Osteoporosis among Bahraini Citizens: The First Report

Background and Objective

Osteoporosis and its complications are increasing as the population is aging world over. Every country needs an initial assessment of prevalence to take appropriate steps in limiting the complications of osteoporosis. The objective of this study was to find the prevalence of osteoporosis in the Kingdom of Bahrain.

Methods

We retrospectively reviewed dual-energy X-ray absorptiometry scans of patients who underwent scans for the diagnosis of osteoporosis between January 2016 and December 2017 at the University Medical Center, King Abdullah Medical City, Dr. Sulaiman AlHabib Hospital, Kingdom of Bahrain. The data were collected from the picture archiving and communication system for the study period. Patients' medical records were reviewed for the investigations and treatment ordered. The data were entered into the database and analyzed using SPSS Inc., version 19.

Results

A total of 205 patients with an average age of 58.39 ± 12.12 years were included in the study. There were 185 (90.25%) females and 20 (9.75%) males. Seventy-nine (38.5%) were osteoporotic based on the T score of either at the hip (-< 2.61 ± 1.08) or the spine (-< 3.26 ± 0.78), with a mean age of 60.8 ± 13.1 years. Seventy-two (91.1%) of the osteoporotic patients were female and 42 (58.4%) were ≥65 years. Patients who were osteoporotic were significantly older with P < 0.001. There were 9 patients (4.39%) who had osteoporosis-related fractures.

Conclusions

This study indicates that the prevalence of osteoporosis is common among Bahraini citizens. As the country's total population is <1.2 million, it will not be difficult to target the ≥65-year-old men and women in early diagnosis and treatment to prevent osteoporosis-related fractures.

State of Fragility Fractures Management during the COVID-19 Pandemic

Osteoporosis is a public health concern all over the world. As a chronic condition, it generally requires prolonged medical interventions to limit the risks of further bone loss, impaired skeletal integrity and the onset of fractures. This problem is further complicated by the fact that the abrupt cessation of some therapies may be associated with an increased risk of harm. It is in this context that the COVID-19 pandemic has caused an unprecedented disruption to the provision of healthcare worldwide, exceeding our worst expectations in terms of the number of lives lost and the rapidity at which consolidated economies and healthcare systems are being significantly damaged. In this review, we assessed the challenges and strategies used in the management of osteoporosis and fragility fracture care during the COVID-19 pandemic. We also examined the available evidence and provided clinical recommendations that will require reassessment as the worldwide response to COVID-19 evolves.

Bone Loss, Osteoporosis, and Fractures in Patients with Rheumatoid Arthritis: A Review

Rheumatoid arthritis (RA) is often characterized by bone loss and fragility fractures and is a frequent comorbidity. Compared with a matched population, RA patients with fractures have more common risk factors of osteoporosis and fragility fractures but also risk factors resulting from the disease itself such as duration, intensity of the inflammation and disability, and cachexia. The inflammatory reaction in the synovium results in the production of numerous cytokines (interleukin-1, interleukin-6, tumor necrosis factor) that activate osteoclasts and mediate cartilage and bone destruction of the joints, but also have a systemic effect leading to generalized bone loss. Regular bone mineral density (BMD) measurement, fracture risk assessment using tools such as the FRAX algorithm, and vertebral fracture assessment (VFA) should be performed for early detection of osteoporosis and accurate treatment in RA patients.

Circulating MicroRNAs as Novel Biomarkers for Osteoporosis and Fragility Fracture Risk: Is There a Use in Assessment Risk?

Osteoporosis is a multifactorial skeletal disease that is associated with both bone mass decline and microstructure damage. The fragility fractures-especially those affecting the femur-that embody the clinical manifestation of this pathology continue to be a great medical and socioeconomic challenge worldwide. The currently available diagnostic tools, such as dual energy X-ray absorptiometry, Fracture Risk Assessment Tool (FRAX) score, and bone turnover markers, show limited specificity and sensitivity; therefore, the identification of alternative approaches is necessary. As a result of their advantageous features, such as non-invasiveness, biofluid stability, and easy detection, circulating cell-free miRs are promising new potential biomarkers for the diagnosis of osteoporosis and low-traumatic fracture risk assessment. However, due to the absence of both standardized pre-analytical, analytical, and post-analytical protocols for their measurement and universally accepted guidelines for diagnostic use, their clinical utility is limited. The aim of this review was to record all the data currently available in the literature concerning the use of circulating microRNAs as both potential biomarkers for osteoporosis diagnosis and fragility fracture risk evaluation, and group them according to the experimental designs, in order to support a more conscious choice of miRs for future research in this field.

