Continuously declining incidence of hip fracture in Finland: Analysis of nationwide database in 1970-2016

Hip Fracture Incidence Over Twenty Years in Poland: The HiPoL Study

INTRODUCTION

In the previous report, we noted a significant increase in hip fracture incidence in the local study area. The aim of the study was the continuous observation of hip fracture incidence in the local community over the last 20 years and to estimate their projection for the next 30 years.

METHODS

Medical records of the patients aged 50 years and older in the period 2002 - 2021 (local data - area of the district Tarnowskie Góry and the city of Piekary Śląskie) with diagnosis ICD-10: S72.0; S72.1; and S72.2 (only the fragility fractures) were taken into analysis.

RESULTS

2,723 fragility hip fractures in the local area were registered (72 % in women). The increase in the rate was constantly observed, even during the COVID - 19 pandemic. The incidence rate ratio for the local population increased to 1.41. The incidence rate in 2021 was for the total population 230.2 (men 151.3; women 294.2). For comparison in 2002, it was 129.0 (men 48.8; women 192.4). In 2050 the number of fractures according to our new estimation will increase.

CONCLUSIONS

The number of fragility hip fractures in Polish men and women aged over 50 years in the local population increased. The epidemiological situation is still worsening. Therefore, especially due to the reduction of orthopedic beds and the aging population phenomenon the situation will be tragic to our patients.

The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period

INTRODUCTION

The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years.

METHODS

Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded.

RESULTS

The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts.

CONCLUSIONS

The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.

Improving hip fracture care: A five-year review of the early contributors to the Australian and New Zealand Hip Fracture Registry

OBJECTIVE

The aim of this study was to examine temporal trends (2016-2020) in hip fracture care in Australian and New Zealand (ANZ) hospitals that started providing patient-level data to the ANZ Hip Fracture Registry (ANZHFR) on/before 1 January 2016 (early contributors).

METHODS

Retrospective cohort study of early contributor hospitals (n = 24) to the ANZHFR. The study cohort included patients aged ≥50 years admitted with a low trauma hip fracture between 1 January 2016 and 31 December 2020 (n = 26,937). Annual performance against 11 quality indicators and 30- and 365-day mortality were examined.

RESULTS

Compared to 2016/2017, year-on-year improvements were demonstrated for preoperative cognitive assessment (2020: OR 3.57, 95% confidence interval [95% CI] 3.29-3.87) and nerve block use prior to surgery (2020: OR 4.62, 95% CI 4.17-5.11). Less consistent improvements over time from 2016/2017 were demonstrated for emergency department (ED) stay of <4 h (2017; 2020), pain assessment ≤30 min of ED presentation (2020), surgery ≤48 h (2020) and bone protection medication prescribed on discharge (2017-2020; 2020 OR 2.22, 95% CI 2.03-2.42). The odds of sustaining a hospital-acquired pressure injury increased in 2019-2020 compared to 2016. The odds of receiving an orthogeriatric model of care and being offered the opportunity to mobilise on Day 1 following surgery fluctuated. There was a reduction in 365-day mortality in 2020 compared to 2016 (OR 0.86, 95% CI 0.74-0.98), whereas 30-day mortality did not change.

CONCLUSIONS

Several quality indicators improved over time in early contributor hospitals. Indicators that did not improve may be targets for future care improvement activities, including considering incentivised hip fracture care, which has previously been shown to improve care/outcomes. COVID-19 and reporting practices may have impacted the study findings.

Global burden of hip fracture: The Global Burden of Disease Study

This study is the first to measure global burden of hip fracture in patients aged 55 years and older across 204 countries and territories from 1990 to 2019. Our study further proved that the global burden of hip fracture is still large. Hip fractures among males are perhaps underestimated, and older adults should be given more attention.

PURPOSE

Hip fracture is a tremendous universal public health challenge, but no updated comprehensive and comparable assessment of hip fracture incidence and burden exists for most of the world in older adults.

METHODS

Using data from the Global Burden of Diseases (GBD) 2019, we estimated the number and rates of the incidence, prevalence, and years lived with disability (YLD) of hip fracture across 204 countries and territories in patients aged 55 years and older from 1990 to 2019.

RESULTS

In 2019, the incidence, prevalence, and YLDs rates of hip fracture in patients aged 55 years and older were 681.35 (95% UI 508.36-892.27) per 100000 population, 1191.39 (95% UI 1083.80-1301.52) per 100000 population, and 130.78 (95% UI 92.26-175.30) per 100000 population. During the three decades, the incidence among people aged below 60 years showed a downward trend, whereas it showed a rapid upward trend among older adults. All the numbers and rates of hip fractures among females were higher than those among males and increased with age, with the highest number and rate in the highest age group. Notably, the male to female ratio of the incidence for people aged over 55 years increased from 0.577 in 1990 to 0.612 in 2019. Falls were the leading cause among both sexes and in all age groups.

CONCLUSIONS

The incidence and the number of hip fractures among patients aged 55 years and older increased over the past three decades, indicating that the global burden of hip fracture is still large. Hip fractures among males are perhaps underestimated, and older adults should be given more attention.

Trends of fall-related and other fatal injuries in older adults in Finland between 1998 and 2020

BACKGROUND

The number of falls and fall-related injuries will likely increase as the number of older adults expands. Increases in total deaths due to falls have been observed over Europe. Less is known about other injuries leading to death.

To examine the incidence trends of fall-related and other fatal injuries among adults aged 65 or older in Finland.

METHODS

We analyzed open data from Statistics Finland's register on the causes of death of those aged ≥65 collected between 1998 and 2020 yielding a total of 32 150 deaths due to injury using Poisson regression and distributional comparisons chi-squared tests.

RESULTS

The most common injuries leading to death among people aged ≥65 in Finland were fall related. There has been an increase in the absolute number of fall-related and other injuries, but when adjusting for person-years in population, a significant decrease can be observed. The crude rates of deaths from fall-related injuries among males annually increased 1.1-4.4% from 1998 to 2020, while the changes in rates among females ranged between -2% and 1.6%. The crude rates of other injuries ranged between -0.5% to +3.8%. Recently (2018-20), nearly 40% of the cases in males and 25% of cases in females were not fall related but comprised other types of injury mechanisms such as traffic, poisoning and drowning.

CONCLUSION

Strengthening the implementation of preventive strategies is essential to prevent injuries. To reduce injury-related mortality and disability, improvement of acute and post-acute care for injured older patients is warranted.

Pertrochanteric hip fracture is associated with mobility decline and poorer physical performance 4 to 6 months post-hip fracture

BACKGROUND

To study the effect of hip fracture type on physical performance, functional ability and change in mobility four to six months after the injury.

