Factors affecting the risk of hip fractures

Predictors of hip fracture in 15 European countries: a longitudinal study of 48,533 geriatric adults using SHARE dataset

We investigated the risk factors for hip fracture in 48,533 European older adults for 8 years from 2013 onward. We identified female gender, age above 80, low handgrip strength, and depression as significant risk factors for hip fracture. Our findings may help identify high-risk populations for hip fractures in pre-clinical settings.

OBJECTIVES

Hip fracture is a major cause of functional disability, mortality, and health costs. However, the identification and characterization of its causative factors remain poor.

METHODS

We investigated demography, handgrip strength (HGS), depression, and multiple age-associated comorbidities for predicting future hip fracture in individuals aged 50 or above from 15 European countries (n = 48,533). All participants were evaluated from 2013 to 2020 using four successive waves of the Survey of Health, Aging, and Retirement in Europe (SHARE).

RESULTS

Altogether, 1130 participants developed hip fractures during the study period. We identified female gender, an advancing age from quinquagenarians onward, and a poor socioeconomic status as critical risk factors for future hip fracture. Having mobility difficulty, a low HGS (< 27 kg in men, < 16 kg in women) and higher scores on Euro-D depression scales were also significant risk factors for hip fracture. Summated scales of hypertension, diabetes mellitus, cancer, Alzheimer's disease, and stroke did not appear as risk factors.

CONCLUSION

Collectively, we report advancing age, female gender, low HGS, and depression as independent risk factors for hip fracture. Our findings are useful in identifying high-risk populations for hip fractures in pre-clinical settings before rigorous evaluation and treatment in clinics.

Association between Smoking Status and the Risk of Hip Fracture in Patients with Type 2 Diabetes: A Nationwide Population-Based Study

BACKGRUOUND

Limited longitudinal evidence exists regarding the potential association between smoking status and hip fracture among individuals with type 2 diabetes. We investigated this association using large-scale, nationwide cohort data for the Korean population.

METHODS

This nationwide cohort study included 1,414,635 adults aged 40 and older who received Korean National Health Insurance Service health examinations between 2009 and 2012. Subjects with type 2 diabetes were categorized according to their smoking status, amount smoked (pack-years), number of cigarettes smoked per day, and duration of smoking. The results are presented as hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between smoking status parameters and risk of hip fracture in multivariable Cox proportional hazard regression analysis.

RESULTS

Compared with never-smokers, an increased adjusted HR (aHR) for hip fracture was observed in current smokers (1.681; 95% CI, 1.578 to 1.791), and a comparable aHR for hip fracture was found in former smokers (1.065; 95% CI, 0.999 to 1.136). For former smokers who had smoked 20 pack-years or more, the risk was slightly higher than that for never-smokers (aHR, 1.107; 95% CI, 1.024 to 1.196). The hip fracture risk of female former smokers was similar to that of female current smokers, but the hip fracture risk in male former smokers was similar to that of male never-smokers.

CONCLUSION

Smoking is associated with an increased risk of hip fracture in patients with type 2 diabetes. Current smokers with diabetes should be encouraged to quit smoking because the risk of hip fracture is greatly reduced in former smokers.

Recent advances in the identification of related factors and preventive strategies of hip fracture

Hip fracture is the most devastating type of osteoporosis-related fracture, and is a major worldwide public health problem with a high socioeconomic burden, morbidity rate, and mortality rate. Thus, it is crucial to uncover the risk factors and protective factors to create a hip fracture prevention strategy. In addition to a briefly review of some well accepted risk and protective factors of hip fracture, this review mainly summarized the recent advances in the identification of emerging risk or protective factors for hip fracture, in terms of regional differences in medical services, diseases, drugs, mechanical load, neuromuscular mass, genes, blood types, cultural differences. This review provides a comprehensive review of the associated factors and effective prevention measures for hip fracture, and discusses issues that need further investigation. These issues include the determination of the influencing mechanism of risk factors triggering hip fracture and their interlinked correlation with other factors, as well as the confirmation or correction of emerging factors associated with hip fracture, particularly those that are still controversial. These recent findings will aid in optimizing the strategy for preventing hip fracture.

Risk of hip fracture in meat-eaters, pescatarians, and vegetarians: results from the UK Women's Cohort Study

BACKGROUND

The risk of hip fracture in women on plant-based diets is unclear. We aimed to investigate the risk of hip fracture in occasional meat-eaters, pescatarians, and vegetarians compared to regular meat-eaters in the UK Women's Cohort Study and to determine if potential associations between each diet group and hip fracture risk are modified by body mass index (BMI).

METHODS

UK women, ages 35-69 years, were classified as regular meat-eaters (≥ 5 servings/week), occasional meat-eaters (< 5 servings/week), pescatarian (ate fish but not meat), or vegetarian (ate neither meat nor fish) based on a validated 217-item food frequency questionnaire completed in 1995-1998. Incident hip fractures were identified via linkage to Hospital Episode Statistics up to March 2019. Cox regression models were used to estimate the associations between each diet group and hip fracture risk over a median follow-up time of 22.3 years.

RESULTS

Amongst 26,318 women, 822 hip fracture cases were observed (556,331 person-years). After adjustment for confounders, vegetarians (HR (95% CI) 1.33 (1.03, 1.71)) but not occasional meat-eaters (1.00 (0.85, 1.18)) or pescatarians (0.97 (0.75, 1.26)) had a greater risk of hip fracture than regular meat-eaters. There was no clear evidence of effect modification by BMI in any diet group (p-interaction = 0.3).

CONCLUSIONS

Vegetarian women were at a higher risk of hip fracture compared to regular meat-eaters. Further research is needed to confirm this in men and non-European populations and to identify factors responsible for the observed risk difference. Further research exploring the role of BMI and nutrients abundant in animal-sourced foods is recommended.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT05081466.

Outcomes After Operative Fixation of Vancouver B2 and B3 Type Periprosthetic Fractures

OBJECTIVES

The incidence of periprosthetic femur fracture in the setting of total hip arthroplasty is steadily increasing. Although the traditional dogma is that loose femoral components must be revised, we propose that in a frail geriatric population, anatomic reduction and fixation of Vancouver B2 and B3 periprosthetic fracture variants can restore stem stability and provide similar outcomes as revision arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center, tertiary academic medical center.

PATIENTS/PARTICIPANTS

We identified 94 patients over 65 years of age with Vancouver B2 and B3 fractures sustained between 2005 and 2019.

INTERVENTION

Patients were treated by either open reduction and internal fixation (ORIF) or revision arthroplasty (RA) with or without fixation.

MAIN OUTCOME MEASUREMENTS

Outcomes were mortality, time to full weight-bearing after surgery, intraoperative estimated blood loss, perioperative complications, reoperation, subsidence rate, and Patient-Reported Outcomes Measurement Information System pain and physical function scores.

