Post-fracture management of patients with hip fracture: a perspective

Impact of bisphosphonates and comorbidities on initial hip fracture prognosis

The aim of this study is to investigate the impact of bisphosphonate treatment on the prognosis of patients with initial hip fracture. Patients aged fifty years and older with initial hip fracture were identified from the Taiwan National Health Insurance Research Database between 2002 and 2011. A multi-state model was established to evaluate the transition between "first to second hip fracture", "first hip fracture to death", and "second hip fracture to death". Transition probability and cumulative hazards were used to compare the prognosis of initial hip fracture in a bisphosphonate treated cohort versus non-treated cohort. In addition, Deyo-Charlson comorbidities, both vertebral and non-vertebral fractures, and cataracts were also included for analysis. After 10-year follow-up, there is decreased cumulative transition probability for both second hip fracture and mortality after both first and second hip fracture in the bisphosphonate treated cohort. Multivariable, transition-specific time-dependent Cox model revealed that bisphosphonate treatment significantly reduced risk for second hip fracture in the first 5 years of the treatment (HR 0.88; 95% CI 0.79-0.99; P: 0.034), first hip fracture mortality (HR 0.88; 95% CI 0.83-0.93; P < 0.001), and second hip fracture mortality in the first 2 years of the treatment (HR 0.78; 95% CI 0.65-0.95; P = 0.011). Female sex, both vertebral and non-vertebral fractures, cataracts, dementia in the first 2 years, and DM with complication were all significantly associated with risk of a second hip fracture. Cerebrovascular disease and hemiplegia comorbidities had less risk of a second hip fracture. The risk of mortality after both first and second hip fracture was significantly associated with congestive heart failure, renal disease, myocardial infarction, and moderate to severe liver disease. Our study demonstrated that bisphosphonate treatment and strict management of comorbidities after the initial hip fracture significantly decrease the risk for a second hip fracture and mortality.

Patients Undergoing Surgery for Hip Fractures Suffer from Severe Oxidative Stress as Compared to Patients with Hip Osteoarthritis Undergoing Total Hip Arthroplasty

Hip fractures are associated with the highest degree of morbidity and mortality of all fractures in elderly patients and pose a major risk for subsequent fractures. Patients with hip fractures also present accelerated bone turnover despite early stable fracture fixation and early mobilization. We aimed to evaluate oxidative stress in two groups of patients (25 patients each, matched for age, side, and BMI) who underwent internal fixation of hip fractures and total hip arthroplasty for hip osteoarthritis. Blood samples were taken from all patients during admission, the day of surgery, the 4^th postoperative day, and the 15^th postoperative day. Reduced (GSH) and oxidized (GSSG) glutathione, GSH/GSSG, catalase (CAT), thiobarbituric acid reactive substances (TBARS), protein carbonyls (PC), and total antioxidant capacity (TAC) as a widely used battery of redox biomarkers were recorded from blood samples. Patients with hip fractures who undergo fixation surgery, compared to those with hip osteoarthritis, suffer significant oxidative stress with an active but insufficient first line of oxidative defense, an intensive first line reaction, a very active second line of oxidative defense, and a low plasma antioxidant capacity. Surgery worsened already present lipid- and protein-related tissue damage. The severe oxidative stress observed may explain high morbidity and mortality rates and high bone turnover status, as well as the high incidence of refractures. Furthermore, the question of whether antioxidant therapy measures should be introduced in the management of hip fracture patients is raised.

Searching for the 'winner' hip fracture patient: the effect of modifiable and non-modifiable factors on clinical outcomes following hip fracture surgery

BACKGROUND

Various factors, other than the quality of surgery, may influence clinical outcomes of hip fracture patients. We aimed to evaluate the relative impact of several factors on functional outcome, quality of life, re-fracture and mortality rates following surgery for hip fractures.

METHODS

We studied 498 (62.2%) women and 302 (37.8%) men with a mean age of 81.3 years (range, 60-95) with hip fractures (femoral neck and pertrochanteric). The mean follow-up was 74 months (range 58-96). Various patient-related and surgery-related parameters were recorded and correlated to both objective and subjective mobility, functional recovery and quality of life scales. Mortality and re-fracture rates were also evaluated.

