Osteoporosis in menopause

OBJECTIVE

To provide guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis.

OUTCOMES

Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response to management, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis.

EVIDENCE

Published literature was retrieved through searches of PubMed and The Cochrane Library on August 30 and September 18, 2012, respectively. The strategy included the use of appropriate controlled vocabulary (e.g., oteoporosis, bone density, menopause) and key words (e.g., bone health, bone loss, BMD). Results were restricted to systematic reviews, practice guidelines, randomized and controlled clinical trials, and observational studies published in English or French. The search was limited to the publication years 2009 and following, and updates were incorporated into the guideline to March 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Peripheral quantitative computed tomography-derived muscle density and peripheral magnetic resonance imaging-derived muscle adiposity: precision and associations with fragility fractures in women

PURPOSE

To determine the degree to which muscle density and fractures are explained by inter and intramuscular fat (IMF).

METHODS

Women ⋝50 years of age (Hamilton, ON, Canada) had peripheral magnetic resonance imaging and peripheral quantitative computed tomography scans at 66% of the tibial length. Muscle on computed tomography images was segmented from subcutaneous fat and bone using fixed thresholds, computing muscle density. IMF was segmented from muscle within magnetic resonance images using a region-growing algorithm, computing IMF volume. Fracture history over the last 14 years was obtained. Odds ratios for fractures were determined for muscle density, adjusting for IMF volume, total hip BMD, age and body mass index.

RESULTS

Women with a history of fractures were older (N=32, age:75.6±8.3 years) than those without (N=39, age: 67.0±5.2 years) (<0.01). IMF volume explained 49.3% of variance in muscle density (p<0.001). Odds for fractures were associated with lower muscle density even after adjusting for IMF volume but were attenuated after adjusting for age.

CONCLUSIONS

Muscle adiposity represents only 50% of the muscle density measurement. Properties of muscle beyond its adiposity may be related to fractures, but larger and prospective studies are needed to confirm these associations.

Secondary osteoporosis: pathophysiology & diagnosis

Osteoporosis is a skeletal disease characterized by decreased bone mass and microarchitectural changes in bone tissue that increase the susceptibility to fracture. Secondary osteoporosis is loosely defined as low bone mineral density or increased risk of fragility fracture caused by any factor other than aging or postmenopausal status. The purpose of this review is to discuss the current understanding of the pathophysiology and contribution to fracture risk of many of the more common causes of secondary osteoporosis, as well as diagnostic considerations, outlined by organ system. While not comprehensive, included are a wide array of diseases, conditions, and medications that have been associated with bone loss and susceptibility to fractures. The hope is to highlight the importance to the general clinician of screening for and treating the osteoporosis in these patients, so to limit the resultant increased morbidity associated with fractures.

Changing the consultant on calls from a daily to weekly rotation system reduces time to theater for patients with hip fracture to improve quality of care: a retrospective study of 2 cohorts of patients presenting with hip fracture

OBJECTIVE

To determine whether changing the consultant on-call schedule resulted in a reduction in time to theater for patients presenting with a hip fracture.

SUMMARY BACKGROUND DATA

Guidelines in the United Kingdom state that patients presenting with a neck of femur fracture should ideally be operated on the day of or the day after admission. However, there is a best practice tariff in the United Kingdom persuading trusts to operate on elderly patients with hip fracture within 36 hours of admission. Differing formats of daily trauma operating lists and varying consultant on-call schedules have the potential to affect a trusts ability to successfully meet such demands.

METHODS

This study retrospectively analyzed whether changing the on-call schedule from a system where the on-call consultant is changed on a daily basis to one which changes weekly resulted in a reduction in time to theater for such patients and an increase in best practice tariffs paid.

RESULTS

With the initial rotation system, the average time to theater for a fractured neck of femur was 44 hours 46 minutes, with 44.7% of patients having a time to surgery of less than 36 hours. Patients in the modified system underwent surgery with an average time to theater of 32 hours 19 minutes. In 71.7% of these patients, time to surgery was less than 36 hours.