RESULTS

A total of 75 (79.8%) ORIF and 19 (20.2%) RA patients were reviewed. One-year mortality for our cohort was 26.3%, and there was no significant difference between groups. Mean time to weight bear and surgical complication rates were similar between groups. The ORIF group had a significantly shorter time to surgery than the RA group. The RA group had greater incidence and amount of subsidence as well as estimated blood loss than the ORIF group.

CONCLUSIONS

In geriatric patients with Vancouver B2 and B3 type periprosthetic fractures with known loose stems, ORIF may offer a similarly safe method of treatment than revision arthroplasty.

LEVEL OF EVIDENCE

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

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

INTRODUCTION

Over the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures.

METHODS

In a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively.

RESULTS

No differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1).

CONCLUSIONS

The results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.

Dietary risk factors for hip fracture in adults: An umbrella review of meta-analyses of prospective cohort studies

AIM

To summarise the totality of evidence regarding dietary risk factors for hip fracture in adults, evaluating the quality of evidence, to provide recommendations for practice and further research.

DESIGN

Systematic review of meta-analyses of prospective cohort studies.

ELIGIBILITY CRITERIA

Systematic reviews with meta-analyses reporting summary risk estimates for associations between hip fracture incidence and dietary exposures including oral intake of a food, food group, beverage, or nutrient, or adherence to dietary patterns.

INFORMATION SOURCES

Medline, Embase, Web of Science, and the Cochrane Library from inception until November 2020.

DATA SYNTHESIS

The methodological quality of systematic reviews and meta-analyses was assessed using AMSTAR-2, and the quality of evidence for each association was assessed using GRADE. Results were synthesised descriptively.

RESULTS

Sixteen systematic reviews were identified, covering thirty-four exposures, including dietary patterns (n = 2 meta-analyses), foods, food groups, or beverages (n = 16), macronutrients (n = 3), and micronutrients (n = 13). Identified meta-analyses included 6,282 to 3,730,424 participants with between 322 and 26,168 hip fractures. The methodological quality (AMSTAR-2) of all systematic reviews was low or critically low. The quality of evidence (GRADE) was low for an inverse association between hip fracture incidence and intake of fruits and vegetables combined (adjusted summary relative risk for higher vs lower intakes: 0.92 [95% confidence interval: 0.87 to 0.98]), and very low for the remaining thirty-three exposures.

CONCLUSION

Dietary factors may play a role in the primary prevention of hip fracture, but the methodological quality of systematic reviews and meta-analyses was below international standards, and there was a lack of high-quality evidence. More long-term cohort studies reporting absolute risks and robust, well-conducted meta-analyses with dose-response information are needed before policy guidelines can be formed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020226190.

Habitual use of fish oil supplements, genetic predisposition, and risk of fractures: a large population-based study

BACKGROUND

Epidemiologic studies have suggested an inverse association between circulating concentrations of long-chain ω-3 PUFAs and fracture risk. However, whether supplementation of long-chain ω-3 PUFA (i.e. fish oil) is associated with fracture risk, and whether the association is modified by genetic predisposition to fracture risk remain unclear.

OBJECTIVES

To evaluate the associations of habitual fish oil supplement use with fracture risk, and to explore the potential effect modification by genetic predisposition.

METHODS

This study included 492,713 participants from the UK Biobank who completed a questionnaire on habitual fish oil supplement use between 2006 and 2010. HRs and 95% CIs for fractures were estimated from multivariable Cox proportional hazards models. A weighted fracture-genetic risk score (GRS) was derived from 14 validated single nucleotide polymorphisms.

RESULTS

During a median follow-up of 8.1 y, 12,070 incident fractures occurred among participants free of fracture at baseline (n = 441,756). Compared with nonuse, habitual use of fish oil supplements was associated with a lower risk of total fractures (HR = 0.93; 95% CI: 0.89, 0.97), hip fractures (HR = 0.83; 95% CI: 0.75, 0.92), and vertebrae fractures (HR = 0.85; 95% CI: 0.72, 0.99). The inverse association for total fractures was more pronounced among participants having a higher fracture-GRS than among those with a lower fracture-GRS (P-interaction <0.001). Among participants with a history of fracture at baseline (n = 50,957), fish oil use was associated with a lower risk of total recurrent fractures (HR = 0.88; 95% CI: 0.82, 0.96) and vertebrae recurrent fractures (HR = 0.64; 95% CI: 0.46, 0.88) but not with hip fracture recurrence.

CONCLUSIONS

Our findings suggest that habitual fish oil supplement use is associated with lower risks of both incident and recurrent fractures. The inverse associations of fish oil use with total fractures appeared to be more pronounced among individuals at higher genetic risk of fractures than those with lower genetic risk.

Place of residence before and place of discharge after femoral neck fracture surgery are associated with mortality: A study of 1238 patients with at least three years' follow-up

BACKGROUND

Femoral neck fractures constitute a major public health challenge. The risk of death after surgery depends chiefly on the patient's general health and comorbidities. No studies assessing place of residence are available. The objectives of this study were to determine whether mortality differed according to the patient's previous place of residence and to the place of discharge, and to describe the complications occurring after femoral neck fracture surgery.

HYPOTHESIS

After femoral neck fracture surgery, the place of discharge is associated with the risk of death, and the complication rate is high.

METHODS

This single-centre retrospective study included 1241 adults who sustained a true femoral neck fracture between 2006 and 2016 and were followed up for at least 3 years. The following data were collected: age at the time of the fracture, sex, hospital stay length, place of residence before and after the fracture, characteristics of the fracture, type of treatment, time from the fracture to surgery, and whether anticoagulant therapy was given. We then recorded data on mortality and complications.

RESULTS

The 3-year mortality rate was 36.0±1.4% (95%CI, 33.3-38.7). Place of residence before the fracture was strongly associated with mortality: the risk of death was higher in patients who lived in care homes (hazard ratio [HR], 2.18) or were hospitalised (HR, 1.78) and lower in patients who lived at home (HR, 0.46). The risk of death was also higher in patients discharged to care homes (HR, 1.82) or to hospitals (HR, 1.90) and lower in patients discharged home (HR, 0.30). All these differences were statistically significant (p<0.0001).

CONCLUSION

Place of residence and likely place of discharge should be evaluated as soon as the patient is admitted to the emergency department, in order to provide the best information possible to the patient and family and to establish the most appropriate treatment strategy. Patient self-sufficiency is a major parameter that should be preserved to the extent possible.

LEVEL OF EVIDENCE

IV.

Sex-specific incidence rates and risk factors for fracture: A 16-year follow-up from the Tehran lipid and glucose study

OBJECTIVE

To examine the population-based incidence of any-fracture and its potential risk factors in a sex-split cohort of the Iranian population.

MATERIALS AND METHODS

A total of 3477 men and 4085 women with a mean (SD) age of 47.92(13.1) and 45.88(11.47) years, respectively were entered into the study. The age-standardized incidence rates per 100,000 person-years were reported for the whole population and each sex separately. Cox proportional hazard models were used to estimate hazard ratios (HR) for potential risk factors. Only fractures requiring inpatients' care were considered as the outcome. We also defined major osteoporotic fractures (MOF) as the composite of the fractures that occurred in the vertebral, wrist, hip and pelvic sites among population aged ≥50 years.

