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Arcidiacono GP, Ceolin C, Sella S, Camozzi V, Bertocco A, Torres MO, Rodà MG, Cannito M, Berizzi A, Romanato G, Venturin A, Cianci V, Pizziol A, Pala E, Cerchiaro M, Savino S, Tessarin M, Simioni P, Sergi G, Ruggieri P, Giannini S. Taking care of inpatients with fragility hip fractures: the hip-padua osteosarcopenia (Hip-POS) fracture liaison service model. J Endocrinol Invest 2024:10.1007/s40618-024-02425-z. [PMID: 38971949 DOI: 10.1007/s40618-024-02425-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/20/2024] [Indexed: 07/08/2024]
Abstract
PURPOSE Osteoporotic fragility fractures (FF), particularly those affecting the hip, represent a major clinical and socio-economic concern. These fractures can lead to various adverse outcomes, which may be exacerbated by the presence of sarcopenia, especially among older and frail patients. Early identification of patients with FF is crucial for implementing effective diagnostic and therapeutic strategies to prevent subsequent fractures and their associated consequences. METHODS The Hip-POS program, implemented at Azienda Ospedale-Università Padova, is a Fracture Liaison Service (FLS) program to evaluate patients aged > 50 years old admitted with fragility hip fractures, involving an interdisciplinary team. After the identification of patients with hip fractures in the Emergency Department, a comprehensive evaluation is conducted to identify risk factors for further fractures, and to assess the main domains of multidimensional geriatric assessment, including muscle status. Patients are then prescribed with anti-fracture therapy, finally undergoing periodic follow-up visits. RESULTS During the first five months, a total of 250 patients were evaluated (70.4% women, median age 85 years). Following assessment by the Hip-POS team, compared to pre-hospitalization, the proportion of patients not receiving antifracture therapy decreased significantly from 60 to 21%. The prescription rates of vitamin D and calcium increased markedly from 29.6% to 81%. CONCLUSIONS We introduced the Hip-POS program for the care of older adults with hip fractures. We aspire that our model will represent a promising approach to enhancing post-fracture care by addressing the multifactorial nature of osteoporosis and its consequences, bridging the gap in secondary fracture prevention, and improving patient outcomes.
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Affiliation(s)
- G P Arcidiacono
- Clinica Medica 1, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - C Ceolin
- Department of Medicine - DIMED, Division of Metabolic Disease (DIMED), University of Padova, Padua, Italy.
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padua, Italy.
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - S Sella
- Clinica Medica 1, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - V Camozzi
- Endocrinology Unit, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - A Bertocco
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padua, Italy
| | - M O Torres
- Clinica Medica 1, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - M G Rodà
- Orthopedics and Orthopedic Oncology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - M Cannito
- Endocrinology Unit, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - A Berizzi
- Orthopedics and Traumatology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - G Romanato
- Orthopedics and Traumatology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - A Venturin
- Physical Medicine and Rehabilitation Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - V Cianci
- Emergency Department, Azienda Ospedale-Università Padova, Padua, Italy
| | - A Pizziol
- Emergency Department, Azienda Ospedale-Università Padova, Padua, Italy
| | - E Pala
- Orthopedics and Orthopedic Oncology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - M Cerchiaro
- Orthopedics and Orthopedic Oncology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - S Savino
- Department of Medicine, Università Di Padova, Padua, Italy
| | - M Tessarin
- Department of Directional Hospital Management, Azienda Ospedale-Università Padova, Padua, Italy
| | - P Simioni
- Clinica Medica 1, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
| | - G Sergi
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padua, Italy
| | - P Ruggieri
- Orthopedics and Orthopedic Oncology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - S Giannini
- Clinica Medica 1, Department of Medicine, Azienda Ospedale-Università Padova, Padua, Italy
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Tahmasbi F, Sadoughi F, Sheikhtaheri A, Zabihiyeganeh M, Ameri F. Developing fracture liaison service framework based on comparative analysis and scoping review. Osteoporos Int 2024:10.1007/s00198-024-07091-8. [PMID: 38831198 DOI: 10.1007/s00198-024-07091-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/16/2024] [Indexed: 06/05/2024]
Abstract
This research conducts a comparative analysis and scoping review of 105 studies in the field of Fracture Liaison Service (FLS). The resulting two-dimensional framework represents a significant step toward FLS implementation. PURPOSE The primary goal is to review interventions in real world settings in order to provide the FLS framework that specifies the essential elements of its implementation and offers different perspectives on that. METHOD This study encompasses two phases: a comparative analysis of existing FLS models, including "Capture the Fracture," "5IQ," and "Ganda," and a scoping review from 2012 to 2022 in PubMed, Web of Science, Scopus, ProQuest, and IEEE databases limited to publications in English. RESULTS The resulting model of comparative analysis identifies patient identification, investigation, intervention and integration or continuity of care as the four main stages of FLS. Additionally, the elements of quality and information span across all stages. Following comparative analysis, the framework is designed to be used for content analysis of the included studies in the scoping review. The intersection of columns (Who, Where, When, What, How, Quality) with rows (Identification, Investigation, Intervention, and continuity of care) yields a set of questions, answered in tabular form based on the scoping review. CONCLUSION The framework offers potential benefits in facilitating the adoption of effective approaches for FLS implementation. It is recommended to undertake an in-depth review of each of these components in order to uncover novel and innovative approaches for improving their implementation.
