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Moretti A, Liguori S, Paoletta M, Migliaccio S, Toro G, Gimigliano F, Iolascon G. Bone fragility during the COVID-19 pandemic: the role of macro- and micronutrients. Ther Adv Musculoskelet Dis 2023; 15:1759720X231158200. [PMID: 36937822 PMCID: PMC10015293 DOI: 10.1177/1759720x231158200] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/01/2023] [Indexed: 03/18/2023] Open
Abstract
Bone fragility is the susceptibility to fracture due to poor bone strength. This condition is usually associated with aging, comorbidities, disability, poor quality of life, and increased mortality. International guidelines for the management of patients with bone fragility include a nutritional approach, mainly aiming at optimal protein, calcium, and vitamin D intakes. Several biomechanical features of the skeleton, such as bone mineral density (BMD), trabecular and cortical microarchitecture, seem to be positively influenced by micro- and macronutrient intake. Patients with major fragility fractures are usually poor consumers of dairy products, fruit, and vegetables as well as of nutrients modulating gut microbiota. The COVID-19 pandemic has further aggravated the health status of patients with skeletal fragility, also in terms of unhealthy dietary patterns that might adversely affect bone health. In this narrative review, we discuss the role of macro- and micronutrients in patients with bone fragility during the COVID-19 pandemic.
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Muacevic A, Adler JR, Sondur S, Rajendran P, Mohanty A, Prakash V, Gutta H, Pundhir HP, Rath S. Zoledronic Acid Does Not Retard Bone Union: A Randomized Controlled Trial in Fragility Intertrochanteric Femur Fractures. Cureus 2023; 15:e33948. [PMID: 36819363 PMCID: PMC9937685 DOI: 10.7759/cureus.33948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Fragility hip fracture is a leading cause of death in the elderly and is common in postmenopausal women and elderly people. In the treatment of osteoporosis, bisphosphonates (BPs) are often considered first-line medications. Zoledronic acid is the most potent and long-acting BP in clinical use and is administered as an intravenous infusion. In the context of acute fractures, the use of BPs has been controversial due to conflicting reports of their positive and negative effects on fracture healing. The purpose of this study was to determine the effect of zoledronic acid on fracture healing in intertrochanteric (IT) fragility fractures. METHODS The study was conducted in a tertiary healthcare center after receiving scientific and ethical approval. The study included 136 patients of either gender over the age of 50 who presented with an IT femur fracture after minor trauma between November 2020 and November 2022. The total number of patients had been classified into two groups, and grouping involved random sampling: Group T (test group, n = 68; zoledronic acid injections were given on postoperative day 3) and Group C (control group, n = 68; interventions were given after fracture healing). Patients were evaluated using the Radiographic Union Score for Hip (RUSH) and Singh Index for radiological outcomes and the Harris Hip Score (HHS) for functional outcomes. The patients were followed for six months. RESULTS The overall mean age was 73.25 years; in Group T, it was 72.5 ± 11.9 years, and in Group C, it was 73.7 ± 11.8 years. Of 136 patients, 69 (51%) were males and 67 (49%) were females. The average fracture healing time in Group T was 12.2 ± 3.6 weeks, while it was 13.0 ± 2.8 weeks in Group C. Functional outcomes, including HHS, were found to be better in Group T than in Group C (p < 0.005). No significant difference was observed between the two groups with respect to the radiological union, the RUSH score, or Singh Index, implying no negative effect of zoledronic acid. CONCLUSIONS This study demonstrates that postoperative intravenous zoledronic acid therapy does not retard fracture healing. Osteoporosis management is frequently neglected because of a surgeon's fear of ZOL retarding fracture healing and a lack of awareness among patients, resulting in low compliance. Thus, opportunistic administration of zoledronic acid postoperatively can be beneficial and will increase compliance for osteoporosis management and fracture prevention to 100%.