CONCLUSION

This study demonstrates that changing the schedule to permit a consultant to have a 7-day period of trauma on call at a time instead of only 1 day dramatically reduced the time to theater for patients with hip fracture. This significantly reduced the number of these cases done outside 36 hours and increased trust financial reward.

"Tiers of delay": warfarin, hip fractures, and target-driven care

Anticoagulation reversal is a common cause of operative delay. We sought to establish for the first time the impact this has on best practice tariff (BPT) for patients with hip fracture admitted on warfarin. All patients with hip fracture treated operatively over a 32-month period were reviewed. Basic demographics, time to theater, length of stay, and mortality were recorded for all patients. Independent samples t-tests were used to identify statistically significant differences between patients on warfarin and those not taking the drug. A total of 83 patients were admitted anticoagulated with a mean international normalized ratio of 2.65 and a median time to theater of 49.7 hours. Of these patients, 79% breached BPT, incurring significant financial loss. In the control group, 908 patients took a median 24.5 hours, a 28% breach of BPT (P < .01). Length of stay, Nottingham Hip Fracture Score, and predicted 30-day mortality were similar for both the groups. As well as affecting clinical outcome following hip fracture, delay due to anticoagulation causes considerable loss of BPT. Potential loss of revenue due to delays over the study period was £80 000, inspiring the establishment of an "early trigger" anticoagulation protocol. Although it is accepted that there are limitations to this work, it should raise awareness of the real impact of warfarin on patients with hip fracture both in terms of outcome and for the first time, loss of potential revenue.

Preoperative factors and early complications associated with hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures

Displaced femoral neck fractures are common injuries in the elderly individuals. There is controversy about the best treatment with regard to total hip arthroplasty (THA) versus hemiarthroplasty. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to evaluate the preoperative risk factors associated with the decision to perform THA over hemiarthroplasty. We also evaluate the risk factors associated with postoperative complications after each procedure. Patients older than 50 years undergoing hemiarthroplasty or THA after fracture in the NSQIP database from 2007 to 2010 were compared to each other in terms of preoperative medical conditions, postoperative complications, and length of stay. Multivariate logistic regression models were used to adjust for preoperative risk factors for undergoing a THA versus a hemiarthroplasty and for complications after each procedure. In all, 783 patients underwent hemiarthroplasty and 419 underwent THA for fracture. Hemiarthroplasty patients had longer hospital stays. On multivariate logistic regression, the only significant predictor for having a THA after fracture over hemiarthroplasty was being aged 50 to 64 years. The patient characteristics/comorbidities that favored having a hemiarthroplasty were age >80 years, hemiplegia, being underweight, having a dependent functional status, being on dialysis, and having an early surgery. High body mass index, American Society of Anesthesiologists (ASA) class, gender, and other comorbidities were not predictors of having one procedure over another. Disseminated cancer and diabetes were predictive of complications after THA while being overweight, obese I, or a smoker were protective. High ASA class and do-not-resuscitate status were significant predictors of complications after a hemiarthroplasty. This study identified clinical factors influencing surgeons toward performing either THA or hemiarthroplasty for elderly patients after femoral neck fractures. Younger, healthier patients were more likely to receive THA. Patients particularly at higher risks of complications after hemiarthroplasty should be monitored closely.

Questioning the association between bisphosphonates and atypical femoral fractures

Bisphosphonates are the first-line treatment for osteoporosis. Structurally, they are stable analogues of pyrophosphate and therefore exhibit a high affinity for bone mineral. They reduce bone loss by attenuating the ability of the osteoclast to resorb bone, decreasing activation frequency, and the rate of remodeling. Large prospective randomized placebo-control trials provide unequivocal evidence for a reduction in the incidence of fractures. Impressively, 40 years since their first use in patients, the safety profile of bisphosphonates has been equally reassuring. Questions have arisen lately as to whether bisphosphonates could cause atypical fractures, a rare type of atraumatic or minimal trauma femur fracture occurring below the great trochanter. This question has prompted calls for a broader examination of the long-term effects of bisphosphonate use. An attempt by the Food and Drug Administration to garner consensus and provide definitive views was not successful. This has led to continued anxiety among treating physicians and patients alike, resulting in an overall reduction in prescriptions for bisphosphonates and for osteoporosis therapies in general. Here, we provide an overview of the current data on atypical fractures and bisphosphonate use.

