Incidence and seasonal variation in hip fracture incidence among elderly women in Norway. The HUNT Study

The Association of Season of Surgery and Patient Reported Outcomes following Total Hip Arthroplasty

Background

Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA). Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience. The aim of this study is to investigate if there are differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season of the index procedure to improve surgeon preoperative counseling.

Methods

A retrospective chart review was performed on patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographic, operative, hospital, and PROMs were gathered from the institutional electronic medical record and our institutional joint replacement outcomes database.

Results

6418 patients underwent primary THA and met inclusion criteria. Of this patient population, 1636 underwent surgery in winter, 1543 in spring, 1811 in summer, and 1428 in fall. PROMs were equivalent across seasons at nearly time points. The average age of patients was 65 (+/- 10) years, with an average BMI of 29.3 (+/- 6). Rates of complications including ED visits within 30 days, readmission within 90 days, unplanned readmission, dislocation, fracture, or wound infection were not significantly different by season (P > .05).

Conclusion

Our findings indicate no differences in complications and PROMs at 1 year in patients undergoing THA during 4 distinct seasons. Notably, patients had functional differences at the second follow-up visit, suggesting variation in short-term recovery. Patients could be counseled that they have similar rates of complications and postoperative recovery regardless of season.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Characteristics of fallers who later sustain a hip fracture: a NOREPOS study

Fall prevention programs have shown inconclusive results concerning hip fracture reduction. We found that fallers with poor health, low societal participation, and use of psychotropics/painkillers had a threefold to fivefold increased hip fracture risk compared to non-fallers without these risk factors. This may help target fall prevention towards high-risk individuals.

INTRODUCTION

To investigate whether self-reported information on health, societal participation, and drug use in older people, easily obtainable by health care providers, contribute to predict future hip fracture beyond self-reported falls.

METHODS

We used data from 3801 women and 6439 men aged 70-79 years participating in population-based studies in five counties in Norway 2000-2003. Height and weight were measured. Socioeconomic status, lifestyle, health status, and history of falling were self-reported through questionnaires. Falls last year were dichotomized into one or more versus no falls. Hip fractures were identified by linkage to hospital data with follow-up through 2013. Hazard ratios (HR) with 95% confidence intervals (95% CI) for hip fracture by combinations of risk factors with history of falling were estimated using Cox proportional hazards regression.

RESULTS

More women (32.4%) than men (27.7%) reported one or more falls during the previous year, and 17.9% of women (n = 682) and 8.9% of men (n = 572) suffered a hip fracture during median 11.6 years of follow-up. Poor health, low societal participation, and use of psychotropics/analgesics among fallers were strong predictors of hip fracture. The presence of all three risk factors and history of falling was associated with HR 2.92 (95% CI 2.10-4.05) for hip fracture in women and HR 4.60 (95% CI 2.71-7.81) in men compared to non-fallers without these factors.

CONCLUSION

Our study indicates that self-assessment of health, information about activities outside home, and drug use among fallers far better identify high risk of hip fracture in older people than information about falls alone.

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study

PURPOSE

The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture.

METHODS

A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures" were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27.

RESULTS

A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978).

CONCLUSION

Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID" and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.

Seasonal variation in fall-related emergency department visits by location of fall - United States, 2015

INTRODUCTION

In the United States, fall-related emergency department (ED) visits among older adults (age 65 and older) have increased over the past decade. Studies document seasonal variation in fall injuries in other countries, while research in the United States is inconclusive. The objectives of this study were to examine seasonal variation in older adult fall-related ED visits and explore if seasonal variation differs by the location of the fall (indoors vs. outdoors), age group, and sex of the faller.

METHODS

Fall-related ED visit data from the National Electronic Injury Surveillance System-All Injury Program were analyzed by season of the ED visit, location of the fall, and demographics for adults aged 65 years and older.

RESULTS

Total fall-related ED visits were higher during winter compared with other seasons. This seasonal variation was found only for falls occurring outdoors. Among outdoor falls, the variation was found among males and adults aged 65 to 74 years. The percentages of visits for weather-related outdoor falls were also higher among males and the 65-74 year age group.

CONCLUSIONS

In 2015, there was a seasonal variation in fall-related ED visits in the United States. Weather-related slips and trips in winter may partially account for the seasonal variation.

PRACTICAL IMPLICATIONS

These results can inform healthcare providers about the importance of screening all older adults for fall risk and help to identify specific patients at increased risk during winter. They may encourage community-based organizations serving older adults to increase fall prevention messaging during winter.

Risk of hip and forearm fracture in subjects with type 2 diabetes mellitus and latent autoimmune diabetes of adults. The HUNT Study, Norway

Type 1 and type 2 diabetes mellitus incur an increased risk of fracture, with a generally higher risk among individuals with type 1 diabetes. The fracture risk among individuals with latent autoimmune diabetes of adulthood (LADA) is not known. The present cohort study aimed to estimate the risk of hip and forearm fracture among individuals with LADA, alongside type 1 and type 2 diabetes, using data from the second survey of the Trøndelag Health Study (HUNT2) in 1995-97. All inhabitants aged 20 years or older (N = 92,936) were invited to attend, of whom 65,234 (70%) participated. A total of 1972 (3%) reported to have diabetes; 1399 were found to have type 2 diabetes, 144 to have LADA, and 138 to have type 1 diabetes. All participants were followed prospectively with respect to hip- and forearm fractures by linkage to the local fracture registry. During a median follow-up of 16.2 years, 2695 persons with hip fractures and 3533 persons with forearm fractures were identified. There was an increased risk of hip fracture in women with type 2 diabetes (HR = 1.51, 95% CI 1.24-1.85) and LADA (HR = 2.15, 95% CI 1.25-3.72), whereas women with type 1 diabetes did not have a significantly increased risk (HR = 2.13, 95% CI 0.89-5.14). Among men, only LADA was associated with an increased risk of hip fracture (HR = 2.69, 95% CI 1.34-5.41). There was no statistically significant association between any of the diabetes types and forearm fracture. In women with type 2 diabetes, the highest risks of hip fracture were observed among those with highest HbA_1c level at baseline, longest time since diagnosis, and most visual and movement impairment. We found that individuals with LADA had an increased risk of hip fracture similar to that previously reported for individuals with type 1 diabetes, and no increased risk of forearm fracture.

Weather Conditions and Outdoor Fall Injuries in Northwestern Russia

This study aimed to investigate associations between the weather conditions and the frequency of medically-treated, non-fatal accidental outdoor fall injuries (AOFIs) in a provincial region of Northwestern Russia. Data on all non-fatal AOFIs that occurred from January 2015 through June 2018 (N = 1125) were extracted from the population-based Shenkursk Injury Registry (SHIR). Associations between the weather conditions and AOFIs were investigated separately for the cold (15 October–14 April) and the warm (15 April–14 October) seasons. Negative binomial regression was used to investigate daily numbers of AOFIs in the cold season, while zero-inflated Poisson regression was used for the warm season. The mean daily number of AOFIs was 1.7 times higher in the cold season compared to the warm season (1.10 vs. 0.65, respectively). The most typical accident mechanism in the cold season was slipping (83%), whereas stepping wrong or stumbling over something was most common (49%) in the warm season. The highest mean daily incidence of AOFIs in the cold season (20.2 per 100,000 population) was observed on days when the ground surface was covered by compact or wet snow, air temperature ranged from −7.0 °C to −0.7 °C, and the amount of precipitation was above 0.4 mm. In the warm season, the highest mean daily incidence (7.0 per 100,000 population) was observed when the air temperature and atmospheric pressure were between 9.0 °C and 15.1 °C and 1003.6 to 1010.9 hPa, respectively. Along with local weather forecasts, broadcasting warnings about the increased risks of outdoor falls may serve as an effective AOFI prevention tool.