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Narayanasamy M, Bishop S, Sahota O, Paskins Z, Gittoes N, Langley T. Acceptability and engagement amongst patients on oral and intravenous bisphosphonates for the treatment of osteoporosis in older adults. Age Ageing 2022; 51:6834153. [PMID: 36413592 DOI: 10.1093/ageing/afac255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Osteoporosis is common in older adults leading to fragility fractures at enormous individual and economic cost. Improving long-term adherence with bisphosphonate treatments reduces fracture risk, but adherence rates for first-line oral bisphosphonate alendronate remains low. Although alternative treatment regimens, including annual intravenous infusions are available, patient acceptability remains unclear. Therefore, understanding patients' acceptability and engagement in different bisphosphonate regimens is important to ensure optimal treatment benefits. METHODS Semi-structured interviews were conducted with 78 patients with a mean age of 69.9 years, who had taken or received bisphosphonates for osteoporosis within the last 24 months. Data analysis included iterative categorisation and used the theoretical framework of acceptability (TFA) to compare the acceptability of treatments regimens. RESULTS Treatment acceptability and engagement were influenced by the extent to which patients understood the prescribed treatment, and evidence of the treatment working. Acceptability and engagement were compromised when treatment was perceived as burdensome, personal costs were incurred, and patients' values were incompatible with the regimen. The balancing of these factors contributed to patients' ability to cope with the treatment and their emotional responses. Intravenous treatment was generally perceived as easier to understand, more effective, less burdensome with fewer opportunity costs, and a preferable regimen compared with oral bisphosphonates. CONCLUSIONS Annual intravenous zoledronate bisphosphonate treatment was generally more acceptable to patients, perceived as more straightforward to engage in, although a small portion of patients on oral bisphosphonates were satisfied with treatment. Further research is needed to identify how acceptability and engagement can be optimised.
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Iolascon G, Paoletta M, Liguori S, Gimigliano F, Moretti A. Bone fragility: conceptual framework, therapeutic implications, and COVID-19-related issues. Ther Adv Musculoskelet Dis 2022; 14:1759720X221133429. [PMID: 36317067 PMCID: PMC9614590 DOI: 10.1177/1759720x221133429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022] Open
Abstract
Bone fragility is the susceptibility to fracture even for common loads because of structural, architectural, or material alterations of bone tissue that result in poor bone strength. In osteoporosis, quantitative and qualitative changes in density, geometry, and micro-architecture modify the internal stress state predisposing to fragility fractures. Bone fragility substantially depends on the structural behavior related to the size and shape of the bone characterized by different responses in the load–deformation curve and on the material behavior that reflects the intrinsic material properties of the bone itself, such as yield and fatigue. From a clinical perspective, the measurement of bone density by DXA remains the gold standard for defining the risk of fragility fracture in all population groups. However, non-quantitative parameters, such as macro-architecture, geometry, tissue material properties, and microcracks accumulation can modify the bone’s mechanical strength. This review provides an overview of the role of different contributors to bone fragility and how these factors might be influenced by the use of anti-osteoporotic drugs and by the COVID-19 pandemic.
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Huyke-Hernández FA, Only AJ, Sorich M, Onizuka N, Switzer JA, Cunningham BP. Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221135480. [PMID: 36310893 PMCID: PMC9608033 DOI: 10.1177/21514593221135480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure. Methods This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality. Results Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved. Conclusions Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.
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The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population. J Clin Med 2022; 11:jcm11195832. [PMID: 36233699 PMCID: PMC9570675 DOI: 10.3390/jcm11195832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.