RESULTS

During the median (IQR) follow-up of 15.9 years, 4.34%men and 3.75% women experienced at least one incident any-fracture. The annual age-standardized incidence rates (95% CI) among men and women were 330.9 (279.6-388.9) and 319.4(268.1-377.3) per 100,000 person-years, respectively; the corresponding values for incidence of MOF was 202.2(142.3-278.6) in men and 342.1(260.4-441.0) per 100,000 person-years for women. In the multivariable model, among the whole population, age groups ≥50 years, central obesity [HR: 95% CI 1.77(1.32-2.39)], current smoking [1.59(1.15-2.20)] and using steroid medications [2.20(1.04-4.67)] significantly increased the risk of incident fracture (all P < 0.05); however the impact of the first two risk factors were more prominent among women (P for interaction ≤0.01). Moreover, being obese was associated with a lower risk of incident first fracture in the total population [HR: 95% CI: 0.61(0.40-0.92)]. Being men [HR: 95% CI: 0.54(0.30-0.99)] and prediabetes status [HR: 95% CI: 0.53(0.30-0.95)] were also associated with lower risk for MOF.

CONCLUSION

This is the first report of long-term incidence rate of any-fracture and MOF conducted in the metropolitan city of Tehran. Among modifiable risk factors of fracture, in the whole population smoking habit and using steroid medications and particularly for women central obesity should be considered as main risk factors for preventive strategies. Prediabetes status was associated with lower risk of MOF.

Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials

INTRODUCTION

Displaced femoral neck fractures (FNF) are complicated by high mortality rates and continue to represent an important cause of disability, having a negative impact on patient mobility and physical independence. The purpose of this study was to update and analyse current outcomes and evidence concerning hip hemiarthroplasty (HHA) versus total hip arthroplasty (THA) for displaced femoral neck fractures in the elderly. Thus, a meta-analysis of randomized clinical trials was conducted.

MATERIALS AND METHODS

This meta-analysis was conducted according to the PRISMA guidelines. In October 2019, the following databases were accessed: Embase, Google Scholar, Pubmed, Scopus. All randomized clinical trials (RCTs) comparing total hip arthroplasty versus hip hemiarthroplasty for displaced femoral neck fractures were included in the present study. For the statistical analysis and the methodological quality assessment, the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen) and STATA/MP Software 14.1 (StataCorp, College Station, TX) were used.

RESULTS

Data from 2325 (1171 HHA vs 1154 THA) patients were collected. The mean follow-up was 58.12 months. The HHA group reported lower values of the mean Harris hip score (EE 3.22; p = 0.2), surgical duration (EE 21.75; p < 0.0001), length of the hospitalization stay (EE 0.8; p = 0.4). The HHA group evidenced lower dislocations rate (OR 1.78; p = 0.01, Fig. 4), but higher rate of acetabular erosion (OR 0.08; p = 0.0006). At a mean of 58.12 ± 52.8 months follow-up, revisions rate scored reduced in the THA group (OR 0.76; p = 0.2). Subgroup analysis of RCTs < 5 years follow-up revealed reduced revision in favour of the HHA group (OR 2.19; p = 0.03), while subgroup analysis of RCTs > 5 years follow-up revealed reduced revision in favour of the THA group (OR 0.25; p = 0.0003). The Kaplan-Meier curve detected similarity of patients survivorship between the two groups (HR 1.06; p = 0.3).

CONCLUSION

For the elderly population, both HHA and THA are valid solutions to treat displaced femoral neck fractures, with comparable survivorship. HHA detected reduced dislocations, while for THA a lower risk of acetabular erosion and further revision surgeries were reported.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized clinical trials.

The Impact of Tenofovir Disoproxil Fumarate on Reduced Bone Mineral Density and Fractures in Liver Transplant Recipients

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is associated with reduced bone density in patients with human immunodeficiency virus, but the effect of TDF on bone density in liver transplant (LT) recipients is unknown.

METHODS

We performed a single-center, retrospective study of LT recipients with hepatitis B taking TDF compared to a control group with non-hepatitis B virus viral hepatitis. The primary outcome was reduced bone density, defined as femoral neck or lumbar T-score less than -1. Other outcomes included mean T-score and fractures.

RESULTS

Three hundred ninety-three patients were studied: 52 patients in the TDF group and 341 patients in the control group; 64.3% patients in the TDF group had reduced bone density vs 71.4% in the control group (P = .58) before LT, compared to 75% and 81.5% (P = .57), respectively, after LT. Mean posttransplant lumbar T-scores were lower in the TDF group (-1.74 vs -0.75, P = .04). There was no difference between the 2 groups for the other outcomes. In a multivariate Cox proportional hazards model, TDF use did not affect the risk of post-LT reduced bone density (hazard ratio = 0.99; 95% confidence interval, 0.56-1.76; P = .97).

CONCLUSION

TDF use was not associated with reduced bone mineral density or increased rates of fractures in LT recipients compared to controls in this study.

Associations of job-related hazards and personal factors with occupational injuries at continuous miner worksites in underground coal mines: a matched case-control study in Indian coal mine workers

A wide range of job-related hazards and personal factors may be associated with injury occurrences at continuous miner worksites but their role has been little documented. To address this issue, a case-control study in India was conducted to compare 135 workers with an injury during the previous 2-yr period and 270 controls without injury during the previous 5-yr period (two controls for each injured worker, matched on age and occupation). Data were collected through face-to-face interviews using standardized questionnaire and analyzed using conditional logistic regression models. We found that the injury occurrences were multifactorial and associated with hand tool-related hazards (adjusted odds ratio/ORa=3.69, p<0.01), working condition-related hazards (ORa=3.11, p<0.01), continuous miner-related hazards (ORa=1.95, p<0.05), and shuttle car-related hazards (ORa=6.95, p<0.001), along with big family size, no-formal education, and presence of disease (adjusted odds ratios varying between 2 to 4). Stratified analyses showed that among the 36-60 yr-old workers, hand tool-related hazards, working condition-related hazards, and shuttle car-related hazards had significant ORa (6.62, 4.38 and 15.65, respectively with p<0.01,) while among the younger workers, only shuttle car-related hazards had significant ORa (4.25, p<0.05). These findings may help to understand the risk patterns of injuries and to implement appropriate prevention strategies.