Bilateral sub-trochanteric femur fragility fractures in a patient on antiretroviral therapy: a case based discussion and review of literature

BACKGROUND

The burden of HIV/AIDS is ever increasing, affecting populations all over the world. Along with the disease, its effects and consequences on bone health are also on a rise. A commonly used drug in managing HIV, "Tenofovir" has been shown to affect bone health, specifically on prolonged usage. Osteomalacia and osteoporosis secondary to drug induced Fanconi syndrome and the disease itself, could lead to pathological/fragility fractures with trivial trauma.

CASE DESCRIPTION

A 45 year old female on antiretroviral drugs (ART) for HIV, presented with right hip pain and inability to bear weight. She has had similar symptoms previously in the left hip which resolved after 6 weeks of limited weight bearing. Anteroposterior and lateral radiographs of pelvis with hips showed bilateral sub-trochanteric fractures; healed on the left side and displaced on the right side. The patient was managed with cessation of tenofovir and right side proximal femoral nail anti-rotation (PFNA). Patient was lost to follow up but had started to ambulate independently with a cane, by the end of 6 weeks, before she succumbed to systemic complications.

CONCLUSION

Patients receiving antiretrovirals especially tenofovir should be regularly investigated for their renal impairment and bone health. Fixation of pathological fractures and early mobilization are important to prevent prolonged bed immobilization and associated complications in these immunocompromised patients.

Load-Bearing Detection with Insole-Force Sensors Provides New Treatment Insights in Fragility Fractures of the Pelvis

Background: Due to an aging society, more and more surgeons are confronted with fragility fractures of the pelvis (FFPs). The aim of treatment of such patients should be the quickest possible mobilization with full weight-bearing. Up to now however, there are no data on loading of the lower extremities in patients suffering FFPs. We hypothesized to find differences in loading of the lower limbs. Methods: 22 patients with a mean age of 84.1 years were included. During gait analysis with insole-force sensors, loading on the lower extremities was recorded during early mobilization after index fracture. Results: Especially the average peak force showed differences in loading, as the affected limb was loaded significantly less {59.78% (SD ± 16.15%) of the bodyweight vs. 73.22% (SD ± 14.84%) (p = <0.001, effect size r = 0.58)}. Furthermore, differences in loading in between the fracture patterns of FFPs were observed. Conclusion: This study shows that it is possible to reliably detect the extremity load, with the help of an insole device, in patients presenting with fragility fractures of the pelvis. There is great potential to improve the choice and time of treatment with insole-force sensors in FFPs in future.

From ER to OR: Results After Implementation of Multidisciplinary Pathway for Fragility Hip Fractures at a Level I Trauma Center

Introduction:

Hip fractures are one of the most common indications for hospitalization and orthopedic intervention. Fragility hip fractures are frequently associated with multiple comorbidities and thus may benefit from a structured multidisciplinary approach for treatment. The purpose of this article was to retrospectively analyze patient outcomes after the implementation of a multidisciplinary hip fracture pathway at a level I trauma center.

Materials and Methods:

A retrospective review of 263 patients over the age of 65 with fragility hip fracture was performed. Time to surgery, hospital length of stay, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists, complication rates, and other clinical outcomes were compared between patients treated in the year before and after implementation of a multidisciplinary hip fracture pathway.

Results:

Timing to OR, hospital length of stay, and complication rates did not differ between pre- and postpathway groups. The postpathway group had a greater CCI score (pre: 3.10 ± 3.11 and post: 3.80 ± 3.18). Fewer total blood products were administered in the postpathway group (pre: 1.5 ± 1.8 and post: 0.8 ± 1.5).