RESULTS

Using multiple regression analysis, age >80 years (p = 0.000; 95% CI, 1.077-1.143) and ASA score III and IV (p = 0.000; 95% CI, 2.088-3.396) (both non-modifiable factors) both proved to be independent (s.s.) factors affecting mortality rates. Age <80 years (p = 0.000; 95% CI, 0.932-0.974), surgery delay less (modifiable factor) than 48 hours (p = 0.046; 95% CI, 0.869-0.999), low dementia CDR index (p = 0.005; 95% CI, 0.471-0.891) (non-modifiable factor), and osteoporosis medical treatment (modifiable factor) (p = 0.006; 95% CI, 0.494-0.891) were shown to be independent (s.s.) factors affecting HOOS-symptoms. Osteoporosis medical treatment used proved to be an independent (s.s.) factor affecting HOOS-daily activities (p = 0.049; 95% CI, 0.563-1.000) and quality of life (E-Qol-5D) (p = 0.036; 95% CI, 0.737-1.325).

CONCLUSIONS

A hip fracture patient aged <80 years old, with an ASA I-II, with low dementia CDR index and on osteoporosis medication has a better chance of an improved outcome (winner patient).

The Journey Toward Taking the Day for Granted Again: The Experiences of Rural Older People's Recovery From Hip Fracture Surgery

BACKGROUND

A hip fracture is an unexpected, subjective, traumatic experience that affects the person in both physical and emotional ways.

PURPOSE

The purpose of this study was to describe rural older people's experiences of recovering after hip fracture surgery.

METHODS

Thirteen individual interviews were conducted with older people. The interview texts were analyzed with qualitative content analysis.

RESULTS

Patients described finding themselves in a new and vulnerable situation, dependent on others for simple everyday chores. They struggled to regain independence while staying positive, convinced that they would recover. Fear of another fall, as well as lack of information, made recovery at home difficult.

CONCLUSION

Older people who experience hip fractures need support during the recovery process. Because recovery begins at the hospital, this study highlight patients' need to participate in recovery planning, as well as the need to have information about what it means to be affected by a hip fracture and how to prevent it from happening again. This study emphasizes that nurses' awareness of patients' need to participate in planning the recovery process is crucial for enabling patients' return to a daily life that is similar to their prefracture life.

Functional recovery in hip fracture patients: the role of pharmacotherapy

BACKGROUND AND AIM

The aim of this prospective observational cohort study was to verify the relationship between number of drugs used and functional outcome in hip fracture patients undergoing rehabilitation.

METHODS

This study was conducted on 139 patients with hip fracture who underwent a rehabilitation program. Efficiency rate in the Functional Independence Measure (FIM) and Berg Balance Scale (BBS), and length of stay (LOS) were the outcome measures.

RESULTS

At the end of rehabilitation, 66.1% of patients showed an increase in number of drugs used, while 33.9% used the same or lower number of drugs than at admission. At the end of rehabilitation patients with increased pharmacotherapy took a higher total number of drug classes (p = 0.001), had longer LOS (p = 0.009) and lower Berg efficiency (p = 0.048) than patients with the same or lower pharmacotherapy. The number of drugs used at discharge was an independent determinant of LOS (beta = 0.19, p = 0.022) and FIM efficiency (beta = - 0.20, p = 0.025). Age was a determinant of LOS (beta = 0.17, p = 0.044) and BBS efficiency (beta = - 0.23, p = 0.009), while CIRS severity was a determinant of BBS efficiency only (beta = - 0.22, p = 0.016).

DISCUSSION

Findings of study indicate that in hip fracture patients, the number of drugs prescribed at discharge is an important indicator of LOS and rehabilitation efficiency.

CONCLUSIONS

These findings can help the physician to better plan the rehabilitation of hip fracture patients who require polypharmacy.

Editorial Commentary: Aging and Rotator Cuff Tears

Osteoporosis is associated with failure of rotator cuff repair. Optimizing bone density, as well as rotator cuff tendon-to-bone fixation in an osteoporotic humeral head, is a necessary approach to the patient as a whole.

Are we treating osteoporotic fractures of the hip adequately? A Middle Eastern cohort study

Fragility hip fractures treated in a center in the Middle East were retrospectively studied for adequacy of osteoporosis management. Of the 318 patients treated, over 70% did not have a structured investigation and about 30% did not receive any therapeutic supplements. Our series showed a preventable 8.8% secondary fracture rate.