METHODS

A total of 1331 patients out of consecutive 2052 patients aged ≥ 65 years who underwent hip fracture surgery were included in the study. Patient information was collected on admission, during hospitalization, by phone interview and at the geriatric outpatient clinic 4 to 6 months after the fracture. Of the 1331 eligible patients, Grip strength, Timed Up and Go -test (TUG), Elderly Mobility Scale (EMS), mobility change compared to pre-fracture mobility level, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) were used to determine physical performance and functional ability. Logistic regression was used for the analyses which was adjusted for gender, age, American Society of Anesthesiologists score, diagnosis of cognitive disorder, pre-fracture living arrangements, mobility and need of mobility aid.

RESULTS

Patients with pertrochanteric hip fracture had an EMS lower than 14 (Odds Ratio (OR) 1.38, 95% confidence intervals (CI) 1.00-1.90), TUG time ≥ 20 s (OR 1.69, 95% CI 1.22-2.33) and they had declined in mobility (OR 1.58, 95% CI 1.20-2.09) compared to femoral neck fracture patients 4 to 6 months post-hip fracture in multivariable-adjusted logistic regression analyses. Grip strength and functional ability (IADL, BADL) 4 to 6 months after hip fracture did not differ between fracture types. There were no statistically significant differences in physical performance in patients with a subtrochanteric fracture compared to patients with a femoral neck fracture.

CONCLUSIONS

Pertrochanteric hip fracture independently associated with poorer physical performance 4 to 6 months post hip fracture compared to other hip fracture types. Pertrochanteric hip fracture patients should be given special attention in terms of regaining their previous level of mobility.

Combining Register and Radiological Visits Data Allows to Reliably Identify Incident Wrist Fractures

Purpose

To evaluate how comprehensively wrist fractures can be tracked from the national medical registers, and to propose a method for complementing the register data using time stamps of wrist radiography visits recorded in the radiological image archive.

Patients and Methods

For the Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) cohort of 14220 post-menopausal women, we analysed the data from the Care Register for Health Care, Register for Primary Health Care Visits, self-reports, radiological image archive PACS, and patient records to identify the wrist fractures occurred between 2011 and 2021. Using this gold standard of fractures, we validated the coverage of the registers and image archive and created algorithms to automatically identify fracture events from the registers and/or metadata of wrist radiography visits.

Results

We show that wrist fractures cannot be comprehensively identified based on national registers. To remedy this, our proposed method of combining register and image archive data can lift the coverage from 81% to 94% and reduce false discoveries from 6% to 2%.

Conclusion

The proposed method offers a more reliable way of gathering fracture information. Comprehensive fracture identification is essential in many research settings, such as incidence statistics, prevention studies, and risk assessment models.

Clinical Guidelines for the Diagnosis and Treatment of Fragility Fractures of the Pelvis

BACKGROUND

Fragility fractures of the pelvis (FFPs) are osteoporotic pelvic fractures or insufficiency pelvic fractures caused by the low energy injury or stress fracture in daily livings in the elderly more than 60 years, which the incidence is increasing with the aging population in our country. FFPs result in considerable morbidity and mortality and as well as massive financial burden on the already strained health systems throughout the world.

METHODS

This clinical guideline was initiated by the Trauma Orthopedic Branch of Chinese Orthopedic Association; the External Fixation and Limb Reconstruction Branch of Chinese Orthopedic Association; the National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation; Senior Department of Orthopedics of Chinese PLA general hospital; the Third Hospital of Hebei Medical University. The grading of recommendations assessment, development and evaluation (GRADE) approach and the reporting items for practice guidelines in healthcare (RIGHT) checklist were adopted.

RESULTS

22 evidence based recommendations were formulated based on 22 most concerned clinical problems among orthopedic surgeons in China.

CONCLUSION

Understanding these trends through this guideline will facilitate better clinical care of FFP patients by medical providers and better allocation of resources by policy makers.

Machine learning algorithms to predict risk of postoperative pneumonia in elderly with hip fracture

BACKGROUND

Hip fracture (HF) is one of the most common fractures in the elderly and is significantly associated with high mortality and unfavorable prognosis. Postoperative pneumonia (POP), the most common postoperative complication of HF, can seriously affect patient prognosis and increase the burden on the healthcare system. The aim of this study was to develop machine learning models for identifying elderly patients at high risk of pneumonia after hip fracture surgery.

METHODS

From May 2016 to November 2022, patients admitted to a single central hospital for HF served as the study population. We extracted data that could be collected within 24 h of patient admission. The dataset was divided into training and validation sets according to 70:30. Based on the screened risk factors, prediction models were developed using seven machine learning algorithms, namely CART, GBM, KNN, LR, NNet, RF, and XGBoost, and their performance was evaluated.

RESULTS

Eight hundred five patients were finally included in the analysis and 75 (9.3%) patients suffered from POP. Age, CI, COPD, WBC, HB, GLU, STB, GLOB, Ka+ which are used as features to build machine learning models. By evaluating the model's AUC value, accuracy, sensitivity, specificity, Kappa value, MCC value, Brier score value, calibration curve, and DCA curve, the model constructed by XGBoost algorithm has the best and near-perfect performance.

CONCLUSION

The machine learning model we created is ideal for detecting elderly patients at high risk of POP after HF at an early stage.

Epidemiology and treatment of proximal femoral fractures in the elderly U.S. population

Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z =  - 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z =  - 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z =  - 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.

Increased incidence among the very elderly in the 2020 Niigata Prefecture Osteoporotic Hip Fracture Study

INTRODUCTION

A 2015 study showed a decreasing trend in the incidence of osteoporotic hip fractures in Niigata Prefecture, Japan, which had been increasing. This study aimed to investigate the incidence of osteoporotic hip fractures in 2020, determine the long-term change in the incidence of hip fractures from 1985 to 2020, and assess whether the decline in fracture incidence since 2010 has continued.

MATERIALS AND METHODS

We obtained data from the registration forms submitted by hospitals and clinics of patients who lived in Niigata Prefecture and were diagnosed with osteoporotic hip fracture through a survey conducted from January 1, 2020 to December 31, 2020.

RESULTS

In 2020, 3,369 hip fractures were recorded in Niigata Prefecture. Although the overall incidence of age-specific hip fractures decreased, it increased in patients aged ≥ 90 years, regardless of sex. The proportion of patients receiving anti-osteoporosis drugs prior to hip fracture increased from 7.6% in 2004 to 17.3% in 2020. Notably, surgical treatment should be performed as early as possible, and the preoperative waiting time was 2.9 days, which was mainly due to holidays.

