April 18, 2013

Increased incidence of orthopedic fractures in cirrhotic patients: A nationwide population-based study

Journal of Hepatology
Volume 58, Issue 4 , Pages 706-714, April 2013

Chia-Fen Tsai, Chia-Jen Liu, Tzeng-Ji Chen, Chi-Jen Chu, Han-Chieh Lin, Fa-Yauh Lee, Tung-Ping Su, Ching-Liang Lu

Received 18 June 2012; received in revised form 28 November 2012; accepted 1 December 2012. published online 11 December 2012.


Background & Aims

Hepatic encephalopathy (HE) is a reversible neuropsychiatric disorder in cirrhotic patients. The cognitive dysfunction and increased accidental falls in HE and osteodystrophy in cirrhotic patients may contribute to orthopedic fractures. This study investigated the fracture incidence and risk factors in cirrhotic patients with HE.


In total, 3764 cirrhotic patients with HE were identified from the Taiwan National Health Insurance database between 2000 and 2009. The fracture incidence of the HE patients was compared with that of 3764 age-, sex-, and comorbidity-matched cirrhotic patients without HE and non-cirrhotic controls. Cox proportional hazard models were used to estimate the risk of fracture in the HE patients.


Cirrhotic patients with and without HE had comparable increased risks of fracture (p <0.05) and cumulative incidences of fracture than controls (log-rank p <0.001). The estimated fracture rates were 7.09% for the HE group, 7.72% for the cirrhosis without HE group, and 4.05% for the controls, during the 18-month follow-up. The HE group had a higher incidence rate of skull fractures (IRR=2.61, 95% CI 1.04–6.57), but a lower rate of upper limb fractures (IRR=0.45, 95% CI 0.29–0.70) than the cirrhosis without HE group. Alcoholism, heart failure, and cerebrovascular disease were associated with increased risk of fracture in HE patients.


Cirrhotic patients, with or without HE, are at an increased risk of orthopedic fractures. Skull fractures, rather than fractures in weight-bearing bones, are more frequently observed in HE patients, particularly those with comorbidities.

Abbreviations: HE, hepatic encephalopathy, IRR, incidence rate ratio, CI, confidence interval, NHI, National Health Insurance, ICD, International Classification of Diseases, DM, diabetes mellitus, HR, hazard ratio

Keywords: Cirrhosis, Injury, Neuropsychiatric syndrome


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