Discussion:

The maintenance of clinical outcomes in the postpathway cohort, while having a greater CCI, indicates the same quality of care was provided for a more medically complex patient population. With a decrease in total blood products in the postpathway group, this highlights the economic importance of perioperative optimization that can be obtained in a multidisciplinary pathway.

Conclusion:

Implementation of a multidisciplinary hip fracture pathway is an effective strategy for maintaining care standards for fragility hip fracture management, particularly in the setting of complex medical comorbidities.

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon’s experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Is There a Role for CT Pan-Scans in the Initial Workup of Fragility Fracture Patients?

Introduction:

Computed tomography (CT) pan-scans have become increasingly commonplace as part of the initial diagnostic workup for patients sustaining traumatic injuries. They have proven effective in improving diagnostic accuracy in those with high-energy mechanisms of injury. However, the utility of pan-scans in the geriatric population sustaining low-energy traumatic injuries remains unproven.

Methods:

A retrospective review was conducted of patients who sustained a fragility fracture at a level-1 trauma center over a 15-month period. Radiologist interpretations of any CT pan-scans were reviewed for acute findings, and charts were reviewed for resulting changes in orthopedic and nonorthopedic management. Additionally, mechanism of injury, definitive management, time to surgery, length of stay, level of care at discharge, and demographic data were compared against similar patients who did not receive a pan-scan.

Results:

Of the 109 patients who underwent a CT pan-scan, 1 (0.92%) had a change in orthopedic treatment. Twelve (11.01%) patients had changes to their nonorthopedic management. In addition, 14 other patients had one or more consultations obtained based on pan-scan results that did not result in any change in management. Discussion: This study found that only 1 of the included patients had a change in orthopedic management and 12 had a change in nonorthopedic management, despite over half of the study population being found to have additional findings. Furthermore, patients who underwent a pan-scan did not have expedited surgical intervention or earlier discharges compared to those who were not pan-scanned.  

Conclusion:

This study demonstrates whole-body CT imaging provides little benefit in geriatric patients who sustain fragility fractures and should be utilized judiciously and in a targeted fashion instead of as a routine part of trauma surgery or emergency department protocol in this patient population.

Level of Evidence:

Level III Retrospective Study.

Predictors of Acute Kidney Injury After Hip Fracture in Older Adults

INTRODUCTION

This study aimed to investigate the prevalence of acute kidney injury (AKI) following hip fracture surgery in geriatric patients and to identify predictors for development of AKI with a focus on possible preventable risk factors.

METHODS

In this retrospective cohort study, we reviewed electronic medical records of all patients above 65 years of age who underwent hip fracture surgery at Copenhagen University Hospital, Bispebjerg, Denmark, in 2018. Acute kidney injury was assessed according to the Kidney Disease Improving Global Outcomes guidelines. Multivariate logistic regression analyses were used to identify independent risk factors for AKI.

RESULTS

Postoperative AKI developed in 28.4% of the included patients (85/299). Acute kidney injury was associated with increased length of admission (11.3 vs 8.7 days, P < .001) and 30-day mortality (18/85 vs 16/214, P = .001). In multivariable analysis, higher age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.08, P = .004), heart disease (OR: 1.78, 95% CI: 1.01-3.11, P = .045), and postoperative blood transfusion (OR: 1.84, 95% CI: 1.01-3.36, P = .048) were associated with AKI. Moreover, a higher postoperative C-reactive protein (199.0 ± 99.9 in patients with AKI, 161.3 ± 75.2 in patients without AKI) and lower postoperative diastolic blood pressure were observed in patients developing AKI.

DISCUSSION AND CONCLUSION

Acute kidney injury was common following hip fracture surgery and associated with longer admissions and increased mortality. Patients developing AKI were older and showed several postoperative similarities, including higher C-reactive protein, lower postoperative diastolic pressure, and the need for blood transfusion.