CONCLUSION

The incidence of hip fractures in Niigata Prefecture has gradually increased over the past 35 years, with an increasing change observed in the very elderly recently in 2020. Although the treatment of osteoporotic hip fractures in Niigata Prefecture is adequate, improvements may include increasing the rate of adoption of osteoporosis treatment further and decreasing the number of days of preoperative waiting.

Variation in bone mineral density and fractures over 20 years among Canadians: a comparison of the Canadian Multicenter Osteoporosis Study and the Canadian Longitudinal Study on Aging

International variations in osteoporosis and fracture rates have been reported, with temporal trends differing between populations. We observed higher BMD and lower fracture prevalence in a recently recruited cohort compared to that of a cohort recruited 20 years ago, even after adjusting for multiple covariates.

PURPOSE

We explored sex-specific differences in femoral neck bone mineral density (FN-BMD) and in prevalent major osteoporotic fractures (MOF) using two Canadian cohorts recruited 20 years apart.

METHODS

We included men and women aged 50-85 years from the Canadian Multicentre Osteoporosis Study (CaMos, N = 6,479; 1995-1997) and the Canadian Longitudinal Study on Aging (CLSA, N = 19,534; 2012-2015). We created regression models to compare FN-BMD and fracture risk between cohorts, adjusting for important covariates. Among participants with prevalent MOF, we compared anti-osteoporosis medication use.

RESULTS

Mean (SD) age in CaMos (65.4 years [8.6]) was higher than in CLSA (63.8 years [9.1]). CaMos participants had lower mean body mass index and higher prevalence of smoking (p < 0.001). Adjusted linear regression models (estimates [95%CI]) demonstrated lower FN-BMD in CaMos women (- 0.017 g/cm² [- 0.021; - 0.014]) and men (- 0.006 g/cm² [- 0.011; 0.000]), while adjusted odds ratios (95%CI) for prevalent MOF were higher in CaMos women (1.99 [1.71; 2.30]) and men (2.33 [1.82; 3.00]) compared to CLSA. In women with prevalent MOF, menopausal hormone therapy use was similar in both cohorts (43.3% vs 37.9%, p = 0.076), but supplements (32.0% vs 48.3%, p < 0.001) and bisphosphonate use (5.8% vs 17.3%, p < 0.001) were lower in CaMos. The proportion of men with MOF who received bisphosphonates was below 10% in both cohorts.

CONCLUSION

Higher BMD and lower fracture prevalence were noted in the more recently recruited CLSA cohort compared to CaMos, even after adjusting for multiple covariates. We noted an increase in bisphosphonate use in the recent cohort, but it remained very low in men.

Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type.

OBJECTIVE

Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland.

METHODS

A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years.

RESULTS

We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m², age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m², ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities.

CONCLUSIONS

Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Substantial changes in fracture rates in German hospitals in 2018 compared with 2002: an epidemiological study

INTRODUCTION

The aim of this study was to present recent epidemiological data on extremity and axial skeletal fractures in German hospitals and to compare them with older data to detect time trends.

MATERIALS AND METHODS

Inpatient data from the German National Hospital Discharge Registry were used. The absolute number and age-standardized incidence of fractures in 2002 and 2018 were analysed by fracture location according to the International Classification of Disease. Data were analysed according to age group. Male: female ratios (MFRs) and incidence rate ratios (IRRs) were calculated to compare the 2018 and 2002 data.

RESULTS

The absolute number of fractures of the nine analysed locations was 15.2% higher in 2018 than in 2002. By fracture location, the changes were as follows (absolute change + IRR): "neck" (S12): + 172%, IRR = 2.6; "rib(s), sternum, thoracic spine" (S22): + 57%, IRR = 1.3; "lumbar spine and pelvis" (S32): + 66%, IRR = 1.3; "shoulder and upper arm" (S42): + 36%, IRR = 1.2; "forearm" (S52): + 13%, IRR = 1.0; "wrist and hand level" (S62): - 32%, IRR = 0.7; "femur" (S72): + 24%, IRR = 0.9; "lower leg, including ankle" (S82): - 24%, IRR = 0.7; "foot, except ankle" (S92): - 4%, IRR = 0.9. The overall MFR changed from 0.7 in 2002 to 0.6 in 2018. The age group of 45-54 years represented a turning point, males were more often affected than females in the younger age groups, and the opposite trend was observed in the older age groups.

CONCLUSIONS

The increase in the absolute fracture rates was due to increased rates of femur, shoulder, upper arm, forearm, and axial skeletal fractures, with elderly women being the main contributors. Femur fractures were found to be the most common fractures treated in German hospitals.

Incidence and treatment of intracapsular femoral neck fractures in Germany

INTRODUCTION

Intracapsular femoral neck fractures are one of the most common fractures in Germany. Nevertheless, the epidemiology and treatment modalities are not described comprehensively. For this reason, this study highlights the epidemiology of femoral neck fractures in different age groups and summarizes treatment strategies within the period from 2009 to 2019 based on nationwide data.

MATERIALS AND METHODS

In this retrospective cohort study all cases of intracapsular femoral neck fractures (ICD-10: S72.0) between 2009 and 2019 in Germany were analyzed with regard to epidemiology, incidence and treatment. Operation and procedure classification system (OPS)- codes in combination with intracapsular femoral neck fracture as main diagnosis were taken to investigation. Data was provided by the Federal Statistical Office of Germany (Destatis).

RESULTS

A total of 807,834 intracapsular femoral neck fractures with a mean incidence of 110.0 per 100,000 inhabitants annually was detected within eleven years. In 68.8% of all fractures patients were female. Most patients were older than 70 years (82.4%), and 56.7% were older than 80 years. The overall increase of fracture numbers between 2009 and 2019 was 23.2%. Joint replacement has been most often performed (80.4%). Hemiarthroplasty (56.8%) and total hip arthroplasty (22.8%) were the most common procedures with an increase of 27.1 and 38.6%, respectively. The proportion of cemented hemiarthroplasties was 86.2% while 51.3% of all total hip arthroplasties were totally or partially cemented. Osteosyntheses were mainly conducted using dynamic compression screws (34.0%), conventional screws (31.3%) and nails (22.2%).

CONCLUSION

The incidence of intracapsular femoral neck fractures in Germany has been increasing continuously within the last decade. In particular, patients over 80 years suffered predominantly from this type of fracture. The majority was treated with a joint replacement procedure, mainly cemented hemiarthroplasty.