PURPOSE

To study the adequacy of evaluation and treatment of osteoporosis after fragility fractures of the hip. The study also attempts to estimate the prevalence of secondary fractures after the original injury.

METHODS

This is a retrospective evaluation of the electronic database to search all the admissions for fractures of the hip in patients over 50 years at a tertiary care Trauma and Orthopaedic center in the Sultanate of Oman. The study period was defined as October 2010 to December 2015. Their case records, BMD reports, and laboratory data were analyzed. Pharmacological interventions and the documented compliance with such therapy were also recorded.

RESULTS

Over the study period, 318 fragility fractures of the hip were treated. Of these, 233 (73.3%) did not receive a DEXA scan and 94% did not have their vitamin D₃ (vit D) tested. About 29.9% percent cases did not receive any nutritional supplement or therapeutic intervention though diagnosed as fragility fracture. Twenty-eight patients (8.8%) reported for secondary fractures of the hip. Of these, 86% was initiated on supplement after their index fracture though 78.6% had not had a BMD study.

CONCLUSIONS

Less than 27% patients receive BMD test following fragility fracture of the hip and only 6% a vit D3 assay. Secondary fractures of the hip tend to occur in approximately 9% of the cases in Oman; this seems to occur equally in patients who have had as well as not had any calcium and vit D supplements after the index injury.

The effects of combined human parathyroid hormone (1-34) and simvastatin treatment on the interface of hydroxyapatite-coated titanium rods implanted into osteopenic rats femurs

The effect of human parathyroid hormone 1-34 (PTH) and simvastatin (SIM) alone could promote bone healing in osteoporotic implant fixation, but there are no reports about the combined use of PTH and SIM for promotion of bone healing around implant in osteoporotic settings. This study aims to investigate effects of PTH + SIM on implant stabilization in osteopenic rats. Fourteen weeks after chronically fed a low protein diet, osteopenic rats randomly received implants. Subsequently, the animals were randomly divided into four groups: Control, SIM, PTH and PTH + SIM. Then all rats from groups PTH, SIM and PTH + SIM received PTH (40 μg/kg, three times a week), SIM (25 mg/kg, daily), or both for 12 weeks. The results of our study indicated that all treatments promoted bone healing around implant compared to Control, but PTH + SIM treatment showed significantly stronger effects than PTH or SIM alone in histological, micro-CT, and biomechanical tests. The results indicated additive effects of PTH and SIM on implant fixation in osteoporotic rats.

Treatment study of distal femur for parathyroid hormone (1-34) and β-tricalcium phosphate on bone formation in critical-sized defects in osteopenic rats

The objective of this study was to evaluate the effect of following combined treatment with parathyroid hormone (1-34) (PTH) and β-tricalcium phosphate (β-TCP) on local bone formation in a rat 3-mm critical-sized defect at the distal femur. Fourteen weeks were allowed to pass before defect surgery for the establishment of osteopenic animal models chronically fed a low-protein diet. All animals were randomly divided into four groups: group PTH; group β-TCP, group PTH + β-TCP, and a control group. All rats then underwent a surgical procedure to create bone defects in the bilateral distal femurs, and β-TCP was implanted into critical-sized defects for the groups designated as β-TCP and group PTH + β-TCP. After the defect operation, all animals from group PTH and group PTH + β-TCP received following subcutaneous injections with PTH (60 μg/kg, three times per week) until euthanasia at 4 and 8 weeks. The distal femurs and blood were collected for evaluation. The results of study showed the strongest effect on accelerating the local bone formation with treatment β-TCP and PTH at 4 weeks and 8 weeks. The results from our study demonstrate that a combination of PTH and β-TCP had an additive effect on local bone formation in osteopenic rats chronically fed a low-protein diet.

The relationship between fracture and quality of life in Korean adults receiving treatment for osteoporosis based on the 2010 Korean Community Health Survey

[Purpose] The purpose of this study was to investigate the relationship between fracture and quality of life in Korean adults receiving treatment for osteoporosis based on the 2010 Korean Community Health Survey (KCHS). [Subjects and Methods] This study utilized the raw data of the 2010 KCHS. In the survey, osteoporosis was assessed in 228,903 subjects, excluding 326 for whom there was insufficient data. There were 17,387 subjects with osteoporosis confirmed by a doctor’s diagnosis and 9,419 of them were being treated for osteoporosis at the time of the survey. [Results] Among the patients being treated, those with fractures had a significantly lower QOL than patients who did not experience fractures. The lower QOL scores were caused by hip, vertebral and wrist fractures, and in all cases, QOL was significantly lower. Greater numbers of fractures significantly lowered QOL scores compared to participants without fractures. [Conclusion] Fractures in patients receiving treatment for osteoporosis have a direct impact on QOL. Among the different types of fractures, hip fractures resulted in the lowest scores. Therefore, to avoid additional fractures caused by inappropriate management of osteoporosis, we suggest that there is a need to improve fall related self-efficacy and prevention programs.