Elevated 1-Year Mortality Rate in Males Sustaining Low-Energy Proximal Femur Fractures and Subgroup Analysis Utilizing Age-Adjusted Charlson Comorbidity Index

INTRODUCTION

Low-energy proximal femur fractures are common in the aging population and the ability to identify patients at increased mortality risk provides surgeons information to improve informed decision-making with patients and families. We evaluated for gender differences in 1-year mortality after sustaining low-energy proximal femur fractures with subgroup analysis to identify the impact of fracture location, age, and comorbidities on mortality.

MATERIALS AND METHODS

Patients ≥40 years of age sustaining a low-energy proximal femur fracture identified at our institution between January 1, 2014, and December 31, 2017. International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes were used to identify comorbidities for calculation of the age-adjusted Charlson comorbidity index (ACCI). The county clerk database was searched to identify mortality within 1 year of injury. One-year mortality rates were calculated and multiple comparisons were made between genders controlling for age, fracture location, and/or ACCI.

RESULTS

Women presented with low-energy proximal femur fractures at a rate of almost 3:1 to men at our institution (P = .001). Men demonstrated a significantly increased ACCI at presentation (5.35 ± 2.55 vs 4.86 ± 1.77, P = .03). Men had an increased 1-year mortality rate for all (31.3% vs 21.5%, P = .004) and intertrochanteric (IT) fractures (36.2% vs 22.9%, P = .008). Controlling for ACCI, gender, and fracture location, men demonstrated increased mortality rate with IT fractures (P = .002) and trended toward but did not reach significance with femoral neck fractures (P = .07).

DISCUSSION

Men presenting with low-energy femur fractures are at an increased mortality risk compared to women. On average, men present with an overall worse health status as identified by ACCI, which could predispose these patients not only to fractures themselves but also impair their ability to recover from injury.

CONCLUSION

Men are at an increased 1-year mortality risk after sustaining proximal femur fractures.

Racial Variation in the Relationship of Glycemic Control with Fracture Risk in Elderly Patients with Diabetes

We investigated racial variation in glycemic control (glycated hemoglobin A1c [HbA1c]) with fracture risk in geriatric patients with diabetes. Compared to an HbA1c of 7.0-7.9% [53-63 mmol/mol], HbA1c ≥9.0% [≥75 mmol/mol] was associated with increased fracture risk among Blacks and those of Unknown race only. This increase was attenuated in Blacks after accounting for the relative frequency of patient-provider interaction.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service

Introduction:

Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care.

Methods:

We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated.

Results:

Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture.

Discussion:

A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients.

Conclusion:

Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

Understanding the role of social factors in recovery after hip fractures: A structured scoping review

Poor recovery among older adults with hip fractures can occur despite successful surgical repair and rehabilitation, suggesting other factors might play a role in recovery, such as social factors. The aim of this scoping review was to provide an overview of the literature on the role of social factors in older adult's recovery after hip fracture. This review followed the York Framework and its modifications and recent reporting guidelines. Two independent researchers searched main medical databases (CINAHL, EMBASE, Medline, PsycINFO and the Cochrane libraries) from inception to June 2017, for studies investigating social factors and recovery post hip fracture. Studies were excluded if they were qualitative, perspective papers or if participants were < 65 years or they were not living in the community. We screened 2,503 unique abstracts in total and 19 studies fulfilled the inclusion criteria. Social factors investigated in the included studies were social support, socioeconomic factors and living arrangement. We classified outcomes in the studies into three subgroups: physical functional recovery, mortality and other outcomes (pain, hospital length of stay and quality of life). We found evidence that social support and socioeconomic factors (e.g. socioeconomic status) were significantly associated with an increase in functional recovery, a decrease in mortality and other outcomes, but conflicting evidence was found for the effect of one's living arrangement. Only two included studies were randomised controlled trials. To conclude, social factors, such as social support and socioeconomic status, affect physical functional recovery and mortality in older adults with hip fractures. However, this is an under researched area that lacks rigorously designed studies and would benefit from more studies with rigorous designs.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures

Introduction:

Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population.

Method:

Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients.

Results:

We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications.

Discussion:

There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture.