Geographic variations in hip fracture incidence in a high-risk country stretching into the Arctic: a NOREPOS study

There are geographic variations in hip fracture incidence rates across Norway, with a lower incidence in the coastal areas of the southwest and in the Arctic north, contrary to what may be expected with regard to vitamin D exposure from sunlight. The regional differences have become smaller in recent years.

INTRODUCTION

To investigate geographic variation in hip fracture incidence within Norway and regional differences in time trends.

METHODS

All hip fractures treated in Norwegian hospitals 2002-2013 were included, and demographic information was obtained from Statistics Norway. Age-standardized incidence rates were calculated separately for 19 counties. Incidence rate ratios with 95% confidence intervals for county differences and time trends were estimated using Poisson regression.

RESULTS

Age-standardized number of hip fractures per 10,000 person-years varied between counties from 69 to 84 in women and from 34 to 41 in men. The highest rates were observed in the southeastern capital city of Oslo, while rates were low in the four northernmost counties. There was an east-west gradient, with lower incidence in the coastal southwest compared with the southeast. Women showed a statistically significant decline during 2002-2013 in almost all counties (up to 31%). In men, only a few counties showed a decline. In both genders, hip fracture rates at age 80 in the combined five counties with the highest rates were significantly higher than in the combined five counties with the lowest rates across the period, although the trends converged over time.

CONCLUSIONS

In Norway, the hip fracture incidence was lower in the north compared with the south. In addition, we observed an east-west gradient with the highest incidence in the southeast and lower incidence in the coastal southwest. While there has been an overall declining trend in hip fracture incidence over time, regional differences are still apparent.

Seasonality of hip fracture and vitamin D deficiency persists in a sub-tropical climate

Both hip fractures and vitamin D (25-hydroxyvitamin D (25-OHD)) deficiency are more common in winter in regions with temperate climates, but few data exist for a sub-tropical climate. In a South East Queensland tertiary hospital over a 7-year period, there were significantly more hip fractures in winter than the other three seasons (analysis of variance P = 0.003), with associated higher frequency of 25-OHD deficiency - 42.5% in winter compared to 28.5% in summer, odds ratio 1.86 (95% confidence interval 1.35-2.56), P = 0.0001. Seasonality of hip fracture and 25-OHD deficiency occurs even in a sub-tropical climate.

Proton pump inhibitors and fracture risk. The HUNT study, Norway

Proton pump inhibitors (PPIs) have been linked to increased risk of fracture; the data have, however, been diverging. We did not find any increased risk of fractures among users of PPIs in a Norwegian population of 15,017 women and 13,241 men aged 50-85 years with detailed information about lifestyle and comorbidity.

INTRODUCTION

Proton pump inhibitors (PPIs) are widely prescribed and have been linked to increased risk of fracture.

METHODS

We used data from the Nord-Trøndelag Health Study (HUNT3), The Fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, including 15,017 women and 13,241 men aged 50-85 years. The study population was followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture (forearm or hip), death, or end of study (31 December 2012). The Cox proportional hazards model with time-dependent exposure to PPIs was applied, and each individual was considered as unexposed until the first prescriptions was filled. To be included, the prescription of PPIs should minimum be equivalent to 90 defined daily doses (DDD) in the period. Individuals were defined as exposed until 6 months after end of drug supply.

RESULTS

The proportion of women and men using PPIs was 17.9% and 15.5%, respectively. During a median of 5.2 years follow-up, 266 women and 134 men had a first hip fracture and 662 women and 127 men, a first forearm fracture. The combined rate/1000 patient-years for forearm and hip fractures in women was 49.2 for users of PPIs compared with 64.1 among non-users; for men 18.6 and 19.8, respectively. The hazard ratios with 95% confidence interval for the first forearm or hip fracture among users of PPIs in the age-adjusted analysis were 0.82 (0.67-1.01) for women and 1.05 (0.72-1.52) for men. Adjusting for age, use of anti-osteoporotic drugs, and FRAX, the HR declined to 0.80 (0.65-0.98) in women and 1.00 (0.69-1.45) in men.

CONCLUSIONS

Use of PPIs was not associated with an increased risk of fractures.

Variation in fracture risk by season and weather: A comprehensive analysis across age and fracture site using a National Database of Health Insurance Claims in Japan

Although age- and season-specific effects on fracture risk have been reported, the effects of seasonality across different age groups and for different fracture sites have not yet been clarified. Therefore, our study aimed to comprehensively investigate the effects of seasonality on fracture risk across age and fracture sites using a large-scale population database of fracture incidence. Fracture data were accumulated over a 3-year period in the region of Tokyo and in surrounding areas, which accounts for a total population of 42 million. Information on fracture occurrence, fracture site, and patient demographics were obtained from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). Over the study period, 508,051 fractures were identified across the following five age groups: 0-19, 20-39, 40-64, 65-79, and 80+ years. The incidence rate for fractures in 10 site groups was calculated. Fracture risk was the highest in the spring and autumn for children aged 0-19 years and was the highest in the winter for elderly individuals (65-79 and 80+ years). Toe fractures, which occurred more frequently in the summer, were the most notable exception. The risk of fracture of the distal radius and hip was associated with daily temperature and rainfall and was elevated on days with a mean temperature higher than that of the previous day. Fracture risk exhibited seasonal variations that differed between children and elderly individuals and between toe fractures and fractures at other sites. These findings can help us understand the epidemiology of fractures and develop preventive strategies, as well as aid in the allocation of healthcare resources.

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register

BACKGROUND

Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study.

METHODS

A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register.

RESULTS

A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients' accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h.

CONCLUSION

Safety measures to prevent fall at elderly patient's accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.

Season of the year influences infection rates following total hip arthroplasty

AIM

To research the influence of season of the year on periprosthetic joint infections.

METHODS

We conducted a retrospective review of the entire Medicare files from 2005 to 2014. Seasons were classified as spring, summer, fall or winter. Regional variations were accounted for by dividing patients into four geographic regions as per the United States Census Bureau (Northeast, Midwest, West and South). Acute postoperative infection and deep periprosthetic infections within 90 d after surgery were tracked.

RESULTS

In all regions, winter had the highest incidence of periprosthetic infections (mean 0.98%, SD 0.1%) and was significantly higher than other seasons in the Midwest, South and West (P < 0.05 for all) but not the Northeast (P = 0.358). Acute postoperative infection rates were more frequent in the summer and were significantly affected by season of the year in the West.