Lipid Profile and Risk of Bone Fracture: A Systematic Review and Meta-Analysis of Observational Studies

Purpose: Earlier studies have linked lipid profile to osteoporotic fractures; however, to our knowledge, no study had summarized available data on this relationship. We aimed to summarize the current evidence on the association between lipid profile and bone fractures. Material and Methods: A systematic search of PubMed and Scopus was done to find relevant published studies until March 2018. To combine effect sizes, we applied fixed- or random-effects analysis, where appropriate. Cochran's Q test and I² were used to assess between-study heterogeneity. Results: Overall, 11 studies (seven prospective, three cross-sectional and one case-control studies) were included in the current systematic review. Out of them, 10 studies with a total sample size of 60,484 individuals, aged 25 years or more, were used in the meta-analysis. The results showed that total cholesterol concentration was positively associated with risk of bone fracture; such that a 50-mg/dl increase in plasma level of TC was associated with 15% greater odds of bone fracture (combined effect size: 1.15, 95% CI: 1.02-1.30, P = .02). Furthermore, we found that individuals with a decreased level of HDL (<40 mg/dl) had a lower risk of bone fracture compared with those with a normal level (≥40 mg/dl) (combined effect size: 0.82, 95% CI: 0.71-0.96, P = .01). No significant association was found between plasma level of TG and LDL with the risk of bone fractures either in prospective or cross-sectional studies. Conclusions: We found that plasma levels of total cholesterol were positively associated with bone fractures. In addition, decreased levels of HDL were associated with an increased risk of osteoporotic fractures. Abbreviations: TG: triglycerides, TC: total cholesterol, HDL: high-density lipoprotein, LDL: low-density lipoprotein, OR: odds ratio, RR: relative risk, HR: hazard ratio, DXA: dual-energy X-ray absorptiometry, ICD: International Classification of Diseases, SD: standard deviation.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

DESIGN AND SETTING

Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

PARTICIPANTS

In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

RESULTS

There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

CONCLUSIONS

There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

Minimally invasive anterior muscle-sparing versus a transgluteal approach for hemiarthroplasty in femoral neck fractures-a prospective randomised controlled trial including 190 elderly patients

BACKGROUND

The relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients.

METHODS

Four hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the "Timed up and go" test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality.

RESULTS

A total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [- 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5-12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [- 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group.

CONCLUSION

These results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population.

TRIAL REGISTRATION

www.clinicaltrials.gov : NCT01408693 (registered August 3rd 2011).

Infiltration Techniques for Local Infiltration Analgesia With Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion

BACKGROUND

Liposomal bupivacaine (LB) has demonstrated efficacy in improving pain scores and reducing opioid consumption across a variety of surgical settings, including orthopaedic surgery. However, meticulous infiltration techniques combined with a multimodal approach are important to optimizing outcomes.

METHODS

A panel of 4 orthopaedic surgeons and 3 anesthesiologists convened on April 1, 2017, to discuss current practices and develop a consensus statement regarding local infiltration analgesia with LB for extracapsular and intracapsular hip fracture surgery, including LB infiltration techniques.

RESULTS

Optimizing surgical outcomes with LB in hip fracture surgery requires an understanding of the neuroanatomy of the surgical site and the pharmacology of the drug. Meticulous infiltration technique is critical to achieve optimal results with LB given its viscosity and reduced diffusion compared with bupivacaine HCl. For extracapsular procedures, a total injection volume of 120 mL is recommended, whereas intracapsular procedures typically require a lower volume (∼80 mL). In both cases, infiltration is best achieved using a 22-gauge needle and applying a tracking and/or fanning technique. To ensure optimal placement, LB should be infiltrated using multiple, small-volume (1- to 5-mL) injections spaced at 1.0-cm intervals.

CONCLUSIONS

These consensus recommendations regarding LB infiltration techniques can serve as a resource for designing clinical studies to evaluate outcomes using periarticular infiltration of LB in extracapsular and intracapsular hip fracture surgery as part of a multimodal pain management approach.

LEVEL OF EVIDENCE

Level V.

Risk factors for trochanteric and femoral neck fracture

INTRODUCTION AND OBJECTIVES

The differences between the two main types of fracture of proximal end of the femur, trochanteric and cervical fractures, are still a subject of study, and could be the key to a better understanding of its pathophysiology and prevention. The aim of this study is to determine whether epidemiological differences in the distribution of risk factors associated with hip fracture exist between these two entities.

PATIENTS AND METHOD

A descriptive cross-sectional study of 428 patients over the age of 65 admitted for trochanteric or cervical fractures in 2015, in which gender, age, previous diagnosis, external causes associated with fracture and place of the event were recorded.

RESULTS

There were 220 patients with a cervical fracture (51.4%) and 208 patients with a trochanteric fracture (48.6%). The average age was higher in the trochanteric fracture, observing a constant increase with age only in women with trochanteric fractures. Cervical fracture showed a significant association with cerebrovascular disease (p=0.039) and trochanteric fracture with accidental falls (p=0.047) and presence of 5-9 previous diseases (p=0.014). A regression analysis maintained this association in the case of a cerebrovascular disease (OR 2.6, 95%CI 1.1-6.4) and the presence of 5-9 diseases (OR 1.5, 95%CI 1.1-2.3).

CONCLUSIONS

Trochanteric fractures are associated with women patients of more advanced ages, 5-9 previous diseases and accidental falls. Cerebrovascular disease shows a higher prevalence in cervical fractures.

Exposure of medical staff to radiation during osteosynthesis of proximal femoral fracture: descriptive analysis and comparison of different devices

BACKGROUND

The use of fluoroscopy is necessary during proximal femoral fracture (PFF) osteosynthesis. The frequency of these procedures justifies a description of radiation exposure and comparisons between different techniques and between the different surgical team members.

METHODS

This observational prospective and comparative study includes a series of 68 patients with PFF receiving osteosynthesis. Radiation exposure was assessed for all members of the operating team. The radiation dose measurements for the different members of the surgical team during PFF osteosynthesis were compared. The factors affecting the radiation dose were investigated.

RESULTS

The mean active dosimeter readings for each operation were 7.39 µSv for the primary surgeon, 3.93 µSv for the assistant surgeon, 1.92 µSv for the instrument nurse, 1.25 µSv for the circulating nurse, and 0.64 µSv for the anaesthesiologist, respectively. Doses decreased significantly between these different members of the medical team (all p < 0.001). The dose also varied with patient age and BMI, as well as with fluoroscopy time and operating time, but not with type of fracture or type of osteosynthesis.

CONCLUSION

Medical staff receives significantly different doses depending on their position in relation to the radiation source. Operating time and fluoroscopy time are the modifiable factors that affect the radiation dose. The radiation doses received by the different members of the medical teams involved in proximal femur osteosynthesis procedures all fall below the doses recommended by the International Commission on Radiation Units and Measurements.