Conclusion:

Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient’s nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Loss of Ambulatory Independence Following Low-Energy Pelvic Ring Fractures

Introduction:

Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring injuries. This fracture pattern is typically seen in older patients. The purpose of this study is to assess the ambulatory status of individuals sustaining LC1 fractures at long-term follow-up and what specific characteristics, if any, effect this status or functional outcomes.

Methods:

Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were identified.

Results:

Fifty patients were available for long-term outcomes (mean: 36 months). Long-term functional outcomes (mean follow-up: 36 months) as measured by SMFA subgroup scores were demonstrated to be 3 times higher in patients currently using assistive devices for walking (P = .012). Increased age (P = .050) was associated with the continued use of assistive walking devices. Of the patients who did not use an ambulatory device prior to LC1 injury, 5 (11.6%) sustained a fall or medical complication within 30 days of the index pelvic fracture; this was associated with the current use of an assistive ambulatory device (P = .010). Forty-three (86%) patients didn’t use an assistive ambulatory device prior to sustaining the LC1 fracture. Seven (14%) patients utilized assistive devices both before and after the LC1 injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior to their injury, necessitated them at long-term follow-up.

Discussion:

Surgeons should be aware of these associations, as they can implement early interventions aimed at patients at risk, for assistive device use, following LC1 pelvic fractures.

Conclusion:

More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use an aid for ambulation at long-term follow-up. Older age, complications, and falls within 30 days of this injury are associated with the utilization of an assistive ambulatory device.

Identifying Disparities in the Management of Hip Fractures Within Europe: A Comparison of 3 Health-Care Systems

Introduction:

This study investigates the management of hip fractures in a German maximum care hospital and compares these data to evidence-based standard and practice in 180 hospitals participating in the UK National Hip Fracture Database (NHFD) and 16 hospitals participating in the Irish Hip Fracture Database (IHFD). This is the first study directly comparing the management of hip fractures between 3 separate health-care systems within Europe.

Methods:

Electronic medical data were collected retrospectively describing the care pathway of elderly patients with a hip fracture admitted to a large trauma unit in the south of Germany “University Hospital Freiburg” (UHF). The audit evaluated demographics, postoperative outcome, and the adherence to the 6 “Blue Book” standards of care. These data were directly compared with the data from the UK NHFD and the IHFD acquired from 180 and 16 hospitals, respectively.

Results:

At 36 hours, 95.8% of patients had received surgery in UHF, compared to 71.5% in the NHFD and 58% of patients in the IHFD. The rate of in-hospital mortality was 4.7% compared to 7.1% in the NHFD and 5% in the IHFD. The mean average acute length of stay was 13.4 days compared to 16.4 days in the NHFD and 20 days in the IHFD. Reoperation rates are 3.3% compared to 1% in the NHFD and 1.1% in the IHFD; 50.5% of patients were discharged on bone protection medication, compared to 47% in the IHFD and 79.3% in the UK NHFD.

Discussion:

Despite uniformly acknowledged evidence-based treatment guidelines, the management of hip fractures remains heterogeneous within Europe.

Conclusion:

These data show that different areas of the hip fracture care pathway in Germany, England, and Ireland, respectively, show room for improvement in light of the growing socioeconomic burden these countries are expected to face.

Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation

Introduction:

Patients with hip fractures pose a significant burden on health services. Malnutrition, frailty, and cognitive impairment are common, and key to addressing the needs of this vulnerable patient group is nutrition optimization, including reduction in arbitrary nil by mouth (NBM) perioperative regimens. In order to understand current practices, we characterize preoperative nutrition in a regional hip fracture population.

Methods:

Prospective data were submitted to the National Hip Fracture Database by 6 hospitals in the north east of England over a 6-month period. Patients were stratified by preoperative nutritional intake, frailty, and cognitive function.

Results:

In all, 24.2% (n = 205) patients received no oral intake at all preoperatively; 15.3% of NBM patients were at risk of malnutrition; and 6.9% were malnourished at the time of assessment. Median time to surgery for NBM patients was 16.75 hours, and 6.34% of patients were fasted with no intake for >36 hours. In all, 6.5% (n = 44) of patients with an Abbreviated Mental Test Score (AMTS) of 8 or above were deemed to be at risk of malnutrition at admission, compared to 11.3% (n = 50) of patients with an AMTS of 7 or below. The NBM patients had similar mean Rockwood (4.97) and AMTS (6.51) scores to patients given oral nutrition.