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Huyke-Hernández FA, Parashos SA, Schroder LK, Switzer JA. Hip Fracture Care in Parkinson Disease: A Retrospective Analysis of 1,239 Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221118225. [PMID: 35967748 PMCID: PMC9364183 DOI: 10.1177/21514593221118225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/24/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Compared to other patients, Parkinson disease (PD) patients may experience
suboptimal outcomes after hip fracture. The purpose of this study was to
describe and compare characteristics and outcomes of hip fracture patients
with PD to those without PD. Methods This retrospective cohort study included all patients admitted for hip
fracture within a large healthcare system between July 1, 2017 and June 30,
2019. Demographics, injury characteristics, Charlson Comorbidity Index
(CCI), treatment characteristics, and outcomes including complications,
readmissions, and mortality were extracted. Patients with PD were compared
to those without PD. Chi-square tests, two-sample t-tests, and Fisher exact
tests were conducted to identify group differences. Results A total of 1239 patients were included (4.0% PD and 96.0% non-PD). PD
patients were mostly male (59.2%) compared to mostly female non-PD patients
69.4%, P < .001). PD patients on average had a higher
CCI (2.3 vs 1.7, P = .040) and more frequently had dementia
(42.9% vs 26.7%, P = .013). No PD patients were discharged
home without additional assistance compared to 8.1% of patients without PD.
More PD patients were discharged to a skilled nursing facility (SNF) than
non-PD patients (65.3% vs 48.2%, P = .021). Only 22.4% of
PD patients were previously prescribed osteoporosis medication, and only
16.3% were referred for osteoporosis follow-up after fracture. In-house
complications, readmissions, and mortality up to 1 year were comparable
between groups (P>.191). Conclusions Outcomes between PD patients and non-PD patients were mostly equivalent, but
more PD patients required discharge to a higher-level care environment
compared to non-PD patients. Although PD seems to be a risk factor for hip
fracture regardless of age and sex, most patients had not undergone proper
screening or preventative treatment for osteoporosis. These results
emphasize the need for early bone health evaluation, multidisciplinary
collaboration, and care coordination in preventing and treating hip
fractures in PD.
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Chang E, Nickel B, Binkley N, Bernatz J, Krueger D, Winzenried A, Anderson PA. A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116413. [PMID: 35967749 PMCID: PMC9364193 DOI: 10.1177/21514593221116413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Osteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA. Materials/Methods This retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD]. Results The study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.). Discussion/Conclusion A simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.
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Richardson C, Bretherton CP, Raza M, Zargaran A, Eardley WGP, Trompeter AJ. The Fragility Fracture Postoperative Mobilisation multicentre audit : the reality of weightbearing practices following operations for lower limb fragility fractures. Bone Joint J 2022; 104-B:972-979. [PMID: 35909372 DOI: 10.1302/0301-620x.104b8.bjj-2022-0074.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. METHODS The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, "all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living". RESULTS A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). CONCLUSION Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972-979.
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Houserman DJ, Raszewski JA, Palmer B, Chavan B, Sferrella A, Campbell M, Santanello S. The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221099107. [PMID: 35794869 PMCID: PMC9251979 DOI: 10.1177/21514593221099107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period. Methods This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant. Results The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups. Conclusions The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway. Level of Evidence Level III Evidence – Retrospective Cohort Study
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Cardiovascular Safety and Effectiveness of Bisphosphonates: From Intervention Trials to Real-Life Data. Nutrients 2022; 14:nu14122369. [PMID: 35745099 PMCID: PMC9227734 DOI: 10.3390/nu14122369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 02/04/2023] Open
Abstract
Both osteoporosis with related fragility fractures and cardiovascular diseases are rapidly outspreading worldwide. Since they are often coexistent in elderly patients and may be related to possible common pathogenetic mechanisms, the possible reciprocal effects of drugs employed to treat these diseases have to be considered in clinical practice. Bisphosphonates, the agents most largely employed to decrease bone fragility, have been shown to be overall safe with respect to cardiovascular diseases and even capable of reducing cardiovascular morbidity in some settings, as mainly shown by real life studies. No randomized controlled trials with cardiovascular outcomes as primary endpoints are available. While contradictory results have emerged about a possible BSP-mediated reduction of overall mortality, it is undeniable that these drugs can be employed safely in patients with high fracture risk, since no increased mortality has ever been demonstrated. Although partial reassurance has emerged from meta-analysis assessing the risk of cardiac arrhythmias during bisphosphonates treatment, caution is warranted in administering this class of drugs to patients at risk for atrial fibrillation, possibly preferring other antiresorptives or anabolics, according to osteoporosis guidelines. This paper focuses on the complex relationship between bisphosphonates use and cardiovascular disease and possible co-management issues.
