models of primary human osteocytes embedded in natural mineralized matrix without artificial scaffolds are lacking. We have established cell culture conditions that favored the natural 3D orientation of the bone cells and stimulated the cascade of signaling needed for primary human osteoblasts to differentiate into osteocytes with the characteristically phenotypical dendritic network between cells. Primary human osteoblasts cultured in a 3D rotating bioreactor and incubated with a combination of vitamins A, C, and D for up to 21 days produced osteospheres resembling native bone. Osteocyte‐like cells were identified as entrapped, stellate‐shaped cells interconnected through canaliculi embedded in a structured, mineralized, collagen matrix. These cells expressed late osteoblast and osteocyte markers such as osteocalcin (OCN), podoplanin (E11), dentin matrix acidic phosphoprotein 1 (DMP1), and sclerostin (SOST). Organized collagen fibrils, observed associated with the cell hydroxyapatite (HAp) crystals, were found throughout the spheroid and in between the collagen fibrils. In addition to osteocyte‐like cells, the spheroids consisted of osteoblasts at various differentiation stages surrounded by a rim of cells resembling lining cells. This resemblance to native bone indicates a model system with potential for studying osteocyte‐like cell differentiation, cross‐talk between bone cells, and the mineralization process in a bonelike structure in vitro without artificial scaffolds. In addition, natural extracellular matrix may allow for the study of tissue‐specific biochemical, biophysical, and mechanical properties. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Objective: Norway has a high incidence of forearm fractures, however, the incidence rates based on secondary care registers can be underestimated, as some fractures are treated exclusively in primary care. We estimated the proportion of forearm fracture diagnoses registered exclusively in primary care and assessed the agreement between diagnosis for forearm fractures in primary and secondary care.Design: Quality assurance study combining nationwide data from 2008 to 2019 on forearm fractures registered in primary care (Norwegian Control and Payment of Health Reimbursement) and secondary care (the Norwegian Patient Registry).Setting and patients: Forearm fracture diagnoses in patients aged & GE;20 treated in primary care (n = 83,357) were combined with injury diagnoses for in- and outpatients in secondary care (n = 3,294,336).Main outcome measures: Proportion of forearm fractures registered exclusively in primary care, and corresponding injury diagnoses for those registered in both primary and secondary care.Results: Of 189,105 forearm fracture registrations in primary and secondary care, 13,948 (7.4%) were registered exclusively in primary care. The proportion ranged from 4.9% to 13.5% on average between counties, but was higher in some municipalities (>30%). Of 66,747 primary care forearm fractures registered with a diagnosis in secondary care, 62% were incident forearm fractures, 28% follow-up controls, and 10% other fractures or non-fracture injuries.Conclusion: An overall small proportion of forearm fractures were registered only in primary care, but it was larger in some areas of Norway. Failing to include fractures exclusively treated in primary care could underestimate the incidence rates in these areas.

Summary The validity of forearm fracture diagnoses recorded in five Norwegian hospitals was investigated using image reports and medical records as gold standard. A relatively high completeness and correctness of the diagnoses was found. Algorithms used to define forearm fractures in administrative data should depend on study purpose. Purpose In Norway, forearm fractures are routinely recorded in the Norwegian Patient Registry (NPR). However, these data have not been validated. Data from patient administrative systems (PAS) at hospitals are sent unabridged to NPR. By using data from PAS, we aimed to examine (1) the validity of the forearm fracture diagnoses and (2) the usefulness of washout periods, follow-up codes, and procedure codes to define incident forearm fracture cases. Methods This hospital-based validation study included women and men aged ≥ 19 years referred to five hospitals for treatment of a forearm fracture during selected periods in 2015. Administrative data for the ICD-10 forearm fracture code S52 (with all subgroups) in PAS and the medical records were reviewed. X-ray and computed tomography (CT) reports from examinations of forearms were reviewed independently and linked to the data from PAS. Sensitivity and positive predictive values (PPVs) were calculated using image reports and/or review of medical records as gold standard. Results Among the 8482 reviewed image reports and medical records, 624 patients were identified with an incident forearm fracture during the study period. The sensitivity of PAS registrations was 90.4% (95% CI: 87.8–92.6). The PPV increased from 73.9% (95% CI: 70.6–77.0) in crude data to 90.5% (95% CI: 88.0–92.7) when using a washout period of 6 months. Using procedure codes and follow-up codes in addition to 6-months washout increased the PPV to 94.0%, but the sensitivity fell to 69.0%. Conclusion A relatively high sensitivity of forearm fracture diagnoses was found in PAS. PPV varied depending on the algorithms used to define cases. Choice of algorithm should therefore depend on study purposes. The results give useful measures of forearm fracture diagnoses from administrative patient registers. Depending on local coding practices and treatment pathways, we infer that the findings are relevant to other fracture diagnoses and registers.