Archives of Osteoporosis

, 13:27 | Cite as

The burden of inpatient care for diabetic and non-diabetic patients with osteoporotic hip fractures—does it differ? An analysis of patients recruited into a fracture liaison service in Southeast Asia

  • M. ChandranEmail author
  • D. Tay
  • X. F. Huang
  • Y. Hao
Original Article



Hospital care and mortality of diabetic and non-diabetic osteoporotic Asian patients undergoing hip fracture surgery were explored with no difference in length of hospitalization, incidence of post-operative complications, or mortality between diabetics and non-diabetics seen. Time to operation correlated with post-operative complications occurrence and therefore surgery should be expeditiously done.


Whether burden of inpatient care, problems after admission, and mortality rates differ between diabetics and non-diabetics undergoing surgery for osteoporotic hip fractures has not been explored in Asian populations.


Three hundred eighty-nine multi-ethnic diabetic and non-diabetic patients recruited into a FLS at a large Asian hospital with new osteoporotic hip fractures requiring operative repair were analyzed.


87.9% were Chinese, 6.4% Malay, and 3.6% Indians. BMI and age did not significantly differ between diabetics and non-diabetics. Median (IQR) length of hospitalization (LOHS) in days was 12 (9, 17) in diabetics and 11 (8, 14) in non-diabetics (p = 0.011). Median time from admission to operation (TTO) was 3 (2, 5) in diabetics versus 2 (1, 4.5) in the non-diabetics (p = 0.003). Occurrence of aggregate post-operative complications did not differ between diabetics and non-diabetics. No in-hospital mortalities occurred in either group. Thirty-day and 1-year mortality rates did not differ between the two groups. One-year mortality was 2.8% in the entire cohort. On multivariate regression analysis adjusted for age and race, only TTO (β; 1.8, 95% CI 1.5–2.0, p < 0.001) and occurrence of post-operative complications (β; 6.3, 95% CI 3.7–7.9, p < 0.001) correlated with LOHS. TTO and age-adjusted Charlson’s Comorbidity Index (CCI) correlated significantly with the development of post-operative complications.


Diabetes was not independently associated with LOHS in patients undergoing hip fracture surgery. Aggregate post-operative complications did not differ between diabetics and non-diabetics. TTO and occurrence of post-operative complications significantly affected LOHS. TTO correlated with post-complications development. Surgery should be expeditiously done in both diabetics and non-diabetics to avoid the development of post-operative complications and to prevent prolonged hospital stay.


Diabetes Length of hospital stay Time to operation Mortality Hip fractures Fracture liaison service 