Antidepressant use and 10-year incident fracture risk: the population-based Canadian Multicentre Osteoporosis Study (CaMoS)

We used data from a large, prospective Canadian cohort to assess the association between selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) and fracture. We found an increased risk of fractures in individuals who used SSRI or SNRI, even after controlling for multiple risk factors.

INTRODUCTION

Previous studies have suggested an association between SSRIs and increasing risk of fragility fractures. However, the majority of these studies were not long-term analyses or were performed using administrative data and, thus, could not fully control for potential confounders. We sought to determine whether the use of SSRIs and SNRIs is associated with increased risk of fragility fracture, in adults aged 50 + .

METHODS

We used data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective randomly selected population-based community cohort; our analyses focused on subjects aged 50+. Time to event methodology was used to assess the association between SSRI/SNRI use, modeled time-dependently, and fragility fracture.

RESULTS

Among 6,645 subjects, 192 (2.9%) were using SSRIs or/and SNRIs at baseline. During the 10-year study period, 978 (14.7%) participants experienced at least one fragility fracture. In our main analysis, SSRI/SNRI use was associated with increased risk of fragility fracture (hazard ratio (HR), 1.88; 95% confidence intervals (CI), 1.48-2.39). After controlling for multiple risk factors, including Charlson score, previous falls, and bone mineral density hip and lumbar bone density, the adjusted HR for current SSRI/SNRI use remained elevated (HR, 1.68; 95% CI, 1.32-2.14).

CONCLUSIONS

Our results lend additional support to an association between SSRI/SNRI use and fragility fractures. Given the high prevalence of antidepressants use, and the impact of fractures on health, our findings may have a significant clinical impact.

Osteoporosis - An Emerging Disease of the 21(st) Century, Part 1: An Overview

Osteoporosis is a condition where bones are fragile with a poor bone mineral density. This increases the risk of fracture especially of the hip, vertebrae, and wrist. These fractures are usually termed “fragility fractures.” In this article, we aim to provide a broad overview of osteoporosis-investigation, management, and prevention.

Glucocorticoids predict 10-year fragility fracture risk in a population-based ambulatory cohort of men and women: Canadian Multicentre Osteoporosis Study (CaMos)

We determined the prospective 10-year association among incident fragility fractures and four glucocorticoid (GC) treatment groups (Never GC, Prior GC, Baseline GC, and Ever GC). Results showed that GC treatment is associated with increased 10-year incident fracture risk in ambulatory men and women across Canada.

PURPOSE

Using the Canadian Multicentre Osteoporosis Study dataset, we determined the prospective 10-year association between incident fragility fractures and GC treatment.

METHODS

We conducted a 10-year prospective observational cohort study at nine sites across Canada. A total of 9,263 ambulatory men and women 25 years of age and older were included in the analysis. Multivariable Cox proportional hazards analyses were conducted to determine the relationship among GC treatment groups in four levels that included Never GC, Prior GC, Baseline GC, and Ever GC (combined baseline and prior groups) and time to fracture.