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Rojas LGP, Cervantes REL, Almejo LL, Pesciallo CA, Garabano G, Bidolegui F, Giordano V, Belangero WD, Hungria JOS, Triana Q MA, Gómez A. Fragility fracture systems, Latin America perspective. OTA Int 2022; 5:e178. [PMID: 35949494 PMCID: PMC9359007 DOI: 10.1097/oi9.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
Osteoporosis is a worldwide epidemic, affecting an average of 30% to 50% of those over 50 years of age in Latin America. Resulting from it is another epidemic, that of fragility fractures, which adversely affects morbidity and mortality of this population. Increasing in their incidence, fragility fractures are expected to occur in 1 in 3 women and 1 in 5 men over 50years of age during their lifetimes. Currently, there are diagnostic and management guidelines for fragility fractures in Latin American countries, especially those for hip and spine fractures. In general, in Latin America, the quality indicators and standards for the care of these fractures vary greatly according to the health system, being suboptimal in many situations. The organization of health services is different in the different countries throughout Latin America. Common underlying characteristics, however, include the distinctions that exist in care between public and private medicine and the lack of economic resources directed to public healthcare systems from the national levels. Several important changes have been implemented in recent years, with the collaboration between national organizations and international associations such as the Fragility Fracture Network and the International Osteoporosis Foundation, aimed at improving quality standards in care and rates of morbidity and mortality in patients treated thorough fragility fracture programs. The underregistration in these programs and absence of formal national registries also contribute to a lack of recognition of the size, scope, and severity of the problem.
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Garg B, Mehta N. Acute Neurological Deficit Due to Sacral Insufficiency Fracture With Coexistent Severe Lumbar Canal Stenosis: A Case Report. HSS J 2022; 18:307-311. [PMID: 35645643 PMCID: PMC9097004 DOI: 10.1177/15563316211006665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
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Khan AA, Alrob HA, Ali DS, Dandurand K, Wolfman W, Fortier M. Guideline No. 422g: Menopause and Osteoporosis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:527-536.e5. [PMID: 35577424 DOI: 10.1016/j.jogc.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. TARGET POPULATION Perimenopausal and postmenopausal women. BENEFITS, HARMS, AND COSTS Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. EVIDENCE Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS RECOMMENDATIONS.
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McDonald CL, Cohen BH, Medina Pérez G, Modest JM, Kuris EO, Born C. Pre-Operative Medications as a Predictor for Post-Operative Complications Following Geriatric Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2022; 13:21514593221091062. [PMID: 35450299 PMCID: PMC9016589 DOI: 10.1177/21514593221091062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/08/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background Fragility hip fractures are a common orthopedic injury seen in Emergency
Departments, with variable outcomes that can range from average to
devastating. Currently, few reliable metrics to predict which patients will
suffer post-operative complications exist. The aim of this study was to
determine if the number and type of pre-operative medications can help
predict post-operative complications. Methods A prospectively collected database of hip fracture patients was
retrospectively reviewed. Patients with isolated greater trochanteric
fractures, periprosthetic fractures, or re-fractures were excluded.