Compliance with ethical standards

Conflict of interest



  1. 1.
    Zimmet PZ, Magliano DJ, Herman WH, Shaw JE (2014) Diabetes: a 21st century challenge. Lancet Diabetes Endocrinol 2(1):56–64CrossRefGoogle Scholar
  2. 2.
    Lee CMY, Huxley RR, Lam TH, Martiniuk ALC, Ueshema H, Pan WH, Welborn T, Woodward M, Asia Pacific Cohort Studies Collaboration (2007) Prevalence of diabetes mellitus and population attributable fractions for coronary heart disease and stroke mortality in the WHO South-East Asia and Western Pacific regions. Asia Pac J Clin Nutr 16(1):187–192PubMedGoogle Scholar
  3. 3.
    Cockram CS (2000) The epidemiology of diabetes mellitus in the Asia-Pacific region. Hong Kong Med J 6(1):43–52PubMedGoogle Scholar
  4. 4.
    Nanditha A, Ma RCW, Ramachandran A, Snehalatha C, Chan JCN, Chia KS, Shaw JE, Zimmet PZ (2016) Diabetes in Asia and the Pacific: implications for the global epidemic. Diabetes Care 39(3):472–485CrossRefGoogle Scholar
  5. 5.
    Dhanwal DK, Cooper C, Dennison EM (2010) Geographic variation in osteoporotic hip fracture incidence: the growing importance of asian influences in coming decades. J Osteoporos 2010:757102CrossRefGoogle Scholar
  6. 6.
    Mithal A, Bansal B, Kyer CS, Ebeling P (2014) The Asia-Pacific regional audit-epidemiology, costs, and burden of osteoporosis in India 2013: a report of International Osteoporosis Foundation. Indian J Endocrinol Metabol 18(4):449–454CrossRefGoogle Scholar
  7. 7.
    Fan Y, Wei F, Lang Y, Liu Y (2016) Diabetes mellitus and risk of hip fractures: a meta-analysis. Osteoporos Int 27(1):219–228CrossRefGoogle Scholar
  8. 8.
    Koh WP, Wang R, Ang LW, Heng D, Yuan JM, Yu MC et al (2010) Diabetes and risk of hip fracture in the Singapore Chinese health study. Diabetes Care 33(8):1766–1770CrossRefGoogle Scholar
  9. 9.
    Kim SH, Kim YM, Yoo JS, Choe EY, Kim TH, Won YJ et al (2016) Increased risk of hip fractures in Korean patients with type 2 diabetes: a 6-year nationwide population-based study. J Bone Miner Metab 35(6):623–629CrossRefGoogle Scholar
  10. 10.
    Napoli N, Strotmeyer ES, Ensrud KE, Sellmeyer DE, Bauer DC, Hoffman AR, Dam TTL, Barrett-Connor E, Palermo L, Orwoll ES, Cummings SR, Black DM, Schwartz AV (2014) Fracture risk in diabetic elderly men: the MrOS study. Diabetologia 57(10):2057–2065CrossRefGoogle Scholar
  11. 11.
    Vokó Z, Gáspár K, Inotai A, Horváth C, Bors K, Speer G, Kaló Z (2017) Osteoporotic fractures may impair life as much as the complications of diabetes. J Eval Clin Pract 23(6):1375–1380CrossRefGoogle Scholar
  12. 12.
    Stephens AS, Toson B, Close JCT (2014) Current and future burden of incident hip fractures in New South Wales, Australia. Arch Osteoporos 9:200CrossRefGoogle Scholar
  13. 13.
    Tan LTJ, Wong SJ, Kwek EBK (2017) Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore. Singap Med J 58(3):139–144CrossRefGoogle Scholar
  14. 14.
    Kayal RA, Alblowi J, McKenzie E, Krothapalli N, Silkman L, Gerstenfeld L, Einhorn TA, Graves DT (2009) Diabetes causes the accelerated loss of cartilage during fracture repair which is reversed by insulin treatment. Bone 44(2):357–363CrossRefGoogle Scholar
  15. 15.
    Wei R, Chen HL, Zha ML, Zhou ZY (2017) Diabetes and pressure ulcer risk in hip fracture patients: a meta-analysis. J Wound Care 26(9):519–527CrossRefGoogle Scholar
  16. 16.
    Norris R, Parker M (2011) Diabetes mellitus and hip fracture: a study of 5966 cases. Injury 42(11):1313–1316CrossRefGoogle Scholar
  17. 17.
    Macheras GA, Kateros K, Koutsostathis SD, Papadakis SA, Tsiridis E (2013) Which patients are at risk for kidney dysfunction after hip fracture surgery? Clin Orthop Relat Res 471(12):3795–3802CrossRefGoogle Scholar
  18. 18.
    Lopez-de-Andrés A, Jiménez-García R, Jiménez-Trujillo I, Hernández-Barrera V, de Miguel-Yanes JM, Méndez-Bailón M, Perez-Farinos N, de Miguel-Diez J, Salinero-Fort MÁ, Carrasco-Garrido P (2016) Incidence, surgical procedures, and outcomes of hip fracture among elderly type 2 diabetic and non-diabetic patients in Spain (2004-2013). Osteoporos Int 27(2):605–616CrossRefGoogle Scholar
  19. 19.