RESULTS

In each of the Never GC, Prior GC, Baseline GC, and Ever GC treatment groups, the number of participants were 8,832 (95.4 %), 303 (3.3 %), 128 (1.4 %), and 431 (4.7 %), respectively. Of the 9,263 individuals enrolled, incident fragility non-spine, hip, spine, and any fractures were experienced by a total of 896 (9.67 %), 157 (1.69 %), 130 (1.40 %), and 1,102 (11.90 %) over 10-years, respectively. For men and women combined, prior GC treatment was associated with a higher hazard ratio (HR) for time to incident non-vertebral (HR = 1.5, 95 % confidence interval [CI] = 1.1, 2.0), hip (HR = 2.1, 95 % CI = 1.1, 4.0), and any fracture (HR = 1.4, 95 % CI = 1.0, 1.8) compared with never GC treatment.

CONCLUSIONS

GC treatment is associated with increased 10-year incident fracture risk; this highlights the importance of considering therapy to prevent GC-induced fractures for patients who are using GC for various medical conditions.

The role of the orthopaedic surgeon in the prevention of refracture in patients treated surgically for fragility hip and vertebral fracture

THE ROLE OF THE ORTHOPAEDIC SURGEON IN THE TREATMENT OF PATIENTS WITH FRAGILITY FRACTURES IS TWOFOLD: the conservative or surgical treatment of the fracture, and the prevention of further fractures, establishing diagnostic and therapeutic procedures for osteoporosis. We evaluated 72 patients treated surgically for fragility vertebral fracture and 801 patients treated surgically for fragility hip fracture, operated from 2009 to 2010 at O.U. Orthopaedics and Traumatology of S.M. Annunziata Hospital of Florence, that have followed a treatment for refractures prevention according to the TARGET (Appropriate Treatment for Refractures GEriatric in Tuscany) Project of Tuscany Region. The average follow-up was 34 months. Patients with vertebral fracture treated for refractures prevention were 58 (80.6%), while patients with hip fracture treated for refractures prevention were 307 (38.3).

RESULTS

the number of patients with vertebral fracture who had a refracture in the first two years after surgery was 12 (16.6%), of which 9 patients were not treated for osteoporosis. The percentage of refracture at 1 year after surgery in patients with hip fractures was 3.19% in 2009 and 2.17% in 2010, compared to 5.16% of refracture of 2006 when the TARGET Project was not yet started. Mortality at 1 year after surgery in patients with hip fracture treated for osteoporosis was 19% compared to 25-31% in the patients not treated for osteoporosis.

Patients' response toward an automated orthopedic osteoporosis intervention program

Osteoporosis is overshadowed in an era of chronic illnesses, and a care gap exists between physicians and patients. The aim of this study was to determine the effectiveness of implementing an automated system for identifying and sending a letter to patients at high risk for osteoporosis. Patients 50 years of age and older were tagged with an International Classification of Diseases, Ninth Revision, diagnostic code upon initial visit to the emergency department (ED), identifying potential fragility fractures. Automatically generated letters were sent via our osteoporosis database system to each patient 3 months after the initial visit to the ED. The letter indicated that he or she was at risk for osteoporosis and suggested that the patient schedule a follow-up appointment with a physician. Patients were subsequently telephoned 3 months after receiving the letter and asked about their current plan for follow-up. The control group did not receive a letter after departure from the ED. In the control group, 84 (85.71%) individuals of the total 98 did not have any follow-up but the remaining 14 (14.29%) sought a follow-up. In the intervention group, 62 (60.19%) individuals of 103 did schedule a follow-up, while the remaining 41 (39.81%) did not seek a follow-up. Thus, the patient follow-up response rate after fracture treatment improved with intervention (P < .0001). Current literature has demonstrated the low rate of follow-up care addressing osteoporosis in patients experiencing fragility fractures (1%-25% without intervention). Research has shown the effectiveness of various types of intervention programs for improving the continuum of care for these high-risk patients. Nonautomated intervention programs can have a multitude of human-related system failures in identifying these patients. Our study successfully implements an automated system that is able to be applied to most hospitals with minimal cost and resources.