CONCLUSION

Season of the year is a risk factor for periprosthetic joint infection following total hip arthroplasty (THA). Understanding the influence of season on outcomes following THA is essential when risk-stratifying patients to optimize outcomes and reduce episode of care costs.

Validation of FRAX and the impact of self-reported falls among elderly in a general population: the HUNT study, Norway

Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) for hip fracture prediction was validated in a Norwegian population 50-90 years. Fracture risk increased with higher FRAX score, and the observed number of hip fractures agreed well with the predicted number, except for the youngest and oldest men. Self-reported fall was an independent risk factor for fracture in women.

INTRODUCTION

The primary aim was to validate FRAX without BMD for hip fracture prediction in a Norwegian population of men and women 50-90 years. Secondary, to study whether information of falls could improve prediction of fractures in the subgroup aged 70-90 years.

METHODS

Data were obtained from the third survey of the Nord-Trøndelag Health Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database (NorPD), including 15,432 women and 13,585 men. FRAX hip without BMD was calculated, and hip fractures were registered for a median follow-up of 5.2 years. The number of estimated and observed fractures was assessed, ROC curves with area under the curve (AUC), and Cox regression analyses. For the group aged 70-90 years, self-reported falls the last year before HUNT3 were included in the Cox regression model.

RESULTS

The risk of fracture increased with higher FRAX score. When FRAX groups were categorized in a 10-year percentage risk for hip fracture as follows, <4, 4-7.9, 8-11.9, and ≥12%, the hazard ratio (HR) for hip fracture between the lowest and the highest group was 17.80 (95% CI: 12.86-24.65) among women and 23.40 (13.93-39.30) in men. Observed number of hip fractures agreed quite well with the predicted number, except for the youngest and oldest men. AUC was 0.81 (0.78-0.83) for women and 0.79 (0.76-0.83) for men. Self-reported fall was an independent risk factor for fracture in women (HR 1.64, 1.20-2.24), and among men, this was not significant (1.09, 0.65-1.83).

CONCLUSIONS

FRAX without BMD predicted hip fracture reasonably well. In the age group 70-90 years, falls seemed to imply an additional risk among women.

Is the association between hip fractures and seasonality modified by influenza vaccination? An ecological study

Osteoporotic hip fractures in 4344 patients were more common during winter. Lower temperatures were associated with higher rates of fracture only in those not vaccinated for influenza. Influenza outbreaks increased the risk of hip fractures. Further studies are needed to assess whether influenza vaccination can prevent hip fractures.

INTRODUCTION

Winter seasonality of osteoporotic hip fracture incidence has been demonstrated, yet the explanation for the association is lacking. We hypothesize that the seasonality of osteoporotic hip fracture can be explained by an association between hip fractures and seasonal influenza outbreaks.

METHODS

This retrospective cohort study included all patients admitted to Soroka University Medical Center with a diagnosis of osteoporotic hip fracture (ICD-9 code 820) between the years 2001 and 2013. Patients with malignancies, trauma, and age under 50 were excluded. In a time series analysis, we examined the association between hip fracture incidence and seasonality adjusted for meteorological factors, and population rates of influenza infection and vaccination using Poisson models.

RESULTS

Four thousand three hundred forty-four patients with a hip fracture were included (69% females, mean age 78). Daily fracture rates were significantly higher in winter (1.1 fractures/day) compared to summer, fall, and spring (0.79, 0.90, and 0.91; p < 0.001). In analysis adjusted for seasons and spline function of time, temperatures were associated with hip fractures risk only in those not vaccinated for influenza (n = 2939, for every decrease of 5 °C, RR 1.08, CI 1.02-1.16; p < 0.05). In subgroup analysis during the years with weekly data on national influenza rates (2010-2013), the risk for hip fracture, adjusted for seasons and temperature, was 1.26 2 weeks following a week with high infection burden (CI 1.05;1.51 p = 0.01), while the temperature was not significantly associated with the fracture risk.

CONCLUSIONS

Under dry and warm desert climate, winter hip fracture incidence increase might be associated with influenza infection, and this effect can be negated by influenza vaccination.

Psychotropics and weak opioid analgesics in plasma samples of older hip fracture patients - detection frequencies and consistency with drug records

AIMS

To determine use of psychotropic drugs and weak opioids in hip fracture patients by analysing plasma samples at admission, and compare detected drug frequencies with prescription registry data and drug records.

METHODS

Plasma from 250 hip fracture patients aged ≥65 years sampled at hospital admission were analysed by ultra-performance liquid chromatography-tandem mass spectrometry methods for detection of psychotropic drugs and weak opioid analgesics (alcohol also determined). Odds ratios for drugs detected in plasma of hip fracture patients vs. prescription frequencies of the same drugs in an age-, time- and region-matched reference population were calculated. Moreover, recorded and measured drugs were compared.

RESULTS

Psychotropic drugs and/or weak opioid analgesics were detected in 158 (63%) of the patients (median age 84 years; 76% females), while alcohol was found in 19 patients (7.6%). The occurrence of diazepam (odds ratio 1.6; 95% confidence interval 1.1-2.4), nitrazepam (2.3; 1.3-4.1), selective serotonin reuptake inhibitors (1.9; 1.3-2.9) and mirtazapine (2.3; 1.2-4.3) was significantly higher in plasma samples of hip fracture patients than in prescription data from the reference population. Poor consistency between recorded and measured drugs was disclosed for z-hypnotics and benzodiazepines; e.g. diazepam was detected in 29 (11.6%), but only recorded in six (2.4%) of the patients.

CONCLUSIONS

Plasma analysis shows that use of antidepressants and benzodiazepines in hip fracture patients is significantly more frequent than respective prescription frequencies in the general elderly population. Moreover, consistency between recorded and actual use of psychotropic fall-risk drugs is poor at hospital admission of hip fracture patients.

Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003-2014

Objectives

to describe the secular trend and seasonal variation in the incidence of hip fracture (HF) over 12 years (2003-2014) in Catalonia, the community with the highest incidence of HF in Spain.

Methods

data about age, gender, type of fracture and month of hospitalisation among patients aged 65 years and older discharged with a diagnosis of HF were collected. Crude and age-standardised annual incidence rate were reckoned. To analyse HF trend, the age/sex-adjusted average annual change in incidence (incidence rate ratio, IRR) was calculated.

Results

we identified 100,110 HF in the period, with an increase of 16.9% (women 13.4%; men 28.4%). Trochanteric fractures were the most frequent (55.8%). The crude incidence rate (per 100,000 population) decreased from 677.2 (95% confidence interval (95% CI) 662.0-692.7) to 657.6 (95% CI 644.0-671.5). The standardised incidence rate decreased from 754.0 (95% CI 738.6-769.3) to 641.5 (95% CI 627.7-655.3), with a sharp decrease in women (-16.8%) while it was stable in men. The incidence by type of fracture was stable. The trend throughout the period showed a slight decrease with IRR 0.99 (95% CI 0.98-0.99; P = 0.025). The incidence was stable in the oldest group (+85 years), while there was a downward trend in the younger groups. A significant seasonal pattern was observed, with more cases in winter and less in summer (spring as reference).