Secular trends in hip fractures in adults over 50 years old: a retrospective analysis of hospital admissions to the Brazilian Public Health System from 2004 to 2013

This was a retrospective observational study to determine the secular trends in osteoporosis hip fractures in Brazil from 2004 to 2013. The fracture rates were stable for both sexes, and there was not a secular trend. Fractures were predominant in the South and Southeast Regions. The hip fracture rate was lower in this study than in other studies. These regional differences may be considered in the FRAX Brazil calibration.

PURPOSE

Hip fractures are well-known osteoporotic fractures with high mortality and morbidity. Epidemiological studies in Brazil on hip fractures are scarce, and the great majority have been performed in small populations from a few cities. None of these studies has analyzed the long-term hip fracture secular trends, which are important data for the promotion of public health actions.

METHODS

This was a retrospective observational study with a secular trend analysis in patients over 50 years old who were admitted to the Brazilian Public Health System from 2004 to 2013. We collected hospitalization data according to the ICD-10 for low-trauma hip fractures. The fracture rate was calculated when the patients were stratified by sex, age, and geographic region, and linear regression analysis was performed to evaluate the secular trends.

RESULTS

The hip fracture rate per 100,000 inhabitants was 59.69; the rate was 74.72 in females and 42.95 in males. The fracture rates were higher in the South and Southeast Regions and steadily increased with age, and the average ratio of women-to-men was 1.74. No secular trend was detected in the overall population. Surprisingly, the secular trend only increased in the South region from 2004 to 2013, and the secular trends were stable in the other regions.

CONCLUSION

Although the secular trend was similar to some worldwide studies, the hip fracture rate was lower than that previously observed in regional studies in Brazil. These regional differences may be considered in the FRAX Brazil calibration.

Prevalence and Risk Factors for Drug-Related Problems in People With Dementia Living in the Community: A Systematic Review and Meta-Analysis

OBJECTIVES

The aims of this systematic review were to identify the prevalence and risk factors associated with of drug-related problems (DRPs) in people living with dementia in the community.

DESIGN

A systematic review and meta-analysis.

SETTING AND PARTICIPANTS

People with dementia living in the community.

METHODS

Six databases (Embase, Medline, PsycINFO, International Pharmaceutical Abstracts, Scopus, and CINAHL) were searched using a combination of keywords and Medical Subject Heading (MeSH) terms with 4 concepts: dementia, older adults, DRPs, and community-dwelling. Primary outcomes were adverse drug reactions (ADRs), adverse drug events (ADEs), and medication errors (MEs).

RESULTS

There were 22 studies included: 4 cross-sectional studies and 18 cohort studies. The number of participants in these studies ranged from 81 to 21,795. The pooled prevalence for any ADEs, including ADRs, in people living with dementia was 19.0% (95% CI 11.6%-27.7%), whereas the pooled prevalence for specific types of ADEs ranged from 2.6% to 10.2%. Furthermore, the prevalence of MEs ranged from 0.9% to 41.3%. Psychotropic medications, polypharmacy, and inappropriate medications contributed to an increased risk of experiencing DRPs, whereas support with medication management was a protective factor.

CONCLUSIONS AND IMPLICATIONS

The prevalence of overall DRPs experienced by people with dementia was highly variable in included studies. Awareness that certain medication, patient, and medication management factors are associated with the risk of people with dementia experiencing DRPs may guide clinicians to identify high-risk situations and implement suitable mitigation strategies.

Fascia Iliaca Blocks Performed in the Emergency Department Decrease Opioid Consumption and Length of Stay in Patients with Hip Fracture

OBJECTIVES

To examine the impact of fascia iliaca (FI) blocks performed in the emergency department on patients with hip fracture on opioid consumption, length of stay, and readmission rate.

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ninety-eight patients with isolated femoral neck, intertrochanteric, and subtrochanteric femur fractures (OTA/AO 31-A and 31-B) presenting from January 1, 2020, to June 30, 2020.

INTERVENTION

Ultrasound-guided FI compartment block using 40 mL of 0.25% bupivacaine.

MAIN OUTCOME MEASUREMENTS

Opioid consumption, length of stay, discharge disposition, and 30-day readmission rate.

RESULTS

Thirty-three patients had contraindication to FI block. Thirty-nine of 65 patients (60%) without contraindications to undergoing FIB received FI block. Mean age, body mass index, fracture type, and surgical procedure were similar between patients undergoing FIB and not receiving FIB. The FIB group had significantly lower opioid consumption preoperatively [17.4 vs. 32.0 morphine milliequivalents (MMEs)], postoperatively (37.1 vs. 85.5 MMEs), over total hospital stay (54.5 vs. 117.5 MMEs), and mean opioid consumption per day of hospital stay (13.3 vs. 24.0 MMEs). Patients in the FIB group had shorter length of stay compared with the control group (4.3 vs. 5.2 days). There was no significant difference in discharge disposition destination between groups. No patients reported complications of FI block.

CONCLUSIONS

Undergoing FI block in the emergency department was associated with decreased opioid consumption, decreased length of stay, and decreased hospital readmission within 30 days of hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Thirty years of hip fracture incidence in Austria: is the worst over?

Nationwide hip fracture incidence in the Austrian population was assessed over a period of 30 years (1989-2018), including 20 years data from a previous study and a recent 10 years follow-up. While absolute numbers in men continued to increase, absolute numbers in women and age-standardized incidences in both men and women decreased.

PURPOSE

In the Austrian population ≥ 50 years, nationwide hip fracture incidences over a period of 20 years (1989-2008) have shown an initial steep increase, followed by a leveling-off during the last few years of observation. The purpose of the present study was to follow up on hip fracture incidences for another 10 years (2009-2018) and to analyze trends over the entire period of 30 years.

METHODS

ICD-10 code classes S72.0, S72.1, and S72.2 were applied. All data were retrieved from the Statistics Austria database and its hospital discharge register. Annual absolute numbers, crude and age-standardized incidences, and incidence rate ratios (IRR) were stratified by sex and 5-year age intervals, and calculated by using a correction factor for multiple registrations.

RESULTS

Total number of hip fracture cases increased from 13,984 (2009) to 14,640 (2015), and decreased thereafter to 14,457 (2018), despite a persistent increase in men. Age-standardized incidences peaked at 476/100,000 (2010), followed by a decrease to 408/100,000 (2018). The observed overall decrease was mainly driven by the female population. Incidence rate ratios (IRRs) yielded a statistically significant average annual decrease of age-standardized incidences in both women and men (∆IRR 0.984; 0.981-0.987).

CONCLUSION

While absolute numbers of hip fracture in women showed a slight decrease during the last 10 years of observation, numbers in men continued to increase. Age-standardized incidences nevertheless decreased in both men and women, which may be interpreted as a trend in the right direction. However, due to the rapid aging of the population, it cannot be precluded that this trend will be compromised during the next few decades.

Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature

Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.

Prediction Model of Osteonecrosis of the Femoral Head After Femoral Neck Fracture: Machine Learning-Based Development and Validation Study

BACKGROUND

The absolute number of femoral neck fractures (FNFs) is increasing; however, the prediction of traumatic femoral head necrosis remains difficult. Machine learning algorithms have the potential to be superior to traditional prediction methods for the prediction of traumatic femoral head necrosis.

OBJECTIVE

The aim of this study is to use machine learning to construct a model for the analysis of risk factors and prediction of osteonecrosis of the femoral head (ONFH) in patients with FNF after internal fixation.

METHODS

We retrospectively collected preoperative, intraoperative, and postoperative clinical data of patients with FNF in 4 hospitals in Shanghai and followed up the patients for more than 2.5 years. A total of 259 patients with 43 variables were included in the study. The data were randomly divided into a training set (181/259, 69.8%) and a validation set (78/259, 30.1%). External data (n=376) were obtained from a retrospective cohort study of patients with FNF in 3 other hospitals. Least absolute shrinkage and selection operator regression and the support vector machine algorithm were used for variable selection. Logistic regression, random forest, support vector machine, and eXtreme Gradient Boosting (XGBoost) were used to develop the model on the training set. The validation set was used to tune the model hyperparameters to determine the final prediction model, and the external data were used to compare and evaluate the model performance. We compared the accuracy, discrimination, and calibration of the models to identify the best machine learning algorithm for predicting ONFH. Shapley additive explanations and local interpretable model-agnostic explanations were used to determine the interpretability of the black box model.

RESULTS

A total of 11 variables were selected for the models. The XGBoost model performed best on the validation set and external data. The accuracy, sensitivity, and area under the receiver operating characteristic curve of the model on the validation set were 0.987, 0.929, and 0.992, respectively. The accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve of the model on the external data were 0.907, 0.807, 0.935, and 0.933, respectively, and the log-loss was 0.279. The calibration curve demonstrated good agreement between the predicted probability and actual risk. The interpretability of the features and individual predictions were realized using the Shapley additive explanations and local interpretable model-agnostic explanations algorithms. In addition, the XGBoost model was translated into a self-made web-based risk calculator to estimate an individual's probability of ONFH.

CONCLUSIONS

Machine learning performs well in predicting ONFH after internal fixation of FNF. The 6-variable XGBoost model predicted the risk of ONFH well and had good generalization ability on the external data, which can be used for the clinical prediction of ONFH after internal fixation of FNF.

Instability of the posterior pelvic ring: introduction of innovative implants

BACKGROUND

Increasing numbers of posterior pelvic ring fractures, especially in elderly patients, demonstrate the need for soft tissue protecting surgical techniques. Standard of care is iliosacral screw osteosynthesis. This type of osteosynthesis has its limitations especially in patients with reduced bone properties. Therefore, the development of new and straightforward surgical techniques and implant designs is favorable.

METHODS

Introducing this modular system for the posterior pelvic ring, known complications of iliosacral screw osteosynthesis, such as implant loosening and malpositioning may be reduced, due to innovative mechanical characteristics.

RESULTS

The shown cases demonstrate the potential benefits of the system with a wide range of treatment options due to its modularity.

CONCLUSION

The modular implant system presented here can significantly facilitate and improve the stabilization of posterior pelvic ring instabilities.

Current status and distribution of hip fractures among older adults in China

China is a middle-risk country for hip fracture at present, which differs from previous data that it was low-risk. By 2050, the total number of hip fractures in people older than 65 years is predicted to be 1.3 million.

INTRODUCTION

To assess hip fracture incidence in China and examine the heterogeneity of hip fracture in seven geographical regions of China.

METHODS

There were 238,230 hip fracture patients aged 65 years or older from 2013 to 2016 from a large national in-patients database (HQMS) involving 30.6 million hospitalizations. Taking into account the total national hospitalization rate per calendar year, we estimated the incidence of hip fracture per 100,000 residents older than 65 years in China overall and in seven geographical Chinese regions.

RESULTS

The proportion of men and women older than 65 years with hip fractures was 1.00:1.95. Between 2013 and 2016, the number of hip fractures per 100,000 people age 65+ was 278. China has vast territories; the number of hip fractures per 100,000 people over 65 years old was 202 in Northeast China and 374 in Northwest China. Northwest has higher altitude, lower population density, is less developed with lower urbanization than Northeast China which is low altitude, and highly urbanized.

CONCLUSIONS

China should no longer be regarded as a low-risk country for hip fracture. By 2050, the total number of hip fractures in people older than 65 years in China is predicted to be 1.3 million. Higher altitude areas had higher hip fracture rates than lower altitude, higher urbanized areas.

Regional and gender-specific analyses give new perspectives for secular trend in hip fracture incidence

In this study, we found that regional disparity in incidence of hip fractures has converged. Also, annual hip fracture risk ratios between genders have systematically diminished over time.

INTRODUCTION

Several studies have reported secular trends in hip fracture incidence, but knowledge about the possible causes is limited. We studied potential explanations by examining spatio-temporal epidemiology of the fractures and estimating relative risks between genders.

METHODS

This observational study was based on all inpatient hospital discharges in 1972-2018 in Finland. We divided the data by gender, 5-year age groups and Finnish sub-regions and estimated gender and age standardized spatio-temporal rates of hip fractures by using a Bayesian age-period-cohort model.

RESULTS

In 1972, women's hip fracture incidence was 1.2-1.3 times higher in western and coastal Finland compared to eastern and inland areas. Also, women had approximately 1.7 times higher average risk to get a hip fracture compared to men. Today, the hip fracture differences between the areas have converged to insignificant and the relative risk between genders has diminished to 1.2. Age-specific relative risks indicate greater hip fracture risk for younger men and older women, and the women's risk increases beyond the risk of men at age 65 which is ten years later than in the beginning of the study period.

CONCLUSION

Incidence of hip fracture has converged significantly between regions and genders. Especially factors related with socioeconomic development and increased frailty and longevity seem to be important. The hip fracture incidence rate ratio between women and men has systematically decreased in time, and more attention should be paid to hip fracture risk in men in the future.

The incidence of arm, forearm, and hip osteoporotic fractures during early stage of COVID-19 pandemic

The study analyzes whether the COVID-19 pandemic affects the incidence of arm, forearm, and hip fractures. Additionally, the change in the overall cost of those fractures treatment was estimated. During the COVID-19 pandemic, the incidence of arm, forearm, and hip fractures and the cost of fracture management are decreased.