Pre-operative baseline characteristics as well as number and type of
post-operative complications were reviewed. Any complication within 6 months
of surgery and complications that could be directly attributable to the
surgical procedure within 2 years of surgery were examined. Major
complications (return to the operating room, deep infection, pulmonary,
cardiac, and hematologic) and minor medical complications were assessed. A
multivariate regression model was performed to identify independent risk
factors. Results Three-hundred ninety-one patients were included. A majority were aged 80–90
and female, and lived at home prior to presentation. Overall, 33.7% of
patients suffered a complication within a 2-year follow-up period. Mortality
rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years,
respectively. After assessing this relationship while controlling for age,
sex, injury type, pre-operative residence, ambulatory status, ASA score, and
CCI score, the relationship remained significant for both an increased
number of complications (P = .048) and a higher likelihood
of having a complication (P = .008). Cardiovascular
(P = .003), pulmonary (P = .001), gout
(P = .002), or diabetes (P = .042)
medications were associated with a higher likelihood for experiencing a
complication. Conclusions Our study suggests that there is a strong and linear relationship between the
number and type of pre-operative medications taken and risk of
post-operative complications. This exists for up to 8 medications, at which
point further increase does not contribute to an increased risk of
complication. This relationship exists even after controlling for
confounding variables and can be used by surgeons to better counsel patients
and families regarding their specific risk for suffering perioperative
complications.
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Suhm N, Gratza SK. Novel Approach to Identify Patients With the Most to Gain From New Treatment Options Intended to Prevent Fragility Fractures. Geriatr Orthop Surg Rehabil 2022; 13:21514593221076620. [PMID: 35450300 PMCID: PMC9016568 DOI: 10.1177/21514593221076620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
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Johnson T, Fox E, Hassanbein S. Implementing an Electronic Medical Record Osteoporosis Self-Assessment Tool Score Which Identifies Patients at Risk for Osteoporosis Promotes Osteoporosis Evaluation. Geriatr Orthop Surg Rehabil 2022; 12:21514593211002157. [PMID: 35186418 PMCID: PMC8848097 DOI: 10.1177/21514593211002157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Osteoporosis affects nearly half of the U.S. population. Screening methods are improving but remain inadequate, leaving the disease underdiagnosed and undertreated. The purpose of this study is to determine the effectiveness of an EMR implemented system that identifies patients at risk for osteoporosis via an OST (osteoporosis screening tool) score in prompting patients toward osteoporosis evaluation. Methods: OST scores are generated on every patient 50 years of age and older that is admitted to the Penn State Hershey Medical Center (PSHMC) and recorded in their electronic medical record. An OST score < 2 indicates that a patient has a potential risk for osteoporosis. Information Technology (IT) implemented the EMR OST calculation, which currently generates a daily filtered list of all patients with an OST score <2; patients with an OST score < 2 are then mailed letters approximately 3 months after their admission informing them of their risk for osteoporosis and suggesting that they schedule a follow-up appointment with a physician for further evaluation. To test the effectiveness of this system in prompting patients toward osteoporosis evaluation, approximately 3 months after letters were mailed, the patients were contacted via telephone and asked a series of questions to determine if the patients had sought osteoporosis evaluation. Results: In the intervention group, 67 (58.26%) of 115 did not schedule a follow-up, while the remaining 48 (41.74%) did seek a follow-up. Thus, the patient follow-up response rate improved with letter intervention using the OST score as an indicator (P < .0001) compared to historical controls (14.29%). Conclusion: Implementing an EMR OST score which identifies patients at risk for osteoporosis, which generates an automatic letter to the patient, significantly promotes patient driven osteoporosis evaluation compared to historical controls.
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Tulipan JE, Lechtig A, Rozental TD, Harper CM. "Age Is Just a Number": Distal Radius Fractures in Patients Over 75. Hand (N Y) 2022; 17:128-133. [PMID: 32102556 PMCID: PMC8721803 DOI: 10.1177/1558944720906552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as "completely independent" and "active," the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.