The T.A.R.Ge.T. project: a regional program to reduce hip fracture in elderly patients. Main results of retrospective phase

The Tuscany Region was the first Italian Region to initiate a program for the prevention of hip fractures in over 65 year old. The T.A.R.Ge.T. project "Appropriate treatment of geriatric re-fractures in Tuscany" (Trattamento Appropriato delle Rifratture Geriatriche in Toscana), which is still on-going, includes a preliminary phase (2009-2010) for baseline analysis and education of the participating centers and a 4-year-prospective phase (2011-2014). The monitoring system is performed horizontally analyzing 5 different flows: SDO (Performance Hospitalization), SPF (Pharmaceutical Distribution Dataset), FED (Direct Distribution Dataset), SAA (Registry of Patients), SPA (Specialized Outpatient) flows. In this review will be shown some of the most important results of analyzes of the retrospective phase. Between 2006 and 2011 only 26% of hip fractured patients has being treated with anti-osteoporotic drugs. The percentage of treatment increases 10% after the second fracture. Until 2011 there wasn't in Tuscany a prevention program of bone fragility; patients were treated with specific treatment only in severe cases: this phenomenon implies that mortality and re-fracture are higher on treated patients than in patients who did not have any kind of treatment. The treated patients are the most severe and therefore they have a higher risk of death and re-fracture.

The effect of osteoporotic treatment on the functional outcome, re-fracture rate, quality of life and mortality in patients with hip fractures: a prospective functional and clinical outcome study on 520 patients

Numerous high quality studies have shown the positive effects of various osteoporotic medical treatment regimens on bone mass and on the reduction of risk for new spinal, hip and non-spinal fractures in osteoporotic patients. However, the effect of osteoporotic treatment on the functional and clinical outcome of patients who have sustained hip fractures and been treated surgically has not yet been addressed. Five hundred and twenty patients out of 611 who were admitted (2009-2011), operated on due to a hip fracture and completed their follow-up evaluations were included in this study. Data related to functional outcome scores, re-fracture rate, quality of life and mortality rate were prospectively recorded, analysed and correlated to osteoporotic medical treatment. There were 151 (25%) men and 369 (71%) women with a mean age of 80.7 years (range, 60 to 90 years). At a mean follow-up of 27.5 months (range, 24 to 36 months) a mortality rate of 23.6% at 2 years was recorded. Mean values of functional and quality of life scores were found to have progressively improved within two years after surgery. Seventy-eight (15%) patients were taking osteoporotic treatment before their hip fracture and 89 (17.1%) started afterwards. Osteoporotic treatment proved to be an important predictor of functional recovery (all p values<0.05), re-fracture rate (p=0.028) and quality of life (EQ-5D, all dimensions, p values<0.05). Osteoporotic treatment did not affect post-fracture mortality rates. Osteoporotic treatment taken before or initiated after fracture is a strong predictor of functional and clinical outcome in patients with hip fractures treated surgically.

Bone marrow stem cells added to a hydroxyapatite scaffold result in better outcomes after surgical treatment of intertrochanteric hip fractures

INTRODUCTION

Intertrochanteric hip fractures occur in the proximal femur. They are very common in the elderly and are responsible for high rates of morbidity and mortality. The authors hypothesized that adding an autologous bone marrow stem cells concentrate (ABMC) to a hydroxyapatite scaffold and placing it in the fracture site would improve the outcome after surgical fixation of intertrochanteric hip fractures.

MATERIAL AND METHODS

30 patients were randomly selected and divided into 2 groups of 15 patients, to receive either the scaffold enriched with the ABMC (Group A) during the surgical procedure, or fracture fixation alone (Group B).

RESULTS

There was a statistically significant difference in favor of group A at days 30, 60, and 90 for Harris Hip Scores (HHS), at days 30 and 60 for VAS pain scales, for bedridden period and time taken to start partial and total weight bearing (P < 0.05).