INTRODUCTION

Purposes of the study were to analyze if COVID-19 pandemic influences the incidence of arm, forearm, and hip osteoporotic fractures and to estimate the changes in costs of their management.

METHODS

Data on arm, forearm, and hip fracture incidence were collected for inhabitants aged over 50 years in the district of Tarnowskie Góry and the city of Piekary Śląskie, South Poland, in the early stage of COVID-19 pandemic (77 days, from March 16th to May 31st 2020). These results were compared with the number of fractures noted in years 2015-2019 in the same period of the year. The ratio of analyzed fractures per 100,000 inhabitants was calculated.

RESULTS

The recorded numbers of fractures of arm, forearm, and hip were 13, 43, and 29, respectively. The respective mean number for fractures reported in corresponding period in 2015-2019 years was 23.6, 52, and 33. The year fracture incidence calculated per 100,000 inhabitants decreased by 45.8%, 18.4%, and 13.4%, respectively. The estimated numbers of avoided fractures extrapolated for the whole country for arm, forearm, and hip were 1722, 1548, and 947, respectively. The total number of avoided fractures was 4217. The expected nationwide cost reduction for the arm, forearm, and hip fracture management was estimated at € 568,260, € 332,820, and € 1,628,840, respectively. The total cost reduction was € 2,529,920 over the period of observation.

CONCLUSION

During COVID-19 pandemic, a decrease of arm, forearm, and hip fracture incidence was observed which may result in decrease of total costs for Polish healthcare system.

Epidemiology and mortality of pelvic and femur fractures-a nationwide register study of 417,840 fractures in Sweden across 16 years: diverging trends for potentially lethal fractures

Background and purpose - Fractures of the pelvis and femur are serious and potentially lethal injuries affecting primarily older, but also younger individuals. Long-term trends on incidence rates and mortality might diverge for these fractures, and few studies compare trends within a complete adult population. We investigated and compared incidence and mortality rates of pelvic, hip, femur shaft, and distal femur fractures in the Swedish adult population.Patients and methods - We analyzed data on all adult patients ≥ 18 years in Sweden with a pelvic, hip, femur shaft, or distal femur fracture, through the Swedish National Patient Register. The studied variables were fracture type, age, sex, and 1-year mortality.Results - While incidence rates for hip fracture decreased by 18% (from 280 to 229 per 105 person-years) from 2001 to 2016, incidence rates for pelvic fracture increased by 25% (from 64 to 80 per 105 person-years). Incidence rates for femur shaft and distal femur fracture remained stable at rates of 15 and 13 per 105 person-years respectively. 1-year mortality after hip fracture was 25%, i.e., higher than for pelvic, femur shaft, and distal femur fracture where mortality rates were 20-21%. Females had an almost 30% lower risk of death within 1 year after hip fracture compared with males.Interpretation - Trends on fracture incidence for pelvic and femur fractures diverged considerably in Sweden between 2001 and 2016. While incidence rates for femur fractures (hip, femur shaft, and distal femur) decreased or remained constant during the studied years, pelvic fracture incidence increased. Mortality rates were different between the fractures, with the highest mortality among patients with hip fracture.

Changing epidemiology of lower extremity fractures in adults over a 15-year period - a National Hospital Discharge Registry study

Background

Demographic changes led to an increasingly ageing population in Germany and thus to possible changes in the frequency of fractures. The primary aim of this study was to report changes in fracture rates of the lower extremities in Germany in 2002 compared to 2017 and to evaluate those changes.

Methods

Inpatient data from the German National Hospital Discharge Registry (ICD10) for 2002 and 2017 were evaluated. Changes in total counts and incidence rates were analysed for fractures in the following locations: femoral neck, pertrochanteric, subtrochanteric, distal femur, femoral shaft, proximal and distal tibia, tibial shaft, medial and lateral malleolus, and other parts of the lower leg (including bi- and trimalleolar fractures), calcaneus, talus, other tarsal bones, metatarsal bones, greater toe, lesser toe, other fractures of foot or unspecific fractures of foot and toe. Patients were classed into age groups by sex: 15–24, 25–34,35–44, 45–54, 55–64, 65–74, 75–84, 85–90 and >  90 years.

Results

The total count for lower extremity fractures in men and women increased slightly by 4.5% from 305,764 in 2002 to 319,422 in 2017. Hip and femur fractures increased by 23.5% from 150,565 in 2002 to 185,979 in 2017. The number of these fractures among men increased by 46% and among women by 15.3%. The total count of lower leg fractures decreased by 15.4% from 131,162 in 2002 to 110,924 in 2017. Especially, younger age groups showed a decline for all tibial segments and ankle fractures. For both sexes, the number of lower leg fractures in those 75 years or older increased in all lower leg fracture locations. Most femur and lower leg fractures occurred in women. The incidence of fractures rose sharply from 2002 to 2017, especially for older cohorts.

Conclusion

The total numbers of lower extremity fractures increased slightly in 2017 compared to 2002 – especially hip and femur fractures among men. The incidence of almost all lower extremity fracture types among older people increased during this time. Women were particularly affected. Therefore, focused prevention programmes should be considered including an extended fracture spectrum in the elderly.

Trends in Hip Fracture Incidence, Recurrence, and Survival by Education and Comorbidity: A Swedish Register-based Study

BACKGROUND

Hip fractures are common and severe conditions among older individuals, associated with high mortality, and the Nordic countries have the highest incidence rates globally. With this study, we aim to present a comprehensive picture of trends in hip fracture incidence and survival in the older Swedish population stratified by education, birth country, and comorbidity level.

METHODS

This study is based on a linkage of several population registers and included the entire population over the age of 60 living in Sweden. We calculated age-standardized incidence rates for first and recurrent hip fractures as well as age-standardized proportions of patients surviving 30 and 365 days through the time period 1998 to 2017. We calculated all outcomes for men and women in the total population and in each population stratum.

RESULTS

Altogether, we observed 289,603 first hip fractures during the study period. Age-standardized incidence rates of first and recurrent fractures declined among men and women in the total population and in each educational-, birth country-, and comorbidity group. Declines in incidence were more pronounced for recurrent than for first fractures. Approximately 20% of women and 30% of men died within 1 year of their first hip fracture. Overall, survival proportions remained constant throughout the study period but improved when taking into account comorbidity level.

CONCLUSIONS

Hip fracture incidence has declined across the Swedish population, but mortality after hip fracture remained high, especially among men. Hip fracture patients constitute a vulnerable population group with increasing comorbidity burden and high mortality risk.