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Affiliation(s)
- Foziye Tahmasbi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Abbas Sheikhtaheri
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Zabihiyeganeh
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Ameri
- School of Manufacturing Systems and Networks, Arizona State University, Arizona, AZ, USA
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Ali A, Huszti E, Noordin S, Ali U, Sale JEM. Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis. Osteoporos Int 2024:10.1007/s00198-024-07078-5. [PMID: 38740589 DOI: 10.1007/s00198-024-07078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. METHODS We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. RESULTS This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. CONCLUSION Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.
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Affiliation(s)
- Anum Ali
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada.
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Shahryar Noordin
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Usman Ali
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Joanna E M Sale
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, 5th Floor - 149 College Street, Toronto, ON, M5B 1W8, Canada
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Wang L, Yang M, Ge Y, Liu Y, Wang G, Su Y, Guo Z, Yin L, Huang P, Geng J, Blake GM, He B, Zhu S, Cheng X, Wu X, Aro HT, Vlug A, Engelke K. Risk prediction of second hip fracture by bone and muscle density of the hip varies with time after first hip fracture: A prospective cohort study. Bone Rep 2024; 20:101732. [PMID: 38226335 PMCID: PMC10788229 DOI: 10.1016/j.bonr.2023.101732] [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: 08/18/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/17/2024] Open
Abstract
Purpose Predictors of 'imminent' risk of second hip fracture are unknown. The aims of the study were to explore strength of hip areal bone mineral density (aBMD), and muscle area and density for predicting second hip fracture at different time intervals. Methods Data of the Chinese Second Hip Fracture Evaluation were analyzed, a longitudinal study to evaluate the risk of second hip fracture (of the contralateral hip) by using CT images obtained immediately after first hip fracture. Muscle cross-sectional area and density were measured of the gluteus maximus (G.MaxM) and gluteus medius and minimus (G.Med/MinM) and aBMD of the proximal femur at the contralateral unfractured side. Patients were followed up for a median time of 4.5 years. Separate Cox models were used to predict second hip fracture risk at different time intervals after first event adjusted for age, sex, BMI and diabetes. Results The mean age of subjects with imminent (within 1st or 2nd year) second hip fracture was 79.80 ± 5.16 and 81.56 ± 3.64 years. In the 1st year after the first hip fracture, femoral neck (FN) aBMD predicted second hip fracture (HR 5.88; 95 % CI, 1.32-26.09). In the remaining years of follow-up after 2nd year, muscle density predicted second hip fracture (G.MaxM HR 2.13; 95 % CI, 1.25-3.65,G.Med/MinM HR 2.10; 95 % CI, 1.32-3.34). Conclusions Our results show that femoral neck aBMD is an important predictor for second hip fracture within the first year and therefore suggest supports the importance concept of early and rapid-acting bone-active drugs to increase hip BMD. In addition, the importance of muscle density predicting second hip fracture after the second year suggest post hip fracture rehabilitation and exercise programs could also be important to reduce muscle fatty infiltration.