DISCUSSION

These results show a significant benefit of adding a bone marrow enriched scaffold to surgical fixation in intertrochanteric hip fractures, which can significantly reduce the associated morbidity and mortality rates.

CONCLUSION

Bone marrow stem cells added to a hydroxyapatite scaffold result in better outcomes after surgical treatment of intertrochanteric hip fractures.

Increased incident hip fractures in postmenopausal women with moderate to severe pelvic organ prolapse

OBJECTIVE

The aim of this study was to examine the association between fracture and pelvic organ prolapse (POP) in postmenopausal women enrolled in the Women's Health Initiative Estrogen Plus Progestin trial.

METHODS

POP was assessed as cystocele, rectocele, or uterine prolapse and was graded as either "absent to mild" or "moderate to severe." Cox proportional hazard analyses (adjusting for age, body mass index, race, asthma, emphysema, thyroid disease, family history of fracture, regular menses, age at menopause, nulliparity, history of hormone therapy [HT], history of falls, socioeconomic status, calcium, and vitamin D supplementation and physical activity) explored the relationships between moderate to severe POP and incident bone fractures.

RESULTS

Moderate- to severe-grade POP was identified in almost 8% of women (n = 1,192). During a follow-up duration of 7.41 (2.18) years (mean [SD]), 2,156 incident fractures were observed; the most common fracture site was the lower arm (n = 615; 28.51%) followed by the hip (n = 205; 9.51%). Adjusted analyses confirmed moderate to severe POP (of any type) as an independent risk factor for incident hip fractures (hazard ratio [HR], 1.83; 95% CI, 1.16-2.89; P = 0.010). On analyses stratified by assigned treatment (HT vs placebo), moderate to severe rectocele emerged as an independent predictor of incident spine (HR, 2.61; 95% CI, 1.04-6.56; P = 0.042) and lower arm fractures (HR, 1.87; 95% CI, 1.06-3.29; P = 0.030) in the placebo group.

CONCLUSIONS

We identify moderate to severe POP (any type) in postmenopausal women as a risk factor for hip fracture; moderate to severe rectocele holds an additional risk of spine and lower arm fractures in women not taking HT.

Increased incident hip fractures in postmenopausal women with moderate to severe pelvic organ prolapse

OBJECTIVE

The aim of this study was to examine the association between fracture and pelvic organ prolapse (POP) in postmenopausal women enrolled in the Women's Health Initiative Estrogen Plus Progestin trial.

METHODS

POP was assessed as cystocele, rectocele, or uterine prolapse and was graded as either "absent to mild" or "moderate to severe." Cox proportional hazard analyses (adjusting for age, body mass index, race, asthma, emphysema, thyroid disease, family history of fracture, regular menses, age at menopause, nulliparity, history of hormone therapy [HT], history of falls, socioeconomic status, calcium, and vitamin D supplementation and physical activity) explored the relationships between moderate to severe POP and incident bone fractures.

RESULTS

Moderate- to severe-grade POP was identified in almost 8% of women (n = 1,192). During a follow-up duration of 7.41 (2.18) years (mean [SD]), 2,156 incident fractures were observed; the most common fracture site was the lower arm (n = 615; 28.51%) followed by the hip (n = 205; 9.51%). Adjusted analyses confirmed moderate to severe POP (of any type) as an independent risk factor for incident hip fractures (hazard ratio [HR], 1.83; 95% CI, 1.16-2.89; P = 0.010). On analyses stratified by assigned treatment (HT vs placebo), moderate to severe rectocele emerged as an independent predictor of incident spine (HR, 2.61; 95% CI, 1.04-6.56; P = 0.042) and lower arm fractures (HR, 1.87; 95% CI, 1.06-3.29; P = 0.030) in the placebo group.

CONCLUSIONS

We identify moderate to severe POP (any type) in postmenopausal women as a risk factor for hip fracture; moderate to severe rectocele holds an additional risk of spine and lower arm fractures in women not taking HT.

Short-term and long-term orthopaedic issues in patients with fragility fractures

BACKGROUND

Patients with impaired bone quality who suffer a fragility fracture face substantial challenges in both their short- and long-term care. In addition to poor bone quality, many of these patients have multiple medical comorbidities that alter their surgical risk and affect their ultimate functional recovery. Some medical issues can contribute to the altered bone quality and must be addressed to prevent future fractures.