Abdominal Obesity and Risk of Hip Fracture: A Systematic Review and Meta-Analysis of Prospective Studies

Data on the association between general obesity and hip fracture were summarized in a 2013 meta-analysis; however, to our knowledge, no study has examined the association between abdominal obesity and the risk of hip fracture. The present systematic review and meta-analysis of prospective studies was undertaken to summarize the association between abdominal obesity and the risk of hip fracture. We searched online databases for relevant publications up to February 2017, using relevant keywords. In total, 14 studies were included in the systematic review and 9 studies, with a total sample size of 295,674 individuals (129,964 men and 165,703 women), were included in the meta-analysis. Participants were apparently healthy and aged ≥40 y. We found that abdominal obesity (defined by various waist-hip ratios) was positively associated with the risk of hip fracture (combined RR: 1.24, 95% CI: 1.05, 1.46, P = 0.01). Combining 8 effect sizes from 6 studies, we noted a marginally significant positive association between abdominal obesity (defined by various waist circumferences) and the risk of hip fracture (combined RR: 1.36; 95% CI: 0.97, 1.89, P = 0.07). This association became significant in a fixed-effects model (combined effect size: 1.40, 95% CI: 1.25, 1.58, P < 0.001). Based on 5 effect sizes, we found that a 0.1-U increase in the waist-hip ratio was associated with a 16% increase in the risk of hip fracture (combined RR: 1.16, 95% CI: 1.04, 1.29, P = 0.007), whereas a 10-cm increase in waist circumference was not significantly associated with a higher risk of hip fracture (combined RR: 1.13, 95% CI: 0.94, 1.36, P = 0.19). This association became significant, however, when we applied a fixed-effects model (combined effect size: 1.21, 95% CI: 1.15, 1.27, P < 0.001). We found that abdominal obesity was associated with a higher risk of hip fracture in 295,674 individuals. Further studies are needed to test whether there are associations between abdominal obesity and fractures at other bone sites.

Decreases in heart rate variability are associated with postoperative complications in hip fracture patients

Background

To explore relevant associations between deviations in linear and nonlinear heart rate variability (HRV) scores, and short-term morbidity and mortality in patients undergoing hip-surgery after a fracture.

Methods

165 patients with hip fractures being admitted for surgery at two hospitals were included in a prospective cohort study. A short-term ECG was recorded within 24 hours of arrival. 15 patients had to be excluded due to insufficient quality of the ECG recordings. 150 patients were included in the final analysis. Linear parameters were calculated in time domain: standard deviation of NN intervals (SDNN), root mean square of successive differences (rMSSD); and frequency domain: Total Power (TP), High Frequency Power (HF), Low Frequency Power (LF), Very Low Frequency Power (VLF), and the ratio of LF/HF. Postoperative outcome was evaluated at the time of discharge. This included occurrence of pneumonia, overall infection rate, stroke, myocardial infarction, and all-cause mortality.

Results

Patients experiencing complications had significantly lower rMSSD (p = 0.04), and TP (p = 0.03) preoperatively. Postoperative infections were predicted by decreased VLF preoperatively (p = 0.04). There was a significant association between pneumonia and LF/HF<1 (p = 0.03). The likelihood ratio to develop pneumonia when LF/HF < 1 was 6,1.

Conclusion

HRV seems to reflect the general frailty of the patient with hip fracture and might be used to identify patients in need of increased surveillance or prophylactic treatment.

Complications after surgical treatment of femoral neck fractures in men with alcohol dependence syndrome: retrospective register analysis of 154 cases

PURPOSE

One-third of hip fractures occur in men. The causes underlying hip fractures in men differ from those in women and include alcohol abuse. This retrospective register study evaluated the trends and results associated with different surgical treatment methods for nondisplaced and displaced femoral neck fractures in male patients with alcohol dependence syndrome.

METHODS

Men with hip fractures were identified from a local district hospital database. Alcohol dependence syndrome was identified as a diagnosis in medical records.

RESULTS

For displaced fractures, implant survival after total hip arthroplasty was significantly lower compared to hemiarthroplasty. For nondisplaced fractures, implant survival of cannulated screws was significantly lower compared to sliding hip screws. Overall patient survival for males with alcohol dependence syndrome with hip fracture was 62% at 1 year and 49% at 2 years. Patient survival in this population did not differ between displaced and nondisplaced fractures or among different surgical methods.

CONCLUSION

Patients with alcoholism who had documented evidence of alcohol dependence syndrome represented nearly half of patients <70 years old with low-energy hip fracture. In patients with nondisplaced femoral neck fractures, stability of the internal fixation appeared to play a major role in implant survival; sliding hip screws should be considered over multiple cannulated screws. In patients with displaced fracture, total hip arthroplasty was associated with a significantly higher risk of complications leading to revision compared to hemiarthoplasty.

LEVEL OF EVIDENCE

Prognostic Level III.

Is depression associated with functional recovery after hip fracture in the elderly?

AIM

The aim of this study was to examine the effects of depression on functional healing and the return to pre-fracture daily activities in elderly patients with a hip fracture.

METHODS

The study comprised 104 elderly patients, who had a unilateral hip fracture between 2009 and 2012. To evaluate daily activities and functional healing of the cases, the study was designed as a prospective comparative study.

RESULTS

The analysis results revealed that the change in the mean ADL scores was related to depression at a statistically significant level (p = 0.000).

DISCUSSION

This study results showed that depression had a negative effect on the daily activity level of these cases.

Analysis of the hip fracture records of a central training and research hospital by selected characteristics

BACKGROUND/AIM

Despite the importance of hip fractures, very few studies have assessed their epidemiological characteristics in Turkey. The aim of this study was to evaluate the frequency and demography of hip fractures from the recent data of a central training and research hospital.

MATERIALS AND METHODS

In this descriptive study, we identified hip fracture cases between 2009 and 2013. The age, sex, region, injury pattern, and calendar year for all patients were evaluated.

RESULTS

Among the 687 patients (488 women, 199 men) described in our clinic's records, 122, 131, 144, 138, and 154 patients applied with hip fractures from the years 2009 to 2013, respectively. The mean ages of the women and men were 74.8 and 68.5 years, respectively. There were 220 patients who had femoral neck fracture (32%), 419 who had intertrochanteric fracture (61%), and 48 who had subtrochanteric fracture (7%).

CONCLUSION

The female geriatric population may have an increasing and distinct hip fracture risk, mainly in the trochanteric region. Furthermore, recent studies that show variations in the frequency and demography of hip fractures highlight the importance of meticulous recording of patients' information. A nationwide survey of different categories of hospitals and various geographic regions of Turkey is also needed to inform effective prevention strategies.

Correlation Between Use of Zopiclone and Risk of Hip Fracture in Elderly Adults: A Case-Control Study in Taiwan

OBJECTIVES

To investigate the correlation between zopiclone use and risk of hip fracture in elderly adults.

DESIGN

Case-control study.

SETTING

Claim data from the Taiwan National Health Insurance Program.

PARTICIPANTS

Individuals aged 65 and older who experienced their first episode of hip fracture between 1998 and 2011 were enrolled as the case group (n = 10,996). Randomly selected subjects aged 65 and older without hip fracture were enrolled as controls (n = 9,081). Case and control groups were matched according to sex, comorbidities, and index year of hip fracture diagnosis.