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Affiliation(s)
- Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Minghui Yang
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Yufeng Ge
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Yandong Liu
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Gang Wang
- Department of Radiology, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yongbin Su
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Zhe Guo
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Lu Yin
- Information Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Fuwai Hospital, Beijing 100037, China
| | - Pengju Huang
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Jian Geng
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Glen M. Blake
- School of Biomedical Engineering & Imaging Sciences, King's College London, St Thomas' Hospital, London, United Kingdom
| | - Bo He
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Shiwen Zhu
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
| | - Xinbao Wu
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Hannu T. Aro
- Department of Orthopaedic Surgery and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Annegreet Vlug
- Center for Bone Quality, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Klaus Engelke
- Department of Medicine 3, FAU University Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
- Institute of Medical Physics, University of Erlangen, Erlangen, Germany
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Ruggiero C, Baroni M, Xenos D, Parretti L, Macchione IG, Bubba V, Laudisio A, Pedone C, Ferracci M, Magierski R, Boccardi V, Antonelli-Incalzi R, Mecocci P. Dementia, osteoporosis and fragility fractures: Intricate epidemiological relationships, plausible biological connections, and twisted clinical practices. Ageing Res Rev 2024; 93:102130. [PMID: 38030092 DOI: 10.1016/j.arr.2023.102130] [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] [Received: 09/20/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
Dementia, osteoporosis, and fragility fractures are chronic diseases, often co-existing in older adults. These conditions pose severe morbidity, long-term disability, and mortality, with relevant socioeconomic implications. While in the research arena, the discussion remains on whether dementia is the cause or the consequence of fragility fractures, healthcare professionals need a better understanding of the interplay between such conditions from epidemiological and physiological standpoints. With this review, we summarized the available literature surrounding the relationship between cognitive impairment, dementia, and both low bone mineral density (BMD) and fragility fractures. Given the strength of the bi-directional associations and their impact on the quality of life, we shed light on the biological connections between brain and bone systems, presenting the main mediators, including gut microbioma, and pathological pathways leading to the dysregulation of bone and brain metabolism. Ultimately, we synthesized the evidence about the impact of available pharmacological treatments for the prevention of fragility fractures on cognitive functions and individuals' outcomes when dementia coexists. Vice versa, the effects of symptomatic treatments for dementia on the risk of falls and fragility fractures are explored. Combining evidence alongside clinical practice, we discuss challenges and opportunities related to the management of older adults affected by cognitive impairment or dementia and at high risk for fragility fracture prevention, which leads to not only an improvement in patient health-related outcomes and survival but also a reduction in healthcare cost and socio-economic burden.
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Affiliation(s)
- C Ruggiero
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy.
| | - M Baroni
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - D Xenos
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - L Parretti
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - I G Macchione
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - V Bubba
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - A Laudisio
- Department of Medicine, Unit of Geriatrics, Campus Bio-Medico di Roma University, Rome, Italy
| | - C Pedone
- Department of Medicine, Unit of Geriatrics, Campus Bio-Medico di Roma University, Rome, Italy
| | - M Ferracci
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - R Magierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - V Boccardi
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
| | - R Antonelli-Incalzi
- Department of Medicine, Unit of Geriatrics, Campus Bio-Medico di Roma University, Rome, Italy
| | - P Mecocci
- Department of Medicine, Section of Gerontology and Geriatrics, University of Perugia, Italy