QUESTIONS/PURPOSES

This review summarizes the modifications in perioperative management and fracture fixation in patients with common fragility fractures who have impaired bone quality. It also summarizes the postoperative diagnosis and treatment of secondary causes of impaired bone quality in these patients.

METHODS

We performed a PubMed search, and literature published after 2000 was prioritized, with the exception of benchmark clinical trial studies published before 2000.

RESULTS

Patients with altered bone quality require rapid perioperative management of multiple medical comorbidities. Implant selection in patients with poor quality bone should permit early weightbearing, and constructs should maximize surface area contact with the remaining bone. Long-term diagnosis and treatment of other disease states contributing to poor bone quality (vitamin D deficiency/insufficiency, hypothyroidism, hyperthyroidism, hyperparathyroidism, Cushing's disease, and hypogonadism) must occur to minimize the chances of future fractures.

CONCLUSIONS

Recognition of patients with impaired bone quality and proper treatment of their special needs in both the short and long term are essential for their best opportunity for maximal functional recovery and prevention of future fractures.

Management of osteoporosis in patients hospitalized for hip fractures

Hip fracture is associated with high morbidity, mortality, and economic burden worldwide. It is also a major risk factor for a subsequent fracture. A literature search on the management of osteoporosis in patients with hip fracture was performed on the Medline database. Only one clinical drug trial was conducted in patients with a recent hip fracture. Further studies that specifically address post-fracture management of hip fracture are needed. The efficacy of anti-osteoporosis medication in older individuals and those at high risk of fall is reviewed in this paper. Adequate nutrition is vital for bone health and to prevent falls, especially in malnourished patients. Protein, calcium, and vitamin D supplementation is associated with increased hip BMD and a reduction in falls. Fall prevention, exercise, and balance training incorporated in a comprehensive rehabilitation program are essential to improve functional disability and survival. Exclusion of secondary causes of osteoporosis and treatment of coexistent medical conditions are also vital. Such a multidisciplinary team approach to the management of hip fracture patients is associated with a better clinical outcome. Although hip fracture is the most serious of all fractures, osteoporosis management should be prioritized to prevent deterioration of health and occurrence of further fracture.

PTH improves titanium implant fixation more than pamidronate or renutrition in osteopenic rats chronically fed a low protein diet

SUMMARY

We evaluated the effects of parathyroid hormone (PTH), pamidronate, or renutrition on osseointegration of titanium implants in the proximal tibia of rats subject to prolonged low-protein diets. PTH improved mechanical fixation, microarchitecture, and increased pull-out strength. Pamidronate or renutrition had lesser effects. PTH can thus improve implant osseointegration in protein-malnourished rats.

INTRODUCTION

Protein malnutrition impairs implant osseointegration in rats. PTH and pamidronate prevent deleterious effects of protein restriction introduced just prior to implantation. Whether these treatments improve osseointegration after chronic protein deprivation, i.e., in osteopenic bone at time of implantation, is unknown. We evaluated effects of PTH, pamidronate, or renutrition on resistance to pull-out of titanium rods implanted into the rat tibiae following isocaloric low-protein intake.

METHODS

Forty-one adult female rats received normal or isocaloric low-protein diets. Six weeks later, implants were surgically inserted into proximal tibiae. Following implantation, rats on low-protein diets were treated with PTH (1-34), pamidronate, saline vehicle, or normal protein diets, for another 8 weeks. Tibiae were removed for micro-computerised tomographic morphometry and evaluation of pull-out strength.

RESULTS

Pull-out strength decreased in rats on isocaloric low-protein diets compared with normal protein group (-33.4%). PTH increased pull-out strength in low-protein group, even compared to controls from the normal protein group. PTH and pamidronate increased bone volume/tissue volume, bone-to-implant contact, and trabecular thickness, whilst trabecular separation was reduced, with a shift to more plate-like bone surrounding the implants.

CONCLUSIONS

PTH reversed the deleterious effects of long-term protein undernutrition on mechanical fixation and bone microarchitecture and improved implant osseointegration more than pamidronate or renutrition, likely through changes to structure model index.

What rate of utilization is appropriate in musculoskeletal care?