Conclusions

the secular trend reveals a decreasing incidence of HF although the absolute number has increased in the last 12 years in Catalonia. Trochanteric fractures were the most prevalent and a seasonal pattern was observed, with more cases in winter.

A combination of low serum concentrations of vitamins K1 and D is associated with increased risk of hip fractures in elderly Norwegians: a NOREPOS study

The present study investigated the risk of incident hip fractures according to serum concentrations of vitamin K1 and 25-hydroxyvitamin D in elderly Norwegians during long-term follow-up. The results showed that the combination of low concentrations of both vitamin D and K1 provides a significant risk factor for hip fractures.

INTRODUCTION

This case-cohort study aims to investigate the associations between serum vitamin K1 and hip fracture and the possible effect of 25-hydroxyvitamin D (25(OH)D) on this association.

METHODS

The source cohort was 21,774 men and women aged 65 to 79 years who attended Norwegian community-based health studies during 1994-2001. Hip fractures were identified through hospital registers during median follow-up of 8.2 years. Vitamins were determined in serum obtained at baseline in all hip fracture cases (n = 1090) and in a randomly selected subcohort (n = 1318). Cox proportional hazards regression with quartiles of serum vitamin K1 as explanatory variable was performed. Analyses were further performed with the following four groups as explanatory variable: I: vitamin K1 ≥ 0.76 and 25(OH)D ≥ 50 nmol/l, II: vitamin K1 ≥ 0.76 and 25(OH)D < 50 nmol/l, III: vitamin K1 < 0.76 and 25(OH)D ≥ 50 nmol/l, and IV: vitamin K1 < 0.76 and 25(OH)D < 50 nmol/l.

RESULTS

Age- and sex-adjusted analyses revealed an inverse association between quartiles of vitamin K1 and the risk of hip fracture. Further, a 50 % higher risk of hip fracture was observed in subjects with both low vitamin K1 and 25(OH)D compared with subjects with high vitamin K1 and 25(OH)D (HR 1.50, 95 % CI 1.18-1.90). The association remained statistically significant after adjusting for body mass index, smoking, triglycerides, and serum α-tocopherol. No increased risk was observed in the groups low in one vitamin only.

CONCLUSION

Combination of low concentrations of vitamin K1 and 25(OH)D is associated with increased risk of hip fractures.

Risk factors for hip fracture in very old people: a population-based study

SUMMARY

Knowledge of risk factors for hip fracture among very old people is limited. Walking indoors with help from ≤1 person, Parkinson's disease, currently smoking, delirium in the previous month, underweight, and age were associated with increased risk of hip fracture and could be important for preventive strategy development.

INTRODUCTION

The purpose of this study is to investigate risk factors for hip fracture among a representative sample of very old people.

METHODS

In total, 953 participants from the Umeå 85+/Gerontological Regional Database population-based cohort study were interviewed and assessed during home visits. Associations of baseline characteristics with hip fracture during the maximum 5-year follow-up period were analyzed using Cox proportional hazards regression.

RESULTS

Participants had a mean age of 89.3 ± 4.7 years; 65.8% were women, 36.8% lived in residential care facilities, 33.6% had dementia, and 20.4% had histories of hip fracture. During a mean follow-up period of 2.7 years, 96 (10.1%) individuals sustained hip fracture. Walking indoors with help from no more than one person (hazard ratio [HR] = 8.57; 95% confidence interval [CI], 1.90-38.71), Parkinson's disease (HR = 5.12; 95% CI, 1.82-14.44), currently smoking (HR = 4.38; 95% CI 2.06-9.33), delirium in the previous month (HR = 2.01; 95% CI, 1.15-3.49), underweight (body mass index <22; HR = 1.74, 95% CI, 1.09-2.77), and age (HR = 1.09; 95% CI, 1.04-1.14) were associated independently with an increased risk of hip fracture. Hip prosthesis at baseline decreased the risk of hip fracture (HR = 0.37; 95% CI, 0.15-0.91), but only for those with bilateral hip prostheses.

CONCLUSIONS

Seven factors were associated independently with incident hip fracture during follow-up in this sample of very old people. These factors could have important clinical implications in identifying persons at high risk of hip fracture, as well as in the development of effective preventive strategies.

Forearm fractures in Central Norway, 1999-2012: incidence, time trends, and seasonal variation

The incidence of forearm fractures for men and women ≥40 years in Central Norway was high during the period 1999-2012. A decline in fractures was observed only among women over 50 years. A seasonal variation with highest incidence in the winter months was found among women.

PURPOSE

The aim of this study was to examine the incidence of forearm fractures in Central Norway in men and women 40 years and older from 1999 to 2012 and assess time trends as well as seasonal variations.

METHODS

Data is from the fracture registry in Nord-Trøndelag, including all forearm fractures in persons ≥40 sustained from 1999 to 2012. Annual incidence of forearm fractures were calculated and tested for trends. Variations in the occurrence of fractures were explored by comparing proportion of fractures by month and seasons.

RESULTS

The study population consisted of 4003 subjects (77.1% women). The total number of fractures were 4240. There was an increase in fractures for women with increasing age, steepest, a three-fold increase between age group 40-50 and the age group 50-60. Among men, this pattern was not observed as incidences did not change with increasing age. The age-standardized incidence rate for all fractures among women ≥50 ranged from 82 fractures per 1000 (95% CI 71-94) to 100 (88-114) and among men from 19 (14-27) to 31 (24-39). Restricting the analysis to the first fracture sustained during the observed period, women ≥50 years showed a reduction in fractures of 1.30% per year (95% CI 0.01%: 2.56%,) and 12.18% per 10 years (3.61%: 19.98%). For all women, there was a trend towards a decline of 0.73% per year (-2.29%: 0.85%), although not significant. For men, there was a trend towards an increase in fractures of 1.66% per year (-0.11%: 3.45%). The occurrence of fractures among women varied by season of the year, with higher fracture rates in the winter months.

CONCLUSIONS

The incidence rate of forearm fractures in Central Norway was high. However, a small decline in the incidence of the first fracture among women older than 50 years was observed. Fractures were more often sustained during winter months among women.

[Seasonal distribution of clinical case codes (DOC study)]

OBJECTIVES

The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management.

METHODS

From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA.

RESULTS

The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1).

CONCLUSION

The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

Use of anti-osteoporotic drugs in central Norway after a forearm fracture

Use of anti-osteoporotic drugs (AOD) the first year after a forearm fracture in central Norway was low in the period 2005-2012. Women with fractures used more AOD compared to the general population only in 2006, 2007, and 2011. Female gender, age ≥ 60 years, use of glucocorticosteroids, or ≥ 4 different drugs were associated with AOD use.

PURPOSE

The primary aim of this study was to examine time trends in prevalence and incidence of AOD use the first year after a forearm fracture from 2005-2012. Further, secondary aims were to investigate if gender, the number of drugs used before fracture, or use of glucocorticoids influenced the prescription of AOD, and to examine adherence to AOD.