    Reistetter TA, Graham JE, Deutsch A, Markello SJ, Granger CV, Ottenbacher KJ et al (2011) Diabetes comorbidity and age influence rehabilitation outcomes after hip fracture. Diabetes Care 34(6):1375–1377CrossRefGoogle Scholar
  20. 20.
    Golinvaux NS, Bohl DD, Basques BA, Baumgaertner MR, Grauer JN (2015) Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients. Clin Orthop Relat Res 473(3):1043–1051CrossRefGoogle Scholar
  21. 21.
    Mizrahi EH, Fleissig Y, Arad M, Adunsky A (2006) Functional outcome of elderly hip fracture patients: does diabetes matter? Arch Gerontol Geriatr 43(2):165–173CrossRefGoogle Scholar
  22. 22.
    Chandran M, Tan MZW, Cheen M, Tan SB, Leong M, Lau TC et al (2013) Secondary prevention of osteoporotic fractures—an “OPTIMAL” model of care from Singapore. Osteoporos Int 24(11):2809–2817CrossRefGoogle Scholar
  23. 23.
    Chandran M (2013) Fracture liaison services in an open system: how was it done? What were the barriers and how were they overcome? Curr Osteoporos Rep 11(4):385–390CrossRefGoogle Scholar
  24. 24.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383CrossRefGoogle Scholar
  25. 25.
    Thomsen RW, Nielsen JS, Ulrichsen SP, Pedersen L, Hansen AMS, Nilsson T et al (2012) The Danish Centre for Strategic Research in type 2 diabetes (DD2) study: collection of baseline data from the first 580 patients. Clin Epidemiol 4:43–48CrossRefGoogle Scholar
  26. 26.
    Vidal EIO, Moreira-Filho DC, Coeli CM, Camargo KR, Fukushima FB, Blais R et al (2009) Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality? Osteoporos Int 20(5):723–729CrossRefGoogle Scholar
  27. 27.
    Majumdar SR, Beaupre LA, Johnston DWC, Dick DA, Cinats JG, Jiang HX et al (2006) Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study. Med Care 44(6):552–559CrossRefGoogle Scholar
  28. 28.
    Liu SK, Ho AW, Wong SH (2017) Early surgery for Hong Kong Chinese elderly patients with hip fracture reduces short-term and long-term mortality. Hong Kong Med J 23(4):374–380PubMedGoogle Scholar
  29. 29.
    Maheshwari K, Planchard J, You J, Sakr WA, George J, Higuera-Rueda C, et al. Early surgery confers one-year mortality benefit in hip-fracture patients. J Orthop Trauma. 2017.Google Scholar
  30. 30.
    Shiga T, Wajima Z, Ohe Y (2008) Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth 55(3):146–154CrossRefGoogle Scholar
  31. 31.
    Vidal EIO, Moreira-Filho DC, Pinheiro RS, Souza RC, Almeida LM, Camargo KR, Boas PJFV, Fukushima FB, Coeli CM (2012) Delay from fracture to hospital admission: a new risk factor for hip fracture mortality? Osteoporos Int 23(12):2847–2853CrossRefGoogle Scholar
  32. 32.
    Fu MC, Boddapati V, Gausden EB, Samuel AM, Russell LA, Lane JM et al (2017) Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications. Bone Joint J 99-B(9):1216–1222CrossRefGoogle Scholar
  33. 33.
    Endara M, Masden D, Goldstein J, Gondek S, Steinberg J, Attinger C et al (2013) The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control. Plast Reconstr Surg 132(4):996–1004CrossRefGoogle Scholar
  34. 34.
    Stryker LS, Abdel MP, Morrey ME, Morrow MM, Kor DJ, Morrey BF et al (2013) Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty. J Bone Joint Surg Am 95(9):808–814 S1CrossRefGoogle Scholar
  35. 35.
    Lee AYJ, Tan J, Koh J, Fook-Chong SMC, Lo NN, Howe TS et al (2012) Five-year outcome of individuals with hip fracture admitted to a Singapore hospital: quality of life and survival rates after treatment. J Am Geriatr Soc 60(5):994–996CrossRefGoogle Scholar
  36. 36.
    Tay E (2016) Hip fractures in the elderly: operative versus nonoperative management. Singap Med J 57(4):178–181CrossRefGoogle Scholar
  37. 37.
    Huntjens KMB, van Geel TACM, van den Bergh JPW, van Helden S, Willems P, Winkens B, Eisman JA, Geusens PP, Brink PRG (2014) Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg Am 96(4):e29CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Department of Endocrinology, Osteoporosis and Bone Metabolism UnitSingapore General HospitalSingaporeSingapore
  2. 2.Health Services Research Unit (HSRU), Division of MedicineSingapore General HospitalSingaporeSingapore

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