Musculoskeletal procedures often show wide variation in rates across geographic areas, which begs the question, "Which rate is right?" Clearly, there is no simple answer to this question. We summarize a conceptual framework for thinking about how to approach this question for different types of interventions. One guiding principle is the "right rate" is usually the one that results from the choices of a fully informed and empowered patient population. For truly effective care without substantial tradeoffs, the right rate may approach 100%. The rate of operative treatment of hip fracture, for example, approaches the underlying incidence of disease; however, the rate of some forms of effective care, like osteoporosis evaluation and treatment after a fragility fracture, is often quite low and undoubtedly reflects underuse. The recommended approach to underuse is to improve the reliability and accountability of the delivery system. Many other musculoskeletal interventions fall into the category of "preference-sensitive care." These interventions involve important tradeoffs between risks and benefits. Variations in these procedure rates may represent insufficient focus on patient values and preferences, relying instead on the enthusiasm of the physician for treatment alternatives. The recommended approach in this setting is the use of decision aids and other approaches to informed choice.

LEVEL OF EVIDENCE

Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.

Short-term relationship between meteorological variables and hip fractures: an analysis carried out in a health area of the Autonomous Region of Valencia, Spain (1996-2005)

INTRODUCTION

Diverse studies have shown a seasonal influence on the incidence of hip fracture (HF), possibly associated with adverse meteorological conditions. In this paper, we present an analysis of the short-term relationship between meteorological conditions and the incidence of HF in people over 45 years of age living in a Mediterranean climate zone.

MATERIAL AND METHODS

HF cases admitted to the two reference hospitals in the health area were selected. The meteorological variables (temperature, relative humidity, rain, wind, and other conditions) were obtained from a weather station centrally located within the area under study. The trend and seasonality of the time series were analyzed with the aid of Poisson regression modeling. The relationship between the incidence of a hip fracture and the meteorological conditions, both on the same day and on the day previous to the patient's admission to the hospital were correlated in a case-crossover analysis with the control periods selected in accordance with two different methods of approximation (symmetric and semi-metric). The results were analyzed for different subgroups defined by age (older or younger than 75 years of age) and sex of subject and by type of fracture (cervical or pertrochanteric).

RESULTS

2121 patients admitted for HF were selected. Of these, 1598 (75.3%) were women and 523 (24.7%) were men. The average age of the subjects was 80, with patients ranging from 45-99 years of age. The time/weather series showed a positive tendency, with a greater occurrence of cases in the autumn and winter months. The case-crossover analysis showed a significant relationship between the daily duration of wind and the incidence of HFs. Divided into quartiles, the windiest days (quartile 4) were associated with a 32% increased risk of HF (OR 1.32 CI 95% 1.10-1.58) with respect to the calmest days (quartile 1), especially in patients under 75 (OR 1.53; CI 95% 1.02-2.29). The remaining meteorological variables were not associated in any significant fashion with the incidence of HFs. The results were comparable across different subgroups classified by age, sex, and type of fracture.

CONCLUSIONS

The incidence of HFs varies seasonally and presents a significant association with the coldest times of the year. In the short-term, lasting windy periods are associated with an increased risk of HFs whereas other meteorological variables show a much lower, non-significant correlation.

Once-yearly zoledronic acid in hip fracture prevention

Osteoporosis is an escalating global problem. Hip fractures, the most catastrophic complication of osteoporosis, continue to cause significant mortality and morbidity despite increasing availability of effective preventative agents. Among these agents, oral bisphosphonates have been the first choice for the treatment and prevention of osteoporotic fractures. However, the use of oral bisphosphonates, especially in the older population, has been limited by their side effects and method of administration thus compromising their persistent use. The resultant low adherence by patients has undermined their full potential and has been associated with an increase in the incidence of fragility fractures. Recently, annual intravenous zoledronic acid (ZOL) has been approved for osteoporosis. Randomized controlled trials have demonstrated ZOL to be safe, have good tolerability and produce significant effect on bone mass and microarchitecture. Adherence has also been shown to be better with ZOL. Furthermore two large trials firmly demonstrated significant anti-osteoporotic effect (∼59% relative risk reduction of hip fractures) and mortality benefit (28% reduction in mortality) of ZOL in older persons with recent hip fractures. In this review, we report the current evidence on the use of ZOL for the prevention of hip fractures in the elderly. We also report the pharmacological characteristics and the advantages and disadvantages of ZOL in this particular group.