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Cedeno-Veloz BA, Casadamon-Munarriz I, Rodríguez-García A, Lozano-Vicario L, Zambom-Ferraresi F, Gonzalo-Lázaro M, Hidalgo-Ovejero ÁM, Izquierdo M, Martínez-Velilla N. Effect of a Multicomponent Intervention with Tele-Rehabilitation and the Vivifrail© Exercise Programme on Functional Capacity after Hip Fracture: Study Protocol for the ActiveFLS Randomized Controlled Trial. J Clin Med 2023; 13:97. [PMID: 38202104 PMCID: PMC10779784 DOI: 10.3390/jcm13010097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Hip fractures are the most common fracture leading to hospitalization and are associated with high costs, mortality rates and functional decline. Although several guidelines exist for preventing new fractures and promoting functional recovery, they tend to focus on osteoporosis treatment and do not take into account the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. Moreover, most health systems are fragmented and are incapable of providing appropriate management for frail and vulnerable individuals who are at risk of experiencing fragility fractures. Multicomponent interventions and physical exercise using tele-rehabilitation could play a role in the management of hip fracture recovery. However, the effectiveness of exercise prescription and its combination with a comprehensive geriatric assessment (CGA) is still unclear. METHODS This randomized clinical trial will be conducted at the Hospital Universitario de Navarra (Pamplona, Spain). A total of 174 older adults who have suffered a hip fracture and fulfil the criteria for inclusion will be randomly allocated to either the intervention group or the control group. The intervention group will receive a multicomponent intervention consisting of individualized home-based exercise using the @ctive hip app for three months, followed by nine months of exercise using Vivifrail. Additionally, the intervention group will receive nutrition intervention, osteoporosis treatment, polypharmacy adjustment and evaluation of patient mood, cognitive impairment and fear of falling. The control group will receive standard outpatient care according to local guidelines. This research aims to evaluate the impact of the intervention on primary outcome measures, which include changes in functional status during the study period based on the Short Physical Performance Battery. DISCUSSION The findings of this study will offer valuable insights into the efficacy of a comprehensive approach that considers the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. This study's findings will contribute to the creation of more effective strategies tailored to the requirements of these at-risk groups.
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Affiliation(s)
- Bernardo Abel Cedeno-Veloz
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
- Navarrabiomed, Institute for Health Research of Navarra (IDISNA), Irunlarrea 3, 31008 Pamplona, Navarra, Spain;
- Department of Health Sciences, Public University of Navarre, Av Cataluña s/n, 31006 Pamplona, Navarra, Spain
| | - Irache Casadamon-Munarriz
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
| | - Alba Rodríguez-García
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
| | - Lucia Lozano-Vicario
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
- Navarrabiomed, Institute for Health Research of Navarra (IDISNA), Irunlarrea 3, 31008 Pamplona, Navarra, Spain;
- Department of Health Sciences, Public University of Navarre, Av Cataluña s/n, 31006 Pamplona, Navarra, Spain
| | - Fabricio Zambom-Ferraresi
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
- Navarrabiomed, Institute for Health Research of Navarra (IDISNA), Irunlarrea 3, 31008 Pamplona, Navarra, Spain;
- Department of Health Sciences, Public University of Navarre, Av Cataluña s/n, 31006 Pamplona, Navarra, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Av Monforte de Lemos 3-5, Pabellón 11, Planta 0, 28029 Madrid, Spain
| | - María Gonzalo-Lázaro
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
| | - Ángel María Hidalgo-Ovejero
- Department of Orthopaedics Clinics and Traumatology, University Hospital of Navarre (HUN), 31008 Pamplona, Navarra, Spain;
| | - Mikel Izquierdo
- Navarrabiomed, Institute for Health Research of Navarra (IDISNA), Irunlarrea 3, 31008 Pamplona, Navarra, Spain;
- Department of Health Sciences, Public University of Navarre, Av Cataluña s/n, 31006 Pamplona, Navarra, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Av Monforte de Lemos 3-5, Pabellón 11, Planta 0, 28029 Madrid, Spain
| | - Nicolás Martínez-Velilla
- Navarre University Hospital (HUN), Irunlarrea 3, 31008 Pamplona, Navarra, Spain; (I.C.-M.); (A.R.-G.); (L.L.-V.); (F.Z.-F.); (M.G.-L.); (N.M.-V.)
- Navarrabiomed, Institute for Health Research of Navarra (IDISNA), Irunlarrea 3, 31008 Pamplona, Navarra, Spain;
- Department of Health Sciences, Public University of Navarre, Av Cataluña s/n, 31006 Pamplona, Navarra, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Av Monforte de Lemos 3-5, Pabellón 11, Planta 0, 28029 Madrid, Spain
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Unnanuntana A, Kuptniratsaikul V, Srinonprasert V, Charatcharoenwitthaya N, Kulachote N, Papinwitchakul L, Wattanachanya L, Chotanaphuti T. A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review. Injury 2023; 54:111039. [PMID: 37757673 DOI: 10.1016/j.injury.2023.111039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand. METHODS A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel. RESULTS Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan. CONCLUSION We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.