METHODS

Data is from the fracture registry in Nord-Trøndelag and the Norwegian Prescription database, including women (N = 1434) and men (N = 513) 40-84 years with their first forearm fracture between 2005 and 2012. AOD were defined as bisphosphonates, teriparatide, denosumab, and raloxifene. Prevalence and incidence were calculated, and prevalent use among women with forearm fracture was compared with the population in Nord-Trøndelag and Norway. Age-adjusted Poisson regression analyses for time trends and odds ratio for treatment with AOD was estimated. Adherence was defined as medication possession ratio ≥ 80 %.

RESULTS

The first year after the fracture, 11.2 % of the women and 2.7 % of the men were prevalent users, while 5.1 % and 1.2 %, respectively, were incident users of AOD. Bisphosphonates comprised 98.8 %. AOD use among women with fractures was significantly higher compared to the general population in Nord-Trøndelag only in 2006, 2007, and 2011. There was a trend towards a decline in AOD use among women with fractures from 2005 to 2012 (coefficient -0.05, p = 0.15). Female gender, age ≥ 60 years, use of glucocorticosteroids, or ≥ 4 different drugs the last year before fracture were associated with AOD use. In women, 54.8 % were adherent during 3 years after fracture.

CONCLUSIONS

The use of AOD after a forearm fracture was low. An increased focus on osteoporosis in fracture patients is needed for secondary fracture prevention.

Weather warnings predict fall-related injuries among older adults

BACKGROUND

weather predictions are a useful tool for informing public health planning and prevention strategies for non-injury health outcomes, but the association between winter weather warnings and fall-related injuries has not been assessed previously.

OBJECTIVE

to examine the association between fall-related injuries among older adults and government-issued winter weather warnings.

METHODS

using a dynamic cohort of individuals ≥65 years of age who lived in Montreal between 1998 and 2006, we identified all fall-related injuries from administrative data using a validated set of diagnostic and procedure codes. We compared rates of injuries on days with freezing rain or snowstorm warnings to rates observed on days without warnings. We also compared the incidence of injuries on winter days to non-winter days. All analyses were performed overall and stratified by age and sex.

RESULTS

freezing rain alerts were associated with an increase in fall-related injuries (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI]: 1.08-1.32), particularly among males (IRR = 1.31, 95% CI: 1.10-1.56), and lower rates of injuries were associated with snowstorm alerts (IRR = 0.89, 95% CI: 0.80-0.99). The rate of fall-related injuries did not differ seasonally (IRR = 1.00, 95% CI: 0.97-1.03).

CONCLUSIONS

official weather warnings are predictive of increases in fall-related injuries among older adults. Public health agencies should consider using these warnings to trigger initiation of injury prevention strategies in advance of inclement weather.

Epidemiology of proximal humerus fractures

There are only a few previous population-based studies that include both inpatient and outpatient treatment data. The aim of this study was to investigate the epidemiology of proximal humerus fractures. The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months.

PURPOSE

Proximal humerus fractures are the third most common osteoporotic fracture type observed in elderly patients, after wrist and hip fractures. However, few previous population-based studies include both inpatient and outpatient treatment data. The aim of this study was to investigate the incidence, fracture morphology, and treatment method provided in cases of proximal humerus fractures.

METHODS

We retrospectively studied patient records from a mid-sized town in Finland between the years 2006 and 2010. The following data were collected from the medical records: age, sex, date of the fracture, laterality of the fracture, mechanism of injury, treatment method, and other associated fractures at the time of the original injury. Sex and age distributions of the patient population at risk (>18 years old) were calculated for the study period.

RESULTS

A total of 678 patients (females n = 503, 73 %) with 692 proximal humerus fractures were identified. The unadjusted incidence was 82 (95 % CI 76 to 88) per 100,000 person-years, 114 (95 % CI 104 to 124), and 47 (95 % CI 41 to 54) per 100,000 person-years in females and males, respectively. Incidence increased toward the older age groups. Clear seasonal variation was observed, two-part fractures were most common (428, 62 %), the majority of the fractures (n = 539, 78 %) were treated nonoperatively with a sling.

CONCLUSION

The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. It is evident that proximal humerus fractures cause considerable morbidity among elderly people and consume health care resources.

The incidence of hip fractures in Norway -accuracy of the national Norwegian patient registry

Background

Hip fractures incur the greatest medical costs of any fracture. Valid epidemiological data are important to monitor for time-dependent changes. In Norway, hip fractures are registered in the Norwegian Patient Registry (NPR), but no published national validation exists. The aim of the present study was a national validation of NPR as a register for hip fractures using diagnostic codes (ICD-10 S 72.0-2) and/or procedure codes (NOMESCO version 1.14 NFBxy (x = 0-9, y = 0-2) or NFJxy (x = 0-9, y = 0-2).

Method

A nationwide, population-based cohort comprising a random sub-sample of 1,000 hip fracture-related entries for the years 2008–09 was drawn from the NPR. 200 entries were defined by a combination of diagnostic and procedure codes (subsample 1), 400 entries were defined by diagnostic codes only (subsample 2) and 400 entries were defined by procedure codes only (subsample 3). Accuracy was ascertained through comparison with discharge summaries, procedure notes and X-ray reports requested from 40 health institutions. Comparisons between groups were done by chi² for categorical and t-test for continuous variables.

Results

792 health records from 32 institutions were reviewed. High accuracy (98.2%, 95% C.I. 96.5-99.9%) was found for subsample 1, a combination of diagnostic and procedure codes. Coding errors were prominent in other subsamples. Defining fractures by a combination of diagnostic and procedure codes, annual average hip fracture incidence in Norway was 9,092 (95% C.I. 8,934 -9,249), excluding only 6.5% of all hip fractures defined by wider definitions.

Conclusions

Based on current coding practice in Norway, a reliable national estimate of hip fracture incidences is found by a combination of relevant ICD-10 and NOMESCO codes in the NPR. This method may be used for monitoring epidemiological changes.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-372) contains supplementary material, which is available to authorized users.

Low serum concentrations of alpha-tocopherol are associated with increased risk of hip fracture. A NOREPOS study

We investigated the risk of hip fracture according to circulating alpha-tocopherol, a plant-derived substance with antioxidant properties, in community-dwelling older Norwegians. We found a linear increasing risk of hip fracture with lower serum alpha-tocopherol concentrations, with a 51% higher risk in the lowest compared to the highest quartile.

INTRODUCTION

Oxidative stress is a suggested contributing cause of osteoporosis and fractures. Vitamin E (α-tocopherol) has potent antioxidant properties in humans. The relationship between circulating α-tocopherol and fracture risk is not established. The aim of this study was to investigate the association between serum α-tocopherol concentrations and risk of hip fracture during up to 11 years of follow-up.

METHODS

We performed a case-cohort analysis among 21,774 men and women aged 65-79 years who participated in four community-based health studies in Norway 1994-2001. Serum α-tocopherol concentrations at baseline were determined in 1,168 men and women who subsequently suffered hip fractures (median follow-up 8.2 years) and in a random sample (n = 1,434) from the same cohort. Cox proportional hazard regression adapted for gender-stratified case-cohort data was performed.