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Polan C, Meyer HL, Burggraf M, Herten M, Beck P, Braitsch H, Becker L, Vogel C, Dudda M, Kauther MD. Geriatric Proximal Femur Fractures During the Covid-19 Pandemic - Fewer Cases, But More Comorbidities. Geriatr Orthop Surg Rehabil 2021; 12:21514593211009657. [PMID: 34938592 PMCID: PMC8687435 DOI: 10.1177/21514593211009657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background: The COVID-19 pandemic is challenging healthcare systems worldwide. This study examines geriatric patients with proximal femur fractures during the COVID-19 pandemic, shifts in secondary disease profile, the impact of the pandemic on hospitalization and further treatment. Methods: In a retrospective monocentric study, geriatric proximal femur fractures treated in the first six months of 2020 were analyzed and compared with the same period of 2019. Pre-traumatic status (living in a care home, under supervision of a legal guardian), type of trauma, accident mechanism, geriatric risk factors, associated comorbidities, time between hospitalization and surgery, inpatient time and post-operative further treatment of 2 groups of patients, aged 65-80 years (Group 1) and 80+ years (Group 2) were investigated. Results: The total number of patients decreased (70 in 2019 vs. 58 in 2020), mostly in Group 1 (25 vs. 16) while the numbers in Group 2 remained almost constant (45 vs. 42). The percentage of patients with pre-existing neurological conditions rose in 2020. This corresponded to an increase in patients under legal supervision (29.3%) and receiving pre-traumatic care in a nursing home (14.7%). Fractures were mostly caused by minor trauma in a home environment. In 2020, total number of inpatient days for Group 2 was lower compared to Group 1 (p = 0.008). Further care differed between the years: fewer Group 1 patients were discharged to geriatric therapy (69.6% vs. 25.0%), whereas in Group 2 the number of patients discharged to a nursing home increased. Conclusions: Falling by elderly patients is correlated to geriatric comorbidities, consequently there was no change in the case numbers in this age group. Strategic measures to avoid COVID-19 infection in hospital setting could include reducing the length of hospital stays by transferring elderly patients to a nursing home as soon as possible and discharging independent, mobile patients to return home.
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Al-Hourani K, Tsang STJ, Simpson AHRW. Osteoporosis: current screening methods, novel techniques, and preoperative assessment of bone mineral density. Bone Joint Res 2021; 10:840-843. [PMID: 34928173 PMCID: PMC8696546 DOI: 10.1302/2046-3758.1012.bjr-2021-0452.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Ishizu H, Shimizu H, Shimizu T, Ebata T, Ogawa Y, Miyano M, Arita K, Ohashi Y, Iwasaki N. Rheumatoid Arthritis is a Risk Factor for Refracture in Patients with Fragility Fractures. Mod Rheumatol 2021; 32:1017-1022. [PMID: 34865103 DOI: 10.1093/mr/roab109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/09/2021] [Accepted: 11/06/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To determine whether patients with rheumatoid arthritis (RA) who have had fragility fractures are at an increased risk of refractures. METHODS Patients with fragility fractures who were treated surgically at ten hospitals from 2008 to 2017 and who underwent follow-up for more than 24 months were either categorized into a group comprising patients with RA or a group comprising patients without RA (controls). The groups were matched 1:1 by propensity score matching. Accordingly, 240 matched participants were included in this study. The primary outcome was the refracture rate in patients with RA as compared to in the controls. Multivariable analyses were also conducted on patients with RA to evaluate the odds ratios (ORs) for the refracture rates. RESULTS Patients with RA were significantly associated with increased rates of refractures during the first 24 months (OR: 2.714, 95% confidence interval [95% CI]: 1.015-7.255; P = 0.040). Multivariable analyses revealed a significant association between increased refracture rates and long-term RA (OR: 6.308, 95% CI: 1.195-33.292; P=0.030). CONCLUSIONS Patients with RA who have experienced fragility fractures are at an increased risk of refractures. Long-term RA is a substantial risk factor for refractures.