MEASUREMENTS

Current users of zopiclone were defined as those whose last remaining tablet of zopiclone was detected within 7 days or less before the date of hip fracture diagnosis. Late users of zopiclone were defined as those whose last remaining tablet of zopiclone was detected more than 7 days before the date of hip fracture diagnosis. Subjects who never received a prescription of zopiclone were defined as nonusers of zopiclone. A multivariable unconditional logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) to investigate the correlation between zopiclone use and risk of hip fracture.

RESULTS

After adjusting for confounders, multivariable logistic regression analysis demonstrated that current users of zopiclone were three and a half times as likely as nonusers to experience a hip fracture (adjusted OR = 3.56, 95% CI = 2.33-4.84), whereas late users were essentially equally as likely as nonusers to experience a hip fracture (OR = 1.05, 95% CI = 0.94-1.18).

CONCLUSION

Current use of zopiclone was associated with greater risk of hip fracture in the elderly adults studied. Clinicians should alert elderly people to the risk of hip fracture when prescribing zopiclone.

Fusion of clinical and stochastic finite element data for hip fracture risk prediction

Hip fracture affects more than 250,000 people in the US and 1.6 million worldwide per year. With an aging population, the development of reliable fracture risk models is therefore of prime importance. Due to the complexity of the hip fracture phenomenon, the use of clinical data only, as it is done traditionally, might not be sufficient to ensure an accurate and robust hip fracture prediction model. In order to increase the predictive ability of the risk model, the authors propose to supplement the clinical data with computational data from finite element models. The fusion of the two types of data is performed using deterministic and stochastic computational data. In the latter case, uncertainties in loading and material properties of the femur are accounted for and propagated through the finite element model. The predictive capability of a support vector machine (SVM) risk model constructed by combining clinical and finite element data was assessed using a Women׳s Health Initiative (WHI) dataset. The dataset includes common factors such as age and BMD as well as geometric factors obtained from DXA imaging. The fusion of computational and clinical data systematically leads to an increase in predictive ability of the SVM risk model as measured by the AUC metric. It is concluded that the largest gains in AUC are obtained by the stochastic approach. This gain decreases as the dimensionality of the problem increases: a 5.3% AUC improvement was achieved for a 9 dimensional problem involving geometric factors and weight while a 1.3% increase was obtained for a 20 dimensional case including geometric and conventional factors.

The relevance of gender in the care of hip fracture patients

As in many conditions, gender interplays with other social structures of inequality to impact upon women's and men's health and healthcare. This narrative review examines knowledge about sex, gender and hip fracture and suggests ways of highlighting the influence of gender in hip fracture healthcare. These will be considered in relation to two areas. Firstly the multifactorial dimension of hip fractures which identifies ethnicity, marital status, lifestyle, co-morbidities, environment in relation to falls and osteoporosis as important factors influencing the experience of hip fracture. Secondly the importance of acknowledging gender as a key element within research and management of care. Implications for practice are that we need a raised awareness of gender when we assess and care for patients, to ask critical questions about the gender bias in the evidence we use and reflect on how services and care practices may be biased towards gendered assumptions.

The interactions between municipal socioeconomic status and age on hip fracture risk

SUMMARY

Age modifies the effect of area-level socioeconomic status (SES) in the risk of fragility hip fractures (HF). For older individuals, the risk of HF increases as SES increases. For younger individuals, risk of HF increases as SES decreases. Our study may help decision-makers to better direct the implementation of political decisions.

INTRODUCTION

The effect of socioeconomic status (SES) on hip fracture (HF) incidence remains unclear. The objective of this study is to evaluate the association between HF incidence and municipality-level SES as well as interactions between age and SES.

METHODS

From the Portuguese Hospital Discharge Database, we selected hospitalizations (2000-2010) of patients aged 50+, with HF diagnosis (codes 820.x, ICD9-CM), caused by traumas of low/moderate energy, excluding bone cancer cases and readmissions for aftercare. Municipalities were classified according to SES (deprived to affluent) using 2001 Census data. A spatial Bayesian hierarchical regression model (controlling for data heterogeneity and spatial autocorrelation), using the Poisson distribution, was used to quantify the relative risk (RR) of HF, 95% credible interval (95%CrI), and analyze the interaction between age and SES after adjusting for rural conditions.

RESULTS

There were 96,905 HF, 77.3% of which were on women who, on average, were older than men (mean age 81.2±8.5 vs 78.2±10.1 years) at admission (p<0.001). In women, there was a lower risk associated with better SES: RR=0.83 (95%CrI 0.65-1.00) for affluent versus deprived. There was an inverse association between SES and HF incidence rate in the youngest and a direct association in the oldest, for both sexes, but significant only between deprived and affluent in older ages (≥75 years).

CONCLUSIONS

Interaction between SES and age may be due to inequalities in lifestyles, access to health systems, and preventive actions. These results may help decision-makers to better understand the epidemiology of hip fractures and to better direct the available funding.

Body mass index as a prognostic factor for fracturing of the proximal extremity of the femur: a case-control study

OBJECTIVES

To compare the body mass index (BMI) of patients with fractures in the proximal extremity of the femur with the BMI of patients without any previous history of fractures.

METHODS

We investigated patients of both sexes, aged 65 years or over, who were admitted to Hospital Independência, Hospital Beneficência Portuguesa or ULBRA University Hospital, between December 2007 and December 2010, with histories of low-energy trauma such as falling from a standing position. These individuals were compared with patients of the same age but without any history of fracturing of the proximal extremity of the femur (n = 89), who were attended at the geriatrics outpatient clinic of the Sociedade Porto-Alegrense de Auxílio aos Necessitados (SPAAN).

RESULTS

The age group of the patients with fractures in the proximal extremity of the femur ranged from 65 to 96 years (mean: 77.58). The main type of fracture was trochanteric (47; 62.2%), followed by femoral neck fractures (27; 36%). Among the patients who presented on fracturing the proximal extremity of the femur, 12% had low weight, 62.7% normal weight, 24% overweight, and 1.3% obesity. Among the patients without any history of fractures, 5.6% presented low weight, 43.8% normal weight, 33.7% overweight, and 9.8% obesity. It was observed that the patients with fractures in the proximal extremity of the femur (n = 75) presented a mean BMI of 22.6, while the patients without fractures presented a mean BMI of 25.5.

CONCLUSION

The patients in the group with fractures were significantly taller than those in the group without fractures and presented significantly lower BMI than those in the group without fractures.

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.

The incidence rate of hip fracture in Shiraz, Iran during 2008-2010

This study aimed to estimate the incidence rate of hip fracture during 2008-2010 in Shiraz, Iran. Overall, the standardized age-related incidence were 329.6/100,000 in men and 1,589.7/100,000 in women. The incidence rate in females was remarkably higher than the previous studies in Iran.

PURPOSE

This study aims to determine the incidence rate of hip fracture and its possible changes during 2008-2010 in Shiraz, Iran.