Fracture risk assessment in postmenopausal women referred to an Italian center for osteoporosis: a single day experience in Messina

Osteoporosis is a major cause of fragility fractures and these are responsible of large social burden; nevertheless, osteoporosis often remains an underdiagnosed disease. FRAX is a new and simple validate fracture risk assessment tool helping physicians to select patients at high risk of future fragility fractures. To promote early diagnosis of osteoporosis, we evaluated fracture risk by FRAX and performed phalangeal quantitative ultrasound (QUS) measurements in a population of postmenopausal women referring to our center during the World Osteoporosis Day on 20th October 2011. Eighty post-menopausal women (age 60.8±8.6) were screened and the risk of major osteoporotic and hip fractures over ten years was calculated by considering multiple clinical risk factors (CRFs). The median risk of major osteoporotic fracture (%) was 4.9 (3.5-8.6) in women younger than 55 years, 7.3 (5.4-11) in women aged between 55 and 65 years and 17.5 (11-27) in women older than 65 years; the median risk of hip fracture (%) was 0.6 (0.3-1.3), 1.5 (0.9-2.5) and 7.2 (3.1-14) respectively. QUS measurements, were lower in the older women and when multiple CRFs coexisted, and were found to correlate with fracture risk, especially with hip fracture risk (p<0.05). Within one month from the screening, 75% (44/59) of the women over 55 years came back and received a diagnosis of osteoporosis/osteopenia by dual x-ray absorptiometry (DXA); a positive association between DXA and QUS measurements was observed (p<0.0001). Adequate treatment of these subjects could reduce fracture rates, improve the quality of life, and reduce the social costs of osteoporosis.

Prevention and clinical management of hip fractures in patients with dementia

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk

Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.

Low 25-hydroxyvitamin D levels and low bone density assessed by quantitative ultrasonometry in a cohort of postmenopausal Italian nuns

This study was aimed at evaluating the effect of clothing style on bone mass and fractures in 70 postmenopausal nuns residing in a monastery in Naples. Sixty healthy women matched for age, body mass index, and menopausal status were enrolled as controls. Each participant underwent measurement by quantitative ultrasonometry (QUS) using a DBM Sonic Bone Profiler (IGEA S.p.A., Carpi, Modena, Italy) at proximal phalanges, responded to questionnaires regarding lifestyle, calcium intake, medical history, including clinical fragility fractures, and was submitted to routine biochemical assessment. A significant reduction in ultrasonometric parameters of bone mass was found in nuns compared with controls (p from 0.007 to <0.0001). 25-hydroxyvitamin D (25-OH vit D) levels were reduced by more than 50% in nuns (9.8 ± 4.2 vs 23.5 ± 5.7 nmol/L; p < 0.0001), whereas their estimated daily calcium intake was higher (1.004 ± 0.23 vs 0.721 ± 0.25 g of controls; p = 0.0007). Age at menopause was significantly lower in nuns' group (p = 0.016). Incidence of fractures was higher in nuns (39% vs 10%; p = 0.0029), and the best predictors of fractures were age at menopause (odds ratio [OR]: 1.12; 95% confidence interval [CI]: 1.01-1.30), amplitude-dependent speed of sound T-score (OR: 1.15; 95% CI: 1.03-1.63), and bone transmission time T-score (OR: 1.30; 95% CI: 1.15-1.81). This study documented low 25-OH vit D levels, increased frequency of clinical fractures, and low bone mass detected by QUS in Southern Italian nuns.

Clinical imaging of bone microarchitecture with HR-pQCT

Osteoporosis, a disease characterized by loss of bone mass and structural deterioration, is currently diagnosed by dual-energy x-ray absorptiometry (DXA). However, DXA does not provide information about bone microstructure, which is a key determinant of bone strength. Recent advances in imaging permit the assessment of bone microstructure in vivo using high-resolution peripheral quantitative computed tomography (HR-pQCT). From these data, novel image processing techniques can be applied to characterize bone quality and strength. To date, most HR-pQCT studies are cross-sectional comparing subjects with and without fracture. These studies have shown that HR-pQCT is capable of discriminating fracture status independent of DXA. Recent longitudinal studies present new challenges in terms of analyzing the same region of interest and multisite calibrations. Careful application of analysis techniques and educated clinical interpretation of HR-pQCT results have improved our understanding of various bone-related diseases and will no doubt continue to do so in the future.