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Affiliation(s)
- Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand.
| | - Vilai Kuptniratsaikul
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natthinee Charatcharoenwitthaya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Noratep Kulachote
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University and Excellence Center for Diabetes, Hormone and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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8
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Becerril DV, Dirschl DR. Team Approach: Organizing and Empowering Multidisciplinary Teams in Postfragility Fracture Care. JBJS Rev 2023; 11:01874474-202311000-00003. [PMID: 37972214 DOI: 10.2106/jbjs.rvw.23.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
» Numerous healthcare roles can be valuable and effective participants in postfracture care programs (PFCPs) and can also serve effectively as program liaisons/champions.» Greatest success seems to have been achieved when a single entity provides cohesive and consistent training, coordination, shared goals, and accountability for program sites and site leaders.» Few PFCPs have solved what seems to be the fundamental challenge of such programs: how to maintain program effectiveness and cohesion when the patient makes the inevitable transition from acute care to primary care? Creating a partnership with shared goals with primary care providers is a challenge for every program in every location.» Programs located in the United States, with its predominantly "open" healthcare system, seem to lag other parts of the world in overcoming this fundamental challenge.» It is hoped that all PFCPs in all systems can learn from the successes of other programs in managing this critical transition from acute to primary care.
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Affiliation(s)
- Daniela Varona Becerril
- División de Ciencias de la Salud, Universidad Anáhuac Querétaro, Santiago de Querétaro, Mexico
| | - Douglas R Dirschl
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
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9
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Valladales-Restrepo LF, Castro-Osorio EE, Ramírez-Osorio J, Echeverry-Martinez LF, Sánchez-Ríos V, Gaviria-Mendoza A, Machado-Duque ME, Machado-Alba JE. Characterization and effectiveness of a Fracture Liaison Services program in Colombia. Arch Osteoporos 2023; 18:124. [PMID: 37789128 PMCID: PMC10547802 DOI: 10.1007/s11657-023-01331-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/10/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Fracture Liaison Services programs reduce mortality and the risk of refracture and increase treatment and adherence rates. Greater coverage is an important priority for the future. The aim was to determine the characteristics of patients over 50 years old who suffered fractures and the effectiveness of a Fracture Liaison Services program in a health care institution in Colombia. METHODS This was a retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services program. Sociodemographic, clinical and pharmacological variables were identified. Key performance indicators were used to evaluate the effectiveness of the program. Descriptive and bivariate analysis was performed. RESULTS A total of 438 patients were analyzed. The average age was 77.5 years, and 78.5% were women. Hip and vertebral fractures were the most common (25.3% and 24.9%, respectively). Vertebral fractures prevailed in men (33.0% vs 22.7%; p = 0.041) and those of the radius/ulna in women (20.3% vs 10.6%; p = 0.031). A total of 29.7% had experienced a previous fracture, and 16.7% had received antiosteoporosis drugs. A total of 63.5% of the cases were managed surgically. At discharge, 58.8% received prescriptions for calcium/vitamin D, and 50.7% with prescriptions of antiosteoporotic therapy, especially teriparatide (21.2%) and denosumab (16.4%), without significant differences by sex. However, in women with hip fractures, anti-osteoporotic management prevailed (83.7% vs 64.0; p = 0.032). The effectiveness of the overall program per year was 74.6%. On follow-up, only 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture. A total of 4.3% died during follow-up. CONCLUSIONS Good adherence to the recommendations of the country's clinical practice guidelines was found, and overall, the effectiveness of the program was very satisfactory, with a low incidence of new fractures during follow-up. Fracture Liaison Services programs reduce mortality and the risk of refracture. A retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services, showed that the effectiveness was 73.6%. On follow-up, 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira, Colombia
- Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira, Risaralda, Colombia
| | | | | | - Luisa Fernanda Echeverry-Martinez
- Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira, Risaralda, Colombia
| | - Verónica Sánchez-Ríos
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira, Colombia
| | - Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de Las Américas, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 # 14-140, Pereira, Risaralda, Colombia.