RESULTS

Median (25, 75 percentile) serum α-tocopherol was 30.0 (22.6, 38.3) μmol/L, and it showed a linear inverse association with hip fracture: hazard ratio (HR) 1.11 (95% confidence interval (CI) 1.04-1.20) per 10-μmol/L decrease in serum α-tocopherol, adjusted for gender and study center. The lowest compared to the highest quartile conferred an HR of 1.51 (95% CI 1.17-1.95), adjusted for gender and study center. Adjustment for smoking, month of blood sample, BMI, education, physical inactivity, self-rated health, and serum 25-hydroxyvitamin D (25(OH)D) yielded similar results. Taking serum total cholesterol concentration into account attenuated the association somewhat: HR of hip fracture was 1.37 (95% CI 1.05-1.77) in first versus fourth quartile of serum α-tocopherol/total cholesterol ratio.

CONCLUSIONS

Low serum concentrations of α-tocopherol were associated with increased risk of hip fracture in older Norwegians.

Cohort profile: Norwegian Epidemiologic Osteoporosis Studies (NOREPOS)

AIMS

This paper describes the history, purpose, data collection and contributions in the research collaboration Norwegian Osteoporosis Epidemiologic Studies (NOREPOS).

METHODS

NOREPOS encompasses almost 85,000 bone mineral density measurements within Cohort of Norway and data on almost 140,000 hip fractures in Norway 1994-2008. Included are anthropometric measurements, blood pressure, lipids and glucose, and 50 standard questions on sociodemographic factors, diseases and risk factors. Blood samples/DNA are stored. The main research question posed in NOREPOS is why hip fracture rates in Norway are the highest in the world. Data on hip fractures 2009-2013 will be added in 2014.

RESULTS

Main findings include: Every hour a Norwegian suffers a hip fracture; hip fracture incidence rates declined after 1999; only 16% of patients used anti-osteoporosis drugs 1 year after hip fracture; 25% of patients died within 1 year after the fracture; 12% suffered a new hip fracture within 10 years; rural dwellers had lower hip and forearm fracture incidence than city dwellers; magnesium in tap water may be protective whereas bacterial contamination, cadmium and lead may be harmful to bone health; low serum vitamin D and E levels were associated with higher hip fracture risk; vitamin A was not associated with fracture risk; and abdominal obesity increased the risk of hip fracture when BMI was accounted for.

CONCLUSIONS

NOREPOS encompasses a unique source of information for aetiological research, genetic studies as well as for biomarkers of osteoporosis and fractures. Because of the increasing number of elderly people in Europe, hip fractures will continue to pose an international public health and health care challenge.

The effect of latitude on the risk and seasonal variation in hip fracture in Sweden

Although the optimal requirement of vitamin D for skeletal health in the general community is controversial, vitamin D deficiency impairs bone mineralization and increases bone turnover via secondary hyperparathyroidism, thus accelerating bone loss and increasing fracture risk. Support for a role of vitamin D deficiency in the epidemiology of hip fracture is found in the seasonal variation of hip fracture incidence that is reported in several studies. If the association were causal, then the incidence and amplitude of the seasonal variation in hip fracture risk should vary by latitude. We addressed this hypothesis by examining the incidence of hip fracture in men and women aged 50 years or more from Sweden (latitudes 55 to 69°) between 1987 and 2009. In order to reduce double counting, only one fracture in a period of a year was counted per individual. Men contributed 104,888 fractures in 33,313,065 person years and women 264,362 fractures in 38,387,660 person years. The effects of season and latitude were examined by Poisson regression. As expected, hip fracture rates were higher in women than in men. After adjustment for age, season and population density, hip fracture incidence increased by 3.0% (95% CI: 2.7-3.2%) per degree increase in latitude for men and by 1.9% (95% CI: 1.8-2.1%) for women. There was a marked seasonal variation of hip fracture with the highest risk in February and lower by 37.5% in men and by 23.5% women during the summer. There were significant interactions of amplitude of the seasonal variation with latitude (p < 0.001 for both men and women), indicating that seasonal variation during the year was more pronounced in the north of Sweden than in the south. The associations found with latitude and season is consistent with a role of vitamin D in hip fracture causation.

Impact of comorbidity, age, and gender on seasonal variation in hip fracture incidence. A NOREPOS study

Based on a total of 136,140 hip fractures, we found a distinct seasonal variation in hip fracture incidence present in subgroups defined by age, gender, and comorbidity. The seasonal variation was most pronounced in the youngest and the healthiest patients.

PURPOSE

The purpose of this study was to examine the possible seasonal variation in hip fracture incidence in Norway by comorbidity, age, and gender.

METHODS

Data were retrieved from the NOREPOS Hip Fracture Database containing all hip fractures in Norway during the time period 1994-2008. Hip fractures were identified by computerized hospital discharge diagnoses. Charlson comorbidity index was calculated based on additional diagnoses and categorized (0, 1, and ≥2). Summer was defined as June, July, and August and winter as December, January, and February. Incidence rate ratios for hip fracture according to season were calculated by negative binomial models.

RESULTS

In patients aged 50-103 years, 136,140 eligible fractures were identified (72.5 % women). The relative risk of hip fracture in winter versus summer was 1.40 (95 % confidence interval (CI) 1.36-1.45) in men and 1.26 (95 % CI 1.23-1.28) in women. June had the lowest number of fractures in both genders. We found seasonal variation in all subgroups by age and gender, although least pronounced in patients >79 years. There was a significant interaction between season and comorbidity (p = 0.022). When comparing winter to summer, we found relative risks of 1.40 (95 % CI 1.31-1.50) in patients with Charlson index = 0, 1.29 (95 % CI 1.19-1.40) in patients with Charlson index = 1, and 1.18 (95 % CI 1.08-1.28) in patients with Charlson index ≥2.

CONCLUSIONS

There was a distinct seasonal variation in hip fracture incidence, present in all subgroups of gender, age, or comorbidity. This variation should be accounted for when planning health-care services.

Modeling climate effects on hip fracture rate by the multivariate GARCH model in Montreal region, Canada

Changes in extreme meteorological variables and the demographic shift towards an older population have made it important to investigate the association of climate variables and hip fracture by advanced methods in order to determine the climate variables that most affect hip fracture incidence. The nonlinear autoregressive moving average with exogenous variable-generalized autoregressive conditional heteroscedasticity (ARMAX-GARCH) and multivariate GARCH (MGARCH) time series approaches were applied to investigate the nonlinear association between hip fracture rate in female and male patients aged 40-74 and 75+ years and climate variables in the period of 1993-2004, in Montreal, Canada. The models describe 50-56% of daily variation in hip fracture rate and identify snow depth, air temperature, day length and air pressure as the influencing variables on the time-varying mean and variance of the hip fracture rate. The conditional covariance between climate variables and hip fracture rate is increasing exponentially, showing that the effect of climate variables on hip fracture rate is most acute when rates are high and climate conditions are at their worst. In Montreal, climate variables, particularly snow depth and air temperature, appear to be important predictors of hip fracture incidence. The association of climate variables and hip fracture does not seem to change linearly with time, but increases exponentially under harsh climate conditions. The results of this study can be used to provide an adaptive climate-related public health program and ti guide allocation of services for avoiding hip fracture risk.