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Farrow L, Zhong M, Ashcroft GP, Anderson L, Meek RMD. Interpretation and reporting of predictive or diagnostic machine-learning research in Trauma & Orthopaedics. Bone Joint J 2021; 103-B:1754-1758. [PMID: 34847720 DOI: 10.1302/0301-620x.103b12.bjj-2021-0851.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is increasing popularity in the use of artificial intelligence and machine-learning techniques to provide diagnostic and prognostic models for various aspects of Trauma & Orthopaedic surgery. However, correct interpretation of these models is difficult for those without specific knowledge of computing or health data science methodology. Lack of current reporting standards leads to the potential for significant heterogeneity in the design and quality of published studies. We provide an overview of machine-learning techniques for the lay individual, including key terminology and best practice reporting guidelines. Cite this article: Bone Joint J 2021;103-B(12):1754-1758.
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Onubogu IK, Relwani S, Grewal US, Bhamra JS, Reddy KG, Dhinsa BS. Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly. Cureus 2021; 13:e18752. [PMID: 34790497 PMCID: PMC8589001 DOI: 10.7759/cureus.18752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.
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Prall WC, Kusmenkov T, Rieger M, Haasters F, Mayr HO, Böcker W, Fürmetz J. Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3). Geriatr Orthop Surg Rehabil 2021; 12:21514593211043967. [PMID: 34671507 PMCID: PMC8521727 DOI: 10.1177/21514593211043967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Split-depression fractures to the lateral tibial plateau (AO41B3) often feature severe joint surface destructions. Precontoured locking compression plates (LCPs) are designed for optimum support of the reduced joint surface and have especially been emphasized in reduced bone quality. A lack of evidence still inhibits their broad utilization in elderly patients. Thus, aim of the present study was to investigate the implant-specific radiological outcomes of AO41B3-fractures in young versus elderly patients. Methods The hospital’s database was screened for isolated AO41B3-factures, open reduction and internal fixation (ORIF), and radiological follow-up ≥12 months. CT-scans, radiographs, and patients’ records were analyzed. Patients were attributed as young (18–49) or elderly (≥50 years). Additional subgrouping was carried out into precontoured LCP and conventional implants. The Rasmussen Radiological Score (RRS) after 12 months was set as primary outcome parameter. The RRS postoperatively and the medial proximal tibial angle (MPTA) postoperatively and after 12 months were secondary outcome parameters. Results Fifty nine consecutive patients were included (26 young, 38.2 ± 7.8 years; 33 elderly, 61.3 ± 9.4 years). There were no significant differences regarding mean size and depression depth of the lateral joint surface fragments. Prior to implant-specific subgrouping, the radiological outcome measures revealed no significant differences between young (RRS = 7.7 ± 1.7; MPTA = 90.3 ± 2.3°) and elderly (RRS = 7.2 ± 1.7; MPTA = 90.5 ± 3.3°). After implant-specific subgrouping, the radiological outcome revealed significantly impaired results in young patients with conventional implants (RRS(C) = 6.9 ± 1.6, RRS(LCP) = 8.5 ± 1.5, P = .015; MPTA(C) = 91.5 ± 1.9°, MPTA(LCP) = 89.1 ± 2.1°, P = .01). The effect was even more pronounced in elderly patients, with highly significant deterioration of the radiological outcome measures for conventional implants compared to precontoured LCP (RRS(C) = 5.7 ± 1.6, RRS(LCP) = 8.2 ± .8, P < .001; MPTA(C) = 92.6 ± 4.2°, MPTA(LCP) = 89.2 ± 1.4°, P = .002). Conclusion Utilizing precontoured LCP in the treatment of AO41B3-fractures is associated with improved radiological outcomes. This effect is significant in young but even more pronounced in elderly patients. Consequently, precontoured LCP should closely be considered in any AO41B3-fracture, but especially in elderly patients.
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Nguyen VH. Superior Bone Health for Promoting Longer and Better Lives. Geriatr Orthop Surg Rehabil 2021; 12:21514593211043966. [PMID: 34603827 PMCID: PMC8485262 DOI: 10.1177/21514593211043966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/17/2021] [Indexed: 12/05/2022] Open
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