The role of having children for the incidence of and survival after hip fracture - A nationwide cohort study

BACKGROUND

Childless older women have a higher risk of sustaining a hip fracture than mothers. Several biological mechanisms linking parity to bone health among women have been proposed but it remains unclear whether a similar association exists among men. Adult children may also support their ageing parents with hip fracture, thereby potentially increasing survival chances.

AIM

To investigate how having children is related to the incidence of and survival after hip fracture among Swedish men and women over the age of 70.

METHODS

This nation-wide cohort study is based on data from several administrative population registers and a clinical hip fracture register. During 2013 to 2017, we estimated multivariable-adjusted incidence rate ratios to examine the association between number of children and incidence of first hip fracture and hazard ratios to examine survival after first hip fracture.

RESULTS

More than two million individuals were followed for hip fracture incidence and 45,991 patients for survival. Women had a higher risk of sustaining a hip fracture, but men had substantially higher mortality than women. Adjusting for education, comorbidity level, and further covariates, having children was associated with a lower risk of sustaining a hip fracture and a longer survival after hip fracture.

CONCLUSIONS

Older childless individuals may constitute risk groups for both the incidence of and mortality after hip fracture. Mechanisms linking parity to hip fracture risk are likely complex and not limited to biological mechanisms related to pregnancy, childbirth, or breastfeeding among women.

The incidence of pelvic fractures and related surgery in the Finnish adult population: a nationwide study of 33,469 patients between 1997 and 2014

Background and purpose - Information on the epidemiological trends of pelvic fractures and fracture surgery in the general population is limited. We therefore determined the incidence of pelvic fractures in the Finnish adult population between 1997 and 2014 and assessed the incidence and trends of fracture surgery.Patients and methods - We used data from the Finnish National Discharge Register (NHDR) to calculate the incidence of pelvic fractures and fracture surgery. All patients 18 years of age or older were included in the study. The NHDR covers the whole Finnish population and gives information on health care services and the surgical procedures performed.Results and interpretation - We found that in Finnish adults the overall incidence of hospitalization for a pelvic fracture increased from 34 to 56/100,000 person-years between 1997 and 2014. This increase was most apparent for the low-energy fragility fractures of the elderly female population. The ageing of the population is likely therefore to partly explain this increase. The annual number and incidence of pelvic fracture surgery also rose between 1997 and 2014, from 118 (number) and 3.0 (incidence) in 1997 to 187 and 4.3 in 2014, respectively. The increasing number and incidence of pelvic fractures in the elderly population will increase the need for social and healthcare services. The main focus should be on fracture prevention.

Sharp Rise in Fall-Induced Cervical Spine Injuries Among Older Adults Between 1970 and 2017

BACKGROUND

Fall-induced injuries in older adults are a major public health challenge.

METHODS

We determined the current trends in the number and age-adjusted incidence of fall-induced severe cervical spine injuries among older adults in Finland by taking into account all persons 50 years of age or older who were admitted to Finnish hospitals for primary treatment of these injuries between 1970 and 2017. Similar patients aged 20-49 years served as a reference group.

RESULTS

The annual number of fall-induced severe cervical spine injuries among older Finnish adults rose steeply during the follow-up, from 59 in 1970 to 502 in 2017. The age-adjusted incidence of injury (per 100,000 persons) was higher in men than women throughout this period and showed a clear increase from 1970 to 2017: from 8.4 to 25.0 in men, and from 2.8 to 13.9 in women. In both sexes, the increase was most prominent in the oldest age group, persons aged 80 years or older. In the reference group, the injury incidence declined by time.

CONCLUSIONS

The number and incidence of fall-induced severe cervical spine injuries among older Finns showed a sharp rise between 1970 and 2017. An increase in the average risk of serious falls may partly explain the phenomenon. Effective fall and injury prevention measures are urgently needed since further aging of the population is likely to aggravate the problem in the near future.

Incidence of and trends in hip fracture among adults in urban China: A nationwide retrospective cohort study

BACKGROUND

Hip fracture is a public health concern because of its considerable morbidity, excess mortality, great risk of disability, and high societal healthcare costs. China has the largest population of older people in the world and is experiencing rapid population aging and facing great challenges from an increasing number of hip fractures. However, few studies reported the epidemiology, especially at a national level. We aimed to evaluate trends in hip fracture incidence and associated costs for hospitalization in China.

METHODS AND FINDINGS

We conducted a population-based study using data between 2012 and 2016 from the national databases of Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance in China, covering about 480 million residents. Data from around 102.56 million participants aged 55 years and older during the study period were analyzed. A total of 190,560 incident hip fracture patients (mean age 77.05 years, standard deviation 8.94; 63.99% female) were identified. Primary outcomes included the age- and sex-specific incidences of hip fracture. Associated annual costs for hospitalization were also calculated. Incidence was described as per 100,000 person-years at risk, and 95% confidence intervals were computed assuming a Poisson distribution. Hip fracture incidence overall in China did not increase during the study period despite rapid population aging. Incidence per 100,000 was 180.72 (95% CI 137.16, 224.28; P < 0.001) in 2012 and 177.13 (95% CI 139.93, 214.33; P < 0.001) in 2016 for females, and 121.86 (95% CI 97.30, 146.42; P < 0.001) in 2012 and 99.15 (95% CI 81.31, 116.99; P < 0.001) in 2016 for males. For both sexes, declines in hip fracture incidence were observed in patients aged 65 years and older, although incidence was relatively stable in younger patients. However, the total absolute number of hip fractures in those 55 years and older increased about 4-fold. The total costs for hospitalization showed a steep rise from US$60 million to US$380 million over the study period. Costs for hospitalization per patient increased about 1.59-fold, from US$4,300 in 2012 to US$6,840 in 2016. The main limitation of the study was the unavailability of data on imaging information to adjudicate cases of hip fracture.

CONCLUSIONS

Our results show that hip fracture incidence among patients aged 55 and over in China reached a plateau between 2012 and 2016. However, the absolute number of hip fractures and associated medical costs for hospitalization increased rapidly because of population aging.