Insights from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

GLOW is an observational, longitudinal, practice-based cohort study of osteoporosis in 60,393 women aged ≥55 years in 10 countries on three continents. In this Review, we present insights from the first 3 years of the study. Despite cost analyses being frequently based on spine and hip fractures, we found that nonvertebral, nonhip fractures were around five times more common and doubled the use of health-care resources compared with hip and spine fractures combined. Fractures not at the four so-called major sites in FRAX(®) (upper arm, forearm, hip and clinical vertebral fractures) account for >40% of all fractures. The risk of fracture is increased by various comorbidities, such as Parkinson disease, multiple sclerosis and lung and heart disease. Obesity, although thought to be protective against all fractures, substantially increased the risk of fractures in the ankle or lower leg. Simple assessment by age plus fracture history has good predictive value for all fractures, but risk profiles differ for first and subsequent fractures. Fractures diminish quality of life as much or more than diabetes mellitus, arthritis and lung disease, yet women substantially underestimate their own fracture risk. Treatment rates in patients at high risk of fracture are below those recommended but might be too frequent in women at low risk. Comorbidities and the limits of current therapeutic regimens jeopardize the efficacy of drugs; new regimens should be explored for severe cases.

Incidence rates and trends of hip/femur fractures in five European countries: comparison using e-healthcare records databases

Hip fractures represent a major public health challenge worldwide. Multinational studies using a common methodology are scarce. We aimed to estimate the incidence rates (IRs) and trends of hip/femur fractures over the period 2003-2009 in five European countries. The study was performed using seven electronic health-care records databases (DBs) from Denmark, The Netherlands, Germany, Spain, and the United Kingdom, based on the same protocol. Yearly IRs of hip/femur fractures were calculated for the general population and for those aged ≥50 years. Trends over time were evaluated using linear regression analysis for both crude and standardized IRs. Sex- and age-standardized IRs for the UK, Netherlands, and Spanish DBs varied from 9 to 11 per 10,000 person-years for the general population and from 22 to 26 for those ≥50 years old; the German DB showed slightly higher IRs (about 13 and 30, respectively), whereas the Danish DB yielded IRs twofold higher (19 and 52, respectively). IRs increased exponentially with age in both sexes. The ratio of females to males was ≥2 for patients aged ≥70-79 years in most DBs. Statistically significant trends over time were only shown for the UK DB (CPRD) (+0.7% per year, P < 0.01) and the Danish DB (-1.4% per year, P < 0.01). IRs of hip/femur fractures varied greatly across European countries. With the exception of Denmark, no decreasing trend was observed over the study period.

The epidemiology of paediatric supracondylar fracture fixation: a population-based study

INTRODUCTION

The epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation.

METHODS

Using administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively.

RESULTS

A total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000 person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0-20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0-8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9-1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8-1.0)).

CONCLUSIONS

While SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months.

Epidemiology of fractures in Iceland and secular trends in major osteoporotic fractures 1989-2008

The incidence of the most common fracture types in Iceland is reported based on individual data from the Reykjavik Study 1967-2008. Time trend is reported for the major osteoporotic fractures (MOS) 1989-2008.

INTRODUCTION

This study aims to assess the incidence of all fractures in Iceland, with emphasis on the rate of hip fractures, and compare the incidence with other populations as well as examine the secular changes.

METHODS

Individuals from the prospective population-based cohort Reykjavik Study were examined between 1967 and 2008 (follow-up 26.5 years), which consisted of 9,116 men and 9,756 women born in 1907-1935, with age range 31-81 years. First fracture incidence was estimated using life table methods with age as the timescale.

RESULTS

Fracture rate increased proportionally with age between the sexes for vertebral and proximal humerus but disproportionally for hip and distal forearm fractures. The ratio of first fracture incidence between the sexes varied considerably by site: 2.65 for hip fractures and the highest for distal forearm fractures at 4.83. By the age of 75, 36.7% of women and 21% of men had sustained a fracture, taking into account competing risk of death. The incidence of hip fractures was similar to results previously published from USA, Sweden, Norway, and Scotland. The incidence of MOS fractures in both sexes decreased over the last decade, except hip fractures in men, which remained unchanged, as reflected in the women/men ratio for the hip, which changed from 2.6 to 1.7.

CONCLUSION

This study adds information to scarce knowledge on the relative fracture incidence of different fractures. The incidence of MOS fractures increased in the latter part of the last century in both sexes and declined during the last decade, less dramatically for men. This information is important for planning health resources.

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

INTRODUCTION

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

METHODS

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

RESULTS

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

CONCLUSION

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.

When, where and how osteoporosis-associated fractures occur: an analysis from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

Objective

To examine when, where and how fractures occur in postmenopausal women.

Methods

We analyzed data from the Global Longitudinal Study of Osteoporosis in Women (GLOW), including women aged ≥55 years from the United States of America, Canada, Australia and seven European countries. Women completed questionnaires including fracture data at baseline and years 1, 2 and 3.

Results

Among 60,393 postmenopausal women, 4122 incident fractures were reported (86% non-hip, non-vertebral [NHNV], 8% presumably clinical vertebral and 6% hip). Hip fractures were more likely to occur in spring, with little seasonal variation for NHNV or spine fractures. Hip fractures occurred equally inside or outside the home, whereas 65% of NHNV fractures occurred outside and 61% of vertebral fractures occurred inside the home. Falls preceded 68–86% of NHNV and 68–83% of hip fractures among women aged ≤64 to ≥85 years, increasing with age. About 45% of vertebral fractures were associated with falls in all age groups except those ≥85 years, when only 24% occurred after falling.

Conclusion

In this multi-national cohort, fractures occurred throughout the year, with only hip fracture having a seasonal variation, with a higher proportion in spring. Hip fractures occurred equally within and outside the home, spine fractures more often in the home, and NHNV fractures outside the home. Falls were a proximate cause of most hip and NHNV fractures. Postmenopausal women at risk for fracture need counseling about reducing potentially modifiable fracture risk factors, particularly falls both inside and outside the home and during all seasons of the year.

Urban versus rural differences in the occurrence of hip fractures in Japan's Kyoto prefecture during 2008-2010: a comparison of femoral neck and trochanteric fractures

BACKGROUND

To investigate the differences in the characteristics of femoral neck and trochanteric fractures between urban and rural areas of Kyoto Prefecture in Japan.

METHODS

Fracture type (neck vs. trochanteric), age, sex, place where fracture occurred (indoors vs. outdoors), and cause of injury were surveyed among patients aged ≥65 years who sustained hip fractures between 2008 and 2010 and who were treated at 1 of 13 participating hospitals (5 urban, 8 rural). The ratio of sick beds to total number of beds at the participating hospitals was 19.6% (2,188/11,158) in the urban area and 34.9% (1,963/5,623) in the rural area. We also investigated the incidence of hip fracture in Tango medical district as a representative rural area.