Comparison of an organized geriatric fracture program to United States government data

OBJECTIVE

This study describes the financial impact of an organized hip fracture program for elderly patients age 65 years and older.

METHODS

This is a retrospective study of 797 fractures in 776 consecutive patients over a 50-month period (May 2005 to July 2009) treated in an organized hip fracture program for the elderly identified from a quality management database. Financial, demographic, and quality-of-care data were collected. The length of hospital stay, in-hospital complications, and Charlson comorbidity scores were collected from patient records, and all data were evaluated using standard statistical methods.

SETTING

261-bed community-based, university-affiliated teaching hospital in an urban setting with a catchment area of approximately 1 million persons. This is a level 3 trauma center.

RESULTS

The average total net revenue per hip fracture was $12 159, with an average total cost to hospital of $8264. Physicians' fees consisted of fees collected by surgeons, anesthesiologists, medical specialty consultants, and consulting geriatricians and averaged $2024 per case. Thus, the average hospital charge to payers was $15 188. Compared to Agency for Healthcare Research and Quality average inpatient hospital costs in 2005 of $33 693, a savings of more than $18 000 was realized per patient. The average length of stay was 4.6 days, markedly less than the national average of 6.2 days.

CONCLUSIONS

This organized geriatric fracture care model with geriatrics comanagement resulted in significant cost savings over a 50-month period, with associated increased quality. With an estimated 330 000 hip fractures annually in the United States, a large cost savings could potentially be realized if this model were more widely applied.

Case discussion: large volume blood loss and delirium in a patient with subtrochanteric fracture, dementia, and multiple comorbidities

This case presents a discussion of a 92-year-old man with multiple comorbidities, who presents with a subtrochanteric fracture. His course is complicated by large volume blood loss intraoperatively, requiring intensive care unit (ICU) monitoring postoperatively. His course is also complicated by delirium.

A prospective review of hip fracture subtypes, surgical procedure, cognitive status, and analgesia use across 4 Australian hospitals

OBJECTIVES

To correlate analgesia use among patients with hip fracture requiring surgery with hip fracture subtype, cognitive status, and type of surgery in the postacute period.

DESIGN AND PARTICIPANTS

Prospective review of patients with hip fractures requiring surgical intervention. A total of 415 patients (mean age: 81.2 ± 9.1 years, 74.3% women) presented with 195 subcapital fractures (39 undisplaced, 156 displaced) and 220 trochanteric fractures (136 stable, 84 unstable) requiring surgery.

SETTING

Inpatient orthopedic units in 4 Australian hospitals.

MEASUREMENTS

The primary outcome measures were mean analgesia usage (oral morphine equivalent) for 4 defined time intervals and total amount 36 hours following surgery.

RESULTS

Patients with subtrochanteric fractures required more analgesia compared with displaced-subcapital, undisplaced-subcapital, basicervical, stable-pertrochanteric, and unstable-pertrochanteric fractures in the 24 to 36 hours following operation (24.7 vs 11.3 vs 8.8 vs 12.1 vs 7.6 vs 9.7, P = .001). Total analgesia requirements were higher in patients treated with an intramedullary nail, increasing by 1.3- to 3.3-fold in the 36 hours postsurgery. Patients with cognitive impairment utilized markedly less analgesia at all time periods measured. At 24 to 36 hours, higher levels of analgesia were noted in patients with higher premorbid level of mobility (P = .015) and activities of daily living function (P = .007).

CONCLUSION

Important differences in utilization of analgesia following hip fracture across readily defined clinical groups exist. Proactive pain management for those with cognitive impairment, certain hip fracture subtypes, and surgical procedures may enable early functional mobility and other activities.