MODERN ASPECTS OF THE PROBLEM OF FRACTURES OF THE PROXIMAL FEMULAR

The purpose of the study is to study the current global clinical and epidemiological features of proximal hip fractures and the risks of their development and spread. The paper identifies the main aspects of the spread and treatment of fractures of the proximal femur; main world modern epidemiological characteristics of hip fractures and levels of risks of their development and spread. The relationship between comorbidities in patients with proximal hip fractures and the risk of various treatment complications is shown. The main types of treatment tactics are identified, the groups of the most common comorbidities in such patients are given. As a result of the work it was established: the percentage of fractures of the proximal thigh is 9.00–45.00 % among all skeletal fractures in the older age group and among all age categories – 17.00–24.00 %; global annual morbidity is 1.7 million people, and mortality – 11.00–23.00 % in 6 months and 22.00–29.00 % in a year; increase in the frequency of these fractures with age with doubling after 50 years every ten years; average age of patients – 75–79 years; predominance of women over men in 2-3 times; the lowest annual age-standardized cases among women are in Nigeria, South Africa, Tunisia and Ecuador, and the highest are in Denmark, Norway, Sweden and Austria, which is also typical for men; significant economic burden of treatment and high levels of fractures with osteoporosis, cardiovascular disease, diabetes, chronic obstructive pulmonary disease and more; the advantage of surgical treatment over conservative.

Use of benzodiazepines, z-hypnotics and antidepressants among hip fracture patients in Finland. Consistency between recorded and detected benzodiazepines

PURPOSE

We described the use of benzodiazepines (BZDs), z-hypnotics, and antidepressants; analyzed the consistency between recorded and detected BZDs among hip fracture patients admitted to two Finnish hospitals during one year; and compared the results with corresponding results from 12 years earlier.

METHODS

Current use of medication was obtained from the National Prescription Register. Urine and blood samples used to detect BZD were taken during admission. The following Anatomical Therapeutic Chemical (ATC) classes were included: BZDs: N05BA, N05CD; z-hypnotics: N05CF; and antidepressants: N06A.The presence of BZDs in urine was analyzed using immunoassay. Positive BZDs were confirmed by gas chromatography mass spectrometry. BZDs in serum were analyzed using liquid chromatography. Concordance between recorded and detected BZDs was calculated with kappa (κ) and described using a Venn diagram.

RESULTS

A total of 245 patients were enrolled in the study. BZD was detected in 18 %. Kappa was 0.39 (95 % CI 0.25-0.53). Overlap of detected and recorded BZDs was 59 %. According to the prescription register, 18 % used z-hypnotics, and according to both the detection of BZDs and register, 49 % used BZDs and/or z-hypnotics. 22 % used antidepressants and 15 % used combinations of the studied drugs concomitantly.

CONCLUSION

Use rate of BZDs and/or z-hypnotics was similar to that 12 years ago. No difference in the consistency between our previous and present study was found either. All studied drugs and their concomitant use increase the risk for fractures. In the elderly, point prevalence of medication and appropriateness should be regularly assessed.

Hardware removal rates after surgical treatment of proximal femur fractures : Nationwide trends in Finland in 1997-2016

BACKGROUND

Various internal fixation methods have been used to treat proximal femur fractures and occasionally the fixation material is removed. However, nationwide trends of hardware removals are not known. Thus, this study investigated the hardware removal rates after proximal femur fractures in Finland during 1997-2016.

MATERIALS AND METHODS

Finnish adults aged 18 years or older in 1997-2016 formed the basic study population. From the National Hospital Discharge Register patients with trochanteric femur fracture treated with an intramedullary nail (IMN) or dynamic hip screw (DHS), and patients with femoral neck fracture treated with screw fixation, were included. Hardware removal and secondary prosthesis rates were assessed.

RESULTS

Altogether 41,253 patients underwent proximal femoral fracture fixation surgery in Finland in 1997-2016. Of these, 16,152 were DHS surgery and 15,724 IMN surgery and 8491 underwent screw operation of femoral neck fracture. The total removal rates of DHS and IMN were 5.5% and 5.4%. The total removal rate of screw fixations of the femoral neck was higher, 18.5%. The total removal rates during the first 3 years after the IMN more than halved in 1997-2013, from 7.6% to 3.7%, whereas the removal rate of the DHS or screw fixation of femoral neck fractures did not show consistent trend. The rate of secondary prosthesis operations following DHS and IMN was low (1.8% for both). This was in clear contrast to the prosthesis rate following screw fixations of the femoral neck (7.2%).

CONCLUSIONS

IMN operations largely replaced DHS operations in trochanteric fractures of the proximal femur in Finland in 1997-2016. The removal and secondary prosthesis rates of the DHS and IMN were clearly lower than the corresponding rates after screw fixations of the femoral neck fracture.

LEVEL OF EVIDENCE

III, Epidemiologic study.

Progress of instability in fragility fractures of the pelvis: An observational study

Fragility fractures of the pelvis (FFP) are an increasing entity among elderly persons. Characteristics are different from high-energy pelvic trauma. Little is known about the natural course of FFP in conservative and after operative treatment.

MATERIALS AND METHODS

Medical charts and radiologic data of 148 patients with an FFP, who were admitted in a 3-year period, were analysed retrospectively. Incidence and characteristics of fracture progression (FP) were noted.

RESULTS

Patients presenting early after a traumatic event had more often non-displaced fractures, fractures with lower FFP Type classification and were more frequently treated conservatively. FP was observed in 21 cases (14.2%), twenty times after conservative and once after operative treatment. FP under conservative treatment occurred in female patients only. Patients with FP were younger than patients without. FP occurred in all fracture types, most frequently in FFP Type I. A second CT scan was positive for FP in 39.2% of patients with prolonged pain or restricted mobility.

CONCLUSION

FP is a real phenomenon, occurring in a minority of FFP patients. Female patients are at highest risk. Repeated CT scan is positive in nearly 40% of patients with continuing pain or restricted mobility. Operative treatment is a good preventive measure of FP as FP does only exceptionally occur after operative fixation of FFP.

Do We Need a Separate Classification for Fragility Fractures of the Pelvis?

Fragility fractures of the pelvis are occurring with increasing frequency. These fractures, occurring in the geriatric patient population, are low-energy injuries and are dissimilar in many ways from those caused by high-energy trauma. For example, the mechanism of injury is different and emergency treatment is usually not necessary. Having diminished bone strength, fragility fracture lines follow areas of low bone mineral density and loss of pelvic stability may increase over time. Based on our clinical experience, we propose a comprehensive classification of pelvic fragility fractures separate from the existing pelvic ring injury classification to provide a framework for distinguishing the different fragility fracture types and their recommended treatment. This classification is derived first from the degree of fracture instability, followed by the location of the fracture. Anterior pelvic fractures are differentiated from posterior pelvic ring fractures, nondisplaced fractures from displaced, and unilateral from bilateral. It is our belief that this new in-depth analysis of these lesions will assist the clinician in identifying the specific patterns of fragility fracture instability and selecting the appropriate choice of treatment. Further investigation is required to determine the ultimate value of this proposed pelvic fragility fracture classification system. LEVEL OF EVIDENCE:: Diagnostic Level V.