RESULTS

There were 1,346 neck (mean age, 82.4 years) and 1,606 trochanteric fractures (mean age, 85.0 years). The ratio of neck to trochanteric fractures was higher in the urban area than in the rural area in all age groups (65-74, 75-84, and ≥ 85 years). There were no apparent differences in place or cause of injury. The incidence of hip fracture in the women of Tango medical district was lower than the national average.

CONCLUSIONS

There was a difference in the ratio of neck to trochanteric fractures between urban and rural areas. This difference is estimated to be caused by the high and low incidence of neck fracture in urban and rural areas, respectively.

When and where do hip fractures occur? A population-based study

We investigated the effects of socio-demographic and health factors on timing and location of hip fracture among 484 subjects. Time of fracture varied between community dwellers and residential care facility dwellers, and in relation to subjects' psychotropic drug status. Indoor hip fracture incidence increased on snow-covered days.

INTRODUCTION

This paper aims to describe the timing and whereabouts of hip fracture cases in a population-based setting and to relate these factors with residential and health status, seasonal variation, and snow-covered ground.

METHODS

We consecutively included 484 incident hip fracture events (age ≥50 years) admitted to a Swedish orthopedic department during a 1-year period. Data concerning socio-demographic details, fall location, time of fracture, comorbidity, and medications were collected from in-patient medical records and through patient or caregiver interviews.

RESULTS

The expected peak in fracture occurrence during daytime was observed among community dwellers but not among subjects living in residential care. Hip fracture was twice as likely to occur during nighttime hours among psychotropic drug users (adjusted odds ratio (Adj. OR), 2.20; 95% confidence interval (CI), 1.12-4.30) compared to those not receiving these medications. Subjects without dementia, taking psychotropic drugs, were also more likely to fracture during nighttime hours (Adj. OR, 2.91; 95% CI, 1.40-6.0). We observed an increase in indoor hip fracture incidence on snow-covered days among community dwellers (incidence rate ratio, 1.34; 95% CI, 1.02-1.74). We observed only a weak seasonal trend in hip fracture incidence, based on month, among community dwellers who fractured indoors.

CONCLUSIONS

Special attention and possibly fall-preventive efforts should be directed not only toward those living in residential care facilities but also toward community-dwelling subjects taking psychotropic drugs since these groups have a higher incidence of nighttime hip fracture. Further research aiming to explain the seasonal variation of indoor fracture incidence among community dwellers is warranted.

Decreased skin temperature of the foot increases gait variability in healthy young adults

We investigated the effects of reduction in plantar skin temperature on gait. Thirty-four healthy subjects (20 men and 14 women; mean age 22.2±2.5 years; mean height 166.8±8.3cm) walked 16m under two different conditions - normal conditions (NC) with the skin at a basal temperature, and cold conditions (CC) after cooling of the plantar skin to about 15°C. Wireless motion-recording sensor units were placed on the back at the level of L3 and on both heels to measure acceleration and angular velocity. Gait velocity and mean stride, stance and swing times were calculated. The variability of lower limb movement was represented by the coefficients of variation (CVs) of stride, stance and swing times, and that of trunk movement was represented by autocorrelation coefficients (ACs) in three directions (vertical: VT; mediolateral: ML; and anteroposterior: AP). Gait velocity was significantly lower under CC conditions than under NC (p<0.0001). None of the temporal parameters were changed by plantar cooling. However, all parameters of gait variability were significantly worse under CC, and AC-VT, AC-ML, and AC-AP were significantly lower under CC than under NC, even after adjusting for gait velocity (p=0.0005, 0.0071, and 0.0126, respectively). Our results suggest that reducing plantar skin temperature induces gait variability among healthy young adults. Further studies are now needed to explore the relationship between plantar skin temperature and gait in the elderly.

Hip fractures in the United States: 2008 nationwide emergency department sample

OBJECTIVE

To evaluate the recent epidemiology of hip fractures in the US.

METHODS

We identified hip fracture cases from the 2008 Nationwide Emergency Department Sample, which contains more than 28 million emergency department (ED) records.

RESULTS

In 2008, approximately 341,000 (95% confidence interval 323,000-358,000) patients visited EDs with hip fractures. Of those, 90% were age >60 years. Between ages 60-85 years, the risk of fracture doubled for every 5- to 6-year increase in age. However, the hip fracture risk increased slowly after age 85 years. The overall trochanteric-to-cervical fracture ratio was nearly 2:1. The risk of trochanteric fracture increased faster with age compared with the risk of cervical fracture. At age 85 years, the rates of trochanteric and cervical fractures (per 100,000) were 1,300 and 700, respectively, among women and 800 and 500, respectively, among men.

CONCLUSION

The slowed growth of hip fracture risk after age 85 years suggests that the eldest old group may have a distinct hip fracture risk. Our study showed that trochanteric fractures were twice as common as cervical fractures. Because trochanteric fractures are more closely related to severe and generalized bone loss than cervical fractures, we hypothesize that the high incidence rate of trochanteric fractures in the US suggests that osteoporosis is a health problem that is linked to hip fracture. In addition to improved safety measures to reduce falls, rigorous preventive treatments of osteoporosis may be needed.

[Seasonal distribution of diagnoses and DRG in trauma surgery]

BACKGROUND

Recording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected.

PATIENTS AND METHODS

From 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled.

RESULTS

The most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer.

CONCLUSION

It has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.

Hip fractures in a city in Northern Norway over 15 years: time trends, seasonal variation and mortality : the Harstad Injury Prevention Study

In this open population-based study from Northern Norway, there was no increase in hip fracture incidence in women and men from 1994 to 2008. Age-adjusted hip fracture rates was lower compared to reported rates from the Norwegian capital Oslo, indicating regional differences within the country.

INTRODUCTION

The aim of the present population-based study was to describe age- and sex-specific incidence of hip fractures in a Northern Norwegian city, compare rates with the Norwegian capital Oslo, describe time trends in hip fracture incidence, place of injury, seasonal variation and compare mortality after hip fracture between women and men.

METHODS

Data on hip fractures from 1994 to 2008 in women and men aged 50 years and above were obtained from the Harstad Injury Registry.

RESULTS

There were altogether 603 hip fractures in Harstad between 1994 and 2008. The annual incidenc rose exponentially from 5.8 to 349.2 per 10,000 in men, and from 8.7 to 582.2 per 10,000 in women from the age group 50-54 to 90+ years. The age-adjusted incidence rates were 101.0 and 37.4 in women and men, respectively, compared to 118.0 in women (p = 0.005) and 44.0 in men (p = 0.09) in Oslo. The age-adjusted incidence rates did not increase between 1994-1996 and 2006-2008. The majority of hip fractures occurred indoors and seasonal variation was significant in fractures occurring outdoors only. After adjusting for age at hip fracture, mortality after fracture was higher in men than in women 3, 6 and 12 months (p ≤ 0.002) after fracture.

CONCLUSIONS

There are regional differences in hip fracture incidence that cannot be explained by a north-south gradient in Norway. Preventive strategies must be targeted to indoor areas throughout the year and to outdoor areas in winter.