Barriers to implementation of an organized geriatric fracture program

INTRODUCTION

There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation.

MATERIALS AND METHODS

An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated.

RESULTS

Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program.

CONCLUSIONS

This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.

Diagnosis and treatment of osteoporosis in high-risk patients prior to hip fracture

PURPOSE

Hip fractures in older adults are common and serious events. Patients who sustain fragility hip fractures are defined as having osteoporosis. Patients with dementia or a history of a prior fragility fracture are at increased risk of a future fracture. This study assesses prefracture osteoporosis diagnosis and treatment in high-risk groups.

METHODS

A case-control analysis of a database of all patients age ≥60 years admitted for surgical repair of nonpathological, low-impact femur fracture between May 2005 and October 2010 was performed.

RESULTS

Of 1070 patients, 511 (47.8%) had dementia and 435 (40.7%) had been diagnosed with osteoporosis prior to admission. Patients with dementia were more likely to have a diagnosis of osteoporosis prior to their fracture than those without dementia (43.8% vs 37.7%, P < .05). Twenty-five percent of the total study population had been treated with calcium and vitamin D (Cal+D) prior to admission, and 12% with other osteoporosis medications. There was a trend toward patients with dementia being more likely to have been on Cal+D prior to admission (27.6% vs 22.5%, P = .06), but no difference in treatment with other agents (10.8% vs 13.1%, P = .25). Patients with prior fragility fractures were more likely to be on Cal+D (32.3% vs 25.0%, P < .02); however, there was no difference in the use of other osteoporosis medications (12.3% vs 12%, P = .90).

CONCLUSION

Fewer than half of patients that presented with hip fractures were diagnosed with osteoporosis prior to fracture and primary preventative treatment rates were low. Although patients with dementia are more likely to be diagnosed with osteoporosis, they were not more likely to be treated, despite having a greater risk. Additionally, those with prior fragility fractures are often not on preventative treatment. This may represent a missed opportunity for prevention and room for improvement in order to reduce osteoporotic hip fractures.

High-energy proximal femur fractures in geriatric patients: a retrospective analysis of short-term complications and in-hospital mortality in 32 consecutive patients

BACKGROUND

There is limited information in the literature on the outcomes and complications in elderly patients who sustain high-energy hip fractures. As the population ages, the incidence of high-energy geriatric hip fractures is expected to increase. The purpose of this study was to analyze the outcomes and complications in patients aged 65 years or older, who sustained a high-energy proximal femur fracture.

METHODS

Retrospective review of a prospective trauma database from January 2000 to April 2011 at a single US academic level-1 trauma center. Inclusion criteria consisted of all patients of age 65 years or older, who sustained a proximal femur fracture related to a high-energy trauma mechanism. Details concerning injury, acute treatment, and clinical course and outcome were obtained from medical records and radiographs.

RESULTS

We identified 509 proximal femur fractures in patients older than 65 years of age, of which 32 (6.3%) were related to a high-energy trauma mechanism. The mean age in the study group was 72.2 years (range 65-87), with a mean injury severity score of 20 points (range 9-57). Three patients died before discharge (9.4%), and 22 of 32 patients sustained at least one complication (68.8%). Blunt chest trauma represented the most frequently associated injury, and the main root cause of pulmonary complications. The patients' age and comorbidities did not significantly correlate with the rate of complications and the 1-year mortality.

CONCLUSIONS

High-energy proximal femur fractures in elderly patients are not very common and are associated with a low in-hospital mortality rate of less than 10%, despite high rate of complications of nearly 70%. This selective cohort of patients requires a particular attention to respiratory management due to the high incidence of associated chest trauma.

Case discussion: hip fracture in a patient on hospice with dementia and anemia

This case presents a discussion of a frail 98-year-old woman in hospice care, with a history of dementia, previous hip fracture, and anemia, who is admitted with a left intertrochanteric fracture. Care is coordinated and expedited by an interdisciplinary team to optimize her outcome, in the context of her goals of care.