MATERIALS AND METHODS

This study reviewed and abstracted the hospital records, demographic, and clinical data of 1,923 patients aged 50 years or older with first time hip fracture admitted to private and public hospitals of Shiraz, Iran during 2008-2010 The age-adjusted incidence rate of hip fracture was determined along with association between gender, age, site of fracture, and socioeconomic status (SES) with the incidence rate.

RESULTS

The mean age of subjects was 74.7 years (±10.6 years). Age-adjusted incidence rates for hip fracture, standardized to the 2000 US white male and female populations were 329.57 and 1,589.71 per 10(5), respectively, while totally it was 461.1 per 10(5). The incidence rate of hip fracture in females was higher than that of males in their 60s (1,229.2 versus 793.3), 70s (4,130.3 versus 2,835.3), and early 80s (4,506.8 versus 3,820.5) per 100,000. The hip fracture incidence in high SES area (157.1 per 100,000) followed by low SES regions (152.5 per 100,000) were higher compared to middle SES area (38.1 per 100,000) and towns around Shiraz (27.7 per 100,000) with fracture of the neck of femur being the most frequent affliction (391 per 100,000).

CONCLUSIONS

The rate of hip fracture is increasing in the area under study particularly in women and to a greater extent in those aged 60 years or older. Therefore, it is necessary to pay special attention to primary and secondary prevention of hip fracture.

Time to surgery and 30-day morbidity and mortality of periprosthetic hip fractures

BACKGROUND AND AIM

The management of femoral periprosthetic fractures following hip replacement surgery is a complex and challenging situation. Whilst the early complications for both primary hip arthroplasty and proximal femoral fracture surgery have been widely documented, there is a paucity of published data regarding early outcomes following periprosthetic fracture surgery. Delay to surgery for native proximal femoral fractures has been clearly documented as a predictor towards adverse outcome. This study therefore aims to correlate the timing of operative intervention with the complication rate following periprosthetic fracture surgery. In addition, the study aims to identify further factors in the perioperative period that positively predict a poor postoperative outcome.

METHODS

Sixty patients who were operatively managed for a femoral implant periprosthetic fracture were identified and each case assessed retrospectively.

RESULTS AND CONCLUSION

There was an overall complication rate of 45% including a 30-day mortality of 10%. An abbreviated mental test score of 8 out of 10 or less and a delay to surgery of >72h were found to be significant risk factors for adverse outcome. Both the patient cohort in this study and the predictors for poor postoperative outcome were comparable to those for native proximal femoral fractures.

A comparison of hip fracture incidence rates among elderly in Sweden by latitude and sunlight exposure

Background: Research has shown that hip fracture risk increases with latitude; hypothetically due to reduced sunlight exposure and its effect on bone quality. Sweden, with large differences in latitude and UV radiation, is ideal to study in order to analyse the association between latitude and UV radiation on age- and sex-specific hip fracture rates among elderly. Method: Aggregated (2006–2008) age- and sex-specific hip fracture data was obtained for each Swedish municipality as well as the municipality’s latitudinal coordinates and aggregated (2006–2008) UV radiation levels. Pearson correlations were calculated between hip fracture incidence rates, latitude and UV radiation. Independent t tests were calculated on tertile-categorized latitudinal data in order to investigate the difference in hip fracture risk between these categories. Results: Statistically significant correlations were seen in all groups between hip fracture incidence rates and latitude as well as UV radiation. The independent t tests showed that this correlation was mainly due to high incidence rates in high latitude municipalities. Conclusions: Statistically significant correlations are seen between hip fracture incidence rates and latitude as well as UV radiation in Sweden and the northern parts of Sweden have an increased risk of hip fractures compared to the middle and southern parts. To our knowledge this is the first study using a national discharge register that shows this relationship and provides a starting point for further research to investigate why populations in northern Sweden have a higher risk of hip fractures compared to other Swedish regions.

The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture

BACKGROUND

The Malnutrition Screening Tool (MST) is the most commonly used screening tool in Australia. Poor screening tool sensitivity may lead to an under-diagnosis of malnutrition, with potential patient and economic ramifications. The present study aimed to determine whether the MST or anthropometric parameters adequately detect malnutrition in patients who were admitted to a hip fracture unit.

METHODS

Data were analysed for a prospective convenience sample (n = 100). MST screening was independently undertaken by nursing staff and a nutrition assistant. Mid upper arm circumference (MUAC) was measured by a trained nutrition assistant. Nutritional risk [MST score ≥ 2, body mass index (BMI) < 22 kg m(-2) , or MUAC < 25 cm] was compared with malnutrition diagnosed by accredited practicing dietitians using International Classification of Diseases version 10-Australian Modification (ICD10-AM) coding criteria.

RESULTS

Malnutrition prevalence was 37.5% using ICD10-AM criteria. Delirium, dementia or preadmission cognitive impairment was present in 65% of patients. The BMI as a nutrition risk screen was the most valid predictor of malnutrition (sensitivity 75%; specificity 93%; positive predictive value 73%; negative predictive value 84%). Nursing MST screening was the least valid (sensitivity 73%; specificity 55%; positive predictive value 50%; negative predictive value 77%). There was only fair agreement between nursing and nutrition assistant screening using the MST (κ = 0.28).

CONCLUSIONS

In this population with a high prevalence of delirium and dementia, further investigation is warranted into the performance of nutrition screening tools and anthropometric parameters such as BMI. All tools failed to predict a considerable number of patients with malnutrition. This may result in the under-diagnosis and treatment of malnutrition, leading to case-mix funding losses.

Secular trends of hip fractures in Québec, Canada

This study examined the secular trends of hip fracture incidence among individuals 50 years and older in Québec between 1993 and 2004. Age-standardized rates decreased at both the provincial and regional levels. The largest relative decrease was observed among younger females, and rates declined more slowly in the elderly.

INTRODUCTION

The population of the province of Québec is among the oldest in North America. Before the trend rupture reported in the late 1990s in several countries, hip fracture (HF) incidence rates did not show a secular trend (between 1981 and 1992). This study examined the secular trends of HF incidence at the provincial level and in two of the most important urban areas of the province, Montréal and Québec City, between 1993 and 2004.

METHODS

All hospitalisations of individuals 50 years and older living in the province of Québec between 1993 and 2004 with a main diagnosis of HF were included. Standardized rates of HF incidence were calculated for females and males, 50-74 years and 75 years and older.

RESULTS

The Québec City area showed a strong decreasing trend in HF rates for younger females, but the other groups did not show an obvious trend. Although our models did not support the existence of significant differences in trends between both areas, the rates of HF of younger males and, to a lesser extent, of older women in the Montréal area were significantly higher than in the Québec City area.

CONCLUSIONS

Differences observed in hip fracture rates as well as in secular trends between age groups and gender emphasise the need for decision makers to rely on results based on age-specific and sex-specific analyses.