Conclusion:

We have demonstrated contemporary preoperative nutritional practices in the management of over 800 hip fracture patients. Contrary to perception, nutrition practices vary little when stratified for age, cognition frailty, or comorbid burden. We have identified widespread prolonged NBM fasting and undersupplementation in patients sustaining hip fracture across a region. This work suggests a need to focus less on patient factors and more on systematic practices.

Hip Fractures: Relevant Anatomy, Classification, and Biomechanics of Fracture and Fixation

Introduction

Hip fractures represent an important health-care dilemma, costing the US$ billions annually. Hip fractures can diminish quality of life and significantly increase morbidity and mortality if not properly treated. Recent research has brought forth new information regarding treatment as well as information on emerging complications seen within the fixation constructs themselves.

Significance

Understanding the pathoanatomy of hip fractures and the biomechanics of surgical fixation constructs is critical for successful treatment. In this article, we review the relevant anatomy and classification of femoral neck and intertrochanteric fractures. Furthermore, the biomechanics of hip fracture fixation strategies as well as implant-related complications are addressed.

Results

Even though laboratory testing demonstrated that intramedullary nails have greater biomechanical stability, the clinical results between fixation constructs have been similar when the chosen implant (ie, sliding hip screw vs cephalomedullary nail) has been correctly applied to the specific fracture pattern. Recently, data have shown that when using cephalomedullary nails, there is potential for increased failure with cutout when using the helical blade versus the lag screw, with majority being the atypical "medial cutout."

Conclusion

The goal of surgical treatment of hip fractures is surgical treatment that allows for early mobilization and weight bearing. A full understanding of the anatomy and fracture characteristics will allow the surgeon to correctly apply the right implant to allow for uneventful healing. Surgeons need to be aware, however, of complications that can arise when using specific implants. Further research is ongoing to further determine the treatments that will allow optimal cost-effective care for the geriatric patient with hip fracture.

The trend of osteoporosis and osteoporotic fragility fractures in inpatients: results from a national database

Osteoporosis is associated with an increased risk of pathologic fractures; however, most patients do not receive diagnosis and adequate treatment. The aim of our study was to compare the yearly trends of osteoporosis and osteoporotic fragility fractures in the USA (US) inpatients.

We used National (Nationwide) Inpatient Sample database to identify adults ≥18 years with diagnoses of osteoporosis and pathologic fractures and excluded pathologic fractures due to other etiologies. We then studied the annual trends, in terms of annual percentage change (APC), of osteoporosis and osteoporotic fractures.

Among overall hospitalizations, osteoporosis was noted to have an increasing trend from 2000 to 2009 (APC = 5.81, p < 0.05) with a decline thereafter (APC = – 3.88, p < 0.05). In contrast, osteoporotic fracture showed an initial downward trend from 2000 to 2010 (APC = −7.31, p < 0.05), followed by a slowly rising trend (APC = 2.0, p = NS).

The initially increasing trend of osteoporosis was followed by a decreasing trend thereafter. In contrast, there was a halt in a previously declining trend of osteoporotic fracture. Potential explanations include inadequate screening and treatment per guidelines along with decreasing patient compliance. In conclusion, primary and secondary prevention measures for osteoporosis have been underutilized by both physicians and patients alike.

The Relationship Between BMI and Stability of Intertrochanteric Fracture Following Low-Energy Falls. A Retrospective Cohort Study

INTRODUCTION

Intertrochanteric proximal femur fractures are common injuries in the elderly. Certain patterns are considered unstable and confer increased risks. Risk factors for these patterns are not well defined. We sought to determine whether increased body mass index (BMI) was associated with increased risk of sustaining an unstable pattern intertrochanteric (IT) fracture following low-energy trauma. Materials and methods: Retrospective case review of all patients presenting to a level-2 trauma center between October 2010 and August 2014 with Intertrochanteric fracture. Fracture pattern (stable or unstable) and BMI were analyzed using odds ratios and age was controlled for.

