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randomised controlled trial.
blinded (healthcare providers).
Follow up period:
a hospital in Sweden.
80 patients >60 years of age (79% women) who had surgery <48 h after cervical or trochanteric hip fracture. Exclusion criteria were multiple or pathological fractures, malignant disease, inflammatory joint disease, pain, or functional impairment other than hip fracture that might inhibit normal mobilisation; substantial cognitive impairment, depression, acute psychosis, epileptic seizures, or alcohol or medication abuse; heart, kidney, or liver insufficiency; or type 1 diabetes mellitus, suspected acute myocardial infarction, or haematemesis.
nutritional supplementation for the first 10 days after surgery plus usual hospital food and beverage (n = 40) or usual hospital food and beverage only (n = 40). Nutritional supplementation consisted of IV Vitrimix® (Kabi Pharmacia AB, Stockholm, Sweden), 1000 ml daily for 3 days (1000 kcal energy/d), and then oral Fortimel® (Nutricia AB, Numico, The Netherlands), 200 ml twice daily for 7 days (400 kcal energy/d). Vitrimix® contained IntralipidA®, 250 ml, and VaminA®-Glucose, 750 ml, amino acids, sodium, potassium, calcium, magnesium, and chloride; trace elements (Tracel®, Kabi Pharmacia AB), and water and fat soluble vitamins (Soluvit Novum® and Vitalipid Novum®, Kabi Pharmacia AB) were added to Vitrimix®. Fortimel® contained protein, 10 g, carbohydrates, 10.3 g, fat, 2.1 g, minerals, and vitamins.
infections (wound infection, urinary infection, or pneumonia), other complications (thrombophlebitis, deep venous thrombosis, pulmonary embolism, pulmonary oedema, or myocardial infarction), and death.
Patient follow up:
At 120 days, fewer patients in the supplementation group than in the usual care group had ⩾1 complication, and fewer died (table⇓); the supplementation group also had fewer infections (cumulative number of infections 5 v 34, p<0.001). The groups did not differ for other complications (table⇓).
Intravenous and oral nutritional supplementation after surgery for hip fracture reduced fracture related complications in otherwise healthy patients.
Evidence to support the assumption that patients with hip fracture benefit from supplemental calories and protein after surgery has been weak.1 In the study by Eneroth et al, the reduction in postoperative complications in otherwise healthy patients with hip fracture was dramatic, especially given their mean age of 84 years (v 78 y in the control group). However, fewer people returned to their own homes in the intervention group. Discharge destination is an important outcome indicator, but it was not explored in the study.
Parenteral nutrition (PN) was given for 3 days after surgery. This is not a common practice because of the expense and risk of infection, especially when given peripherally, as in this study. Another possible limitation is the mixed use of both IV and oral supplements, which makes it impossible to know which method of administration accounts for the end result. Patients may have equally benefited from 10 days of the cheaper, less invasive oral supplements.
Current best practice is to use the gut (ie, the most physiological method of feeding) if there are no contraindications.2 Even nasogastric feeding is less expensive and has less risk than PN. The use of PN would have required more nursing surveillance, which may have positively affected the intervention group. What must be considered is whether the risks and cost of PN outweigh the possible benefits of a considerable reduction in complications with its attendant risks and cost. A larger definitive trial is probably required (with blinded adjudication of complications). The study by Eneroth et al highlights the benefit of early nutritional intervention for healthy hip fracture patients. Further research comparing mixed parenteral and oral nutrition with oral supplementation will address the most pressing issue arising from this study.
↵* Information provided by author.
For correspondence: Dr M Eneroth, Department of Orthopaedics, Lund University Hospital, Lund, Sweden.
Sources of funding: County of Skane and Swedish National Board of Health and Welfare.
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