Modeling seasonal variation of hip fracture in Montreal, Canada

The investigation of the association of the climate variables with hip fracture incidences is important in social health issues. This study examined and modeled the seasonal variation of monthly population based hip fracture rate (HFr) time series. The seasonal ARIMA time series modeling approach is used to model monthly HFr incidences time series of female and male patients of the ages 40-74 and 75+ of Montreal, Québec province, Canada, in the period of 1993-2004. The correlation coefficients between meteorological variables such as temperature, snow depth, rainfall depth and day length and HFr are significant. The nonparametric Mann-Kendall test for trend assessment and the nonparametric Levene's test and Wilcoxon's test for checking the difference of HFr before and after change point are also used. The seasonality in HFr indicated sharp difference between winter and summer time. The trend assessment showed decreasing trends in HFr of female and male groups. The nonparametric test also indicated a significant change of the mean HFr. A seasonal ARIMA model was applied for HFr time series without trend and a time trend ARIMA model (TT-ARIMA) was developed and fitted to HFr time series with a significant trend. The multi criteria evaluation showed the adequacy of SARIMA and TT-ARIMA models for modeling seasonal hip fracture time series with and without significant trend. In the time series analysis of HFr of the Montreal region, the effects of the seasonal variation of climate variables on hip fracture are clear. The Seasonal ARIMA model is useful for modeling HFr time series without trend. However, for time series with significant trend, the TT-ARIMA model should be applied for modeling HFr time series.

Thiazide diuretics and the risk of hip fracture

BACKGROUND

Thiazide diuretics are one of the most commonly prescribed antihypertensive agents worldwide. Thiazides reduce urinary calcium excretion. Chronic ingestion of thiazides is associated with higher bone mineral density. It has been suggested that thiazides may prevent hip fracture. However, there are concerns that diuretics, by increasing the risk of fall in elderly, could potentially negate its beneficial effects on hip fracture.

OBJECTIVES

To assess any association between the use of thiazide diuretics and the risk of hip fracture in adults.

SEARCH STRATEGY

We searched eligible studies up to December 2008 in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE) and reference lists of previous reviews and included studies.

SELECTION CRITERIA

All randomized controlled trials and observational studies, which assessed the association between thiazide diuretic use and hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the selection criteria, extracted data and assessed risk of bias of each study selected.  The results were summarized descriptively and quantitatively. Cohort studies and case control studies were analysed separately.

MAIN RESULTS

No randomized control trials were found. Twenty-one observational studies with nearly four hundred thousand participants were included. Six of them were cohort studies and 15 were case-control studies. Two cohort studies appear to involve the same cohort so there were only 5 unique ones. The risk of bias was assessed with the Newcastle-Ottawa Scale (NOS). Five cohort studies had low risk of bias and one had moderate risk of bias. Seven case control studies had low risk of bias and 8 had moderate risk of bias. Meta-analysis of cohort studies showed that thiazide use was associated with a reduction in risk of hip fracture by 24%, pooled RR 0.76 (95% CI 0.64-0.89; p = 0.0009). We chose not to provide a pooled summary statistics for case-control studies because of high heterogeneity (Tau(2) = 0.03, I(2) = 62%, p = 0.0008).

AUTHORS' CONCLUSIONS

Thiazides appear to reduce the risk of hip fracture based on observational studies. Randomized controlled trials are needed to confirm these findings.  

[Hip and pelvic injuries in the elderly]

Fractures of the hip and pelvis are frequent and serious injuries in elderly patients. Due to the aging population, their incidence should double by 2050. Therefore, the social and economical implications of these fractures are significant. Delay in diagnosis increases the associated morbidity and mortality. The purpose is to review the imaging features of these fractures, the imaging techniques (projections, CT) to depict them and their classification based on severity.

Anthropometry, physical activity and hip fractures in the elderly

INTRODUCTION

Hip fractures constitute a major and growing public health problem amongst the elderly worldwide. We examined the association of anthropometry and physical activity with hip fracture incidence in a cohort of elderly Europeans, participants in the European Prospective Investigation into Cancer and nutrition (EPIC) study.

MATERIALS AND METHODS

The study population consisted of 27 982 volunteers (10 553 men and 17 429 women) aged 60 years and above from five European countries. Information on anthropometry, physical activity, medical history and other characteristics was collected at baseline. During a median follow-up of 8 years, 261 incident hip fractures (203 women and 58 men) were recorded. Data were analysed through Cox proportional hazard regression with adjustment for potential confounders.

RESULTS

A higher body mass index (BMI) was associated with lower hip fracture risk (hazard ratio (HR)per increasing sex-specific-quintile: 0.85, 95% confidence interval (95% CI): 0.77–0.94). Body height was associated with increased hip fracture risk (HR per 5 cm: 1.13, 95% CI: 1.01–1.25). Waist-to-hip ratio was not related to hip fracture risk. Increasing levels of leisure-time physical activity were related to lower risk (HR per increasing tertile: 0.84, 95% CI: 0.70–0.99, p for trend: 0.039).

CONCLUSIONS

In a prospective cohort study of elderly Europeans, we found evidence that high body stature increased and high BMI decreased the incidence of hip fractures. After adjustment for BMI,waist to-hip ratio was not associated with hip fracture risk. Leisure-time physical activity appears to play a beneficial role in the prevention of hip fractures.

Diet and hip fractures among elderly Europeans in the EPIC cohort

BACKGROUND/OBJECTIVES

Evidence on the role of diet during adulthood and beyond on fracture occurrence is limited. We investigated diet and hip fracture incidence in a population of elderly Europeans, participants in the European Prospective Investigation into Cancer and nutrition study.

SUBJECTS/METHODS

29, 122 volunteers (10,538 men, 18,584 women) aged 60 years and above (mean age: 64.3) from five countries were followed up for a median of 8 years and 275 incident hip fractures (222 women and 53 men) were recorded. Diet was assessed at baseline through validated dietary questionnaires. Data were analyzed through Cox proportional-hazards regression with adjustment for potential confounders.

RESULTS

No food group or nutrient was significantly associated with hip fracture occurrence. There were suggestive inverse associations, however, with vegetable consumption (hazard ratio (HR) per increasing sex-specific quintile: 0.93, 95% confidence interval (CI): 0.85-1.01), fish consumption (HR per increasing sex-specific quintile: 0.93, 95% CI: 0.85-1.02) and polyunsaturated lipid intake (HR per increasing sex-specific quintile: 0.92, 95% CI: 0.82-1.02), whereas saturated lipid intake was positively associated with hip fracture risk (HR per increasing sex-specific quintile: 1.13, 95% CI: 0.99-1.29). Consumption of dairy products did not appear to influence the risk (HR per increasing sex-specific quintile: 1.02, 95% CI: 0.93-1.12).

CONCLUSIONS

In a prospective study of the elderly, diet, including consumption of dairy products, alcohol and vitamin D, did not appear to play a major role in hip fracture incidence. There is however, weak and statistically non-significant evidence that vegetable and fish consumption and intake of polyunsaturated lipids may have a beneficial, whereas saturated lipid intake a detrimental effect.