RESULTS

Four hundred fifty-two patients were identified. No difference was found between fracture stability when BMI of 25 was used as a cutoff. However, when a BMI of 30 was used as a cutoff, there was a trend of difference (relative difference 30%) in rates of fracture type favoring unstable patterns in the obese group. This difference approached but did not reach statistical significance (P = .08). When adjusted for age, the difference remained but still did not reach statistical significance (P = .11).

DISCUSSION

Unstable type IT fractures were found more frequently in the obese cohort (BMI >30) than those who were not obese.

Hemiarthroplasty or Total Hip Arthroplasty: Is There a Racial Bias in Treatment Selection for Femoral Neck Fractures?

Introduction

Hip fractures in the elderly individuals are associated with significant morbidity and mortality, and outcomes are directly related to prompt surgical intervention with either total hip arthroplasty (THA) or hemiarthroplasty. Minority hip fracture patients have increased delays to surgical intervention and poorer functional outcomes. This study explored racial biases in the surgical treatment decision between THA and hemiarthroplasty for displaced femoral neck fractures as well as racial disparities in postoperative complications, readmission rates, and 30-day mortality.

Methods

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2014. Patients were identified using diagnosis code for transcervical femoral neck fractures and Current Procedural Terminology codes for THA or hemiarthroplasty. A multivariable regression analysis was conducted including race, demographic information, and medical comorbidities.

Results

Of 11 408 patients, race was recorded in 8538 individuals. Most patients were white (88.3%), followed by Hispanic (4.7%), African American (4.1%), and Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native (2.9%). No differences were observed in the likelihood of receiving a THA versus hemiarthroplasty among racial groups. Only younger age and steroid use were independent risk factors for receiving a THA. Race was significantly associated with postoperative mortality (P = .014) and major postoperative complications for the Asian cohort (P = .013).

Discussion

The NSQIP data do not support a racial bias in the selection of patients for THA versus hemiarthroplasty. However, this study found racial disparities in postoperative mortality and complications. The reasons underlying the differences in postoperative outcomes are uncertain but may be the result of specific challenges to accessing care.

Conclusion

There was no racial bias in the treatment of femoral neck fractures. However, there were racial disparities in postoperative mortality and complication rates. Further research is warranted to elucidate the true causes of these observed disparities.

Evaluation and Treatment of Posterior Tibialis Tendon Insufficiency in the Elderly Patients

Introduction:

Posterior tibialis tendon insufficiency is the most common cause of adult acquired flatfoot deformity in elderly patients. We performed a literature search of primary and secondary journal articles pertaining to posterior tibialis tendon insufficiency in the geriatric population. We examined relevant data from these articles regarding current evaluation in addition to both conservative and advanced treatment approaches that correspond to disease severity.

Significance:

There is a paucity of literature to guide treatment of posterior tibialis tendon insufficiency in the elderly, and this condition may be more prevalent in geriatric patients than previously realized.

Results:

Posterior tibialis tendon insufficiency is an acquired defect that affects 10% of the geriatric population and disproportionately affects women. It is typically caused by degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Conservative treatment with a variety of available ankle braces and non-steroidal anti-inflammatory medications are typically used to treat the first and second stage disease. Surgical repair is warranted for advanced second stage and above posterior tendon insufficiency. A variety of techniques have been proposed, and can include tendon transfer, hindfoot fusion, and even total ankle arthroplasty in extreme cases.

Conclusion:

Posterior tibialis tendon insufficiency causes marked discomfort and alters normal gait biomechanics. Elderly patients typically present with more severe manifestations of the disease. For patients requiring surgery, and especially geriatric patients, the ideal treatment is thought to be a procedure that is minimally invasive in order to maximize positive outcomes for elderly patients. More work is needed to examine clinical and radiographic outcomes of geriatric patients treated for posterior tibialis tendon insufficiency.

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate

Introduction

Despite increasing recognition of atypical femoral fractures (AFFs), there's conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs).

Methods

A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality.

Results

Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05).

Discussion

In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit.

Conclusion

With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.