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10
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Cianferotti L, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML, Corrao G, Biffi A. The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years. Arch Osteoporos 2023; 18:109. [PMID: 37603196 PMCID: PMC10442313 DOI: 10.1007/s11657-023-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023]
Abstract
Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline. PURPOSE After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines. METHODS PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance. RESULTS Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures. CONCLUSIONS Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.
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Affiliation(s)
- L Cianferotti
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - R Ronco
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - G Adami
- Rheumatology Unit, University of Verona, Verona, Italy
| | - R Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - R Bogini
- Local Health Unit (USL) Umbria, Perugia, Italy
| | - A P Caputi
- Department of Pharmacology, School of Medicine, University of Messina, Sicily, Italy
| | - B Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - D Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - S Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - G Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - S Leone
- AMICI Onlus, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino, Milan, Italy
| | - R Michieli
- Italian Society of General Medicine and Primary Care (SIMG), Florence, Italy
| | - S Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - T Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - M Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - E Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M Rossini
- Rheumatology Unit, University of Verona, Verona, Italy
| | - U Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M L Brandi
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Corrao
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - A Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
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11
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Rubiño FJ, Naranjo A, Molina A, Fuentes S, Santana F, Navarro R, Montesdeoca A, Fernández T, Lorenzo JA, Ojeda S. Active identification of vertebral fracture in the FLS model of care. Arch Osteoporos 2023; 18:89. [PMID: 37382649 PMCID: PMC10310566 DOI: 10.1007/s11657-023-01289-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023]
Abstract
The identification of vertebral fracture is a key point in an FLS. We have analyzed the characteristics of 570 patients according to the route of identification (referral by other doctors, emergency registry or through VFA), concluding that promoting referral by other doctors with a training campaign is effective. PURPOSE Vertebral fractures (VF) are associated with increased risk of further VFs. Our objective was to analyze the characteristics of patients with VF seen in a Fracture Liaison Service (FLS). METHODS An observational study was carried out on patients with VF referred to the outpatient metabolic clinic (OMC) after a training campaign, identified in the emergency registry, and captured by VF assessment with bone densitometry (DXA-VFA) in patients with non-VFs. Patients with traumatic VF or VF > 1 year, infiltrative or neoplastic disease were excluded. The number and severity of VFs (Genant) were analyzed. Treatment initiation in the first 6 months after baseline visit was reviewed. RESULTS Overall, 570 patients were included, mean age 73. The most common route for identifying VF was through referral to OMC (303 cases), followed by the emergency registry (198) and DXA-VFA (69). Osteoporosis by DXA was found in 312 (58%) patients and 259 (45%) had ≥ 2 VFs. The rate of grade 3 VFs was highest among patients on the emergency registry. Those identified through OMC had a higher number of VFs, a higher rate of osteoporosis, more risk factors and greater treatment initiation. Patients with VFs detected by DXA-VFA were mostly women with a single VF and had a lower rate of osteoporosis by DXA. CONCLUSIONS We present the distribution of VFs by the route of identification in an FLS. Promoting referral by other doctors with a training campaign may help in the quality improvement of the FLS-based model of care.
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Affiliation(s)
- Francisco J Rubiño
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain
| | - Antonio Naranjo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain.
- University of Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - Amparo Molina
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain
| | - Sonia Fuentes
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain
| | - Fabiola Santana
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain
| | - Ricardo Navarro
- Department of Orthopedics, Spine Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Arturo Montesdeoca
- Department of Orthopedics, Spine Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Tito Fernández
- Department of Orthopedics, Spine Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - José A Lorenzo
- Department of Orthopedics, Spine Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Soledad Ojeda
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Reumatología Barranco de La Ballena, 35011, Las Palmas, Spain
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12
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Bogoch E, Marcano-Fernández FA, Schemitsch EH, Zhou Q, Bzovsky S, Bhandari M, Schneider PS, Swiontkowski M, Sprague S. High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly. J Bone Joint Surg Am 2022; 104:1984-1992. [PMID: 36017942 DOI: 10.2106/jbjs.22.00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients. METHODS As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects. RESULTS In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication. CONCLUSIONS Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Earl Bogoch
- Department of Surgery, University of Toronto, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Francesc A Marcano-Fernández
- Orthopaedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Qi Zhou
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Prism S Schneider
- Division of Orthopaedic Trauma, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Marc Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Sheila Sprague
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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