Prescribing and adherence to bone protection medications following hip fracture in the United Kingdom: results from the World Hip Trauma Evaluation (WHiTE) cohort study

Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures

BACKGROUND

Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures.

MATERIALS AND METHODS

This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contra-lateral hip fracture, with the second treated at our tertiary referral center.

RESULTS

The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event.

CONCLUSION

Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 202x;4x(x):xx-xx.].

The role of frailty risk for fracture-related hospital readmission and mortality after a hip fracture

BACKGROUND

Frailty risk estimated using hospital administrative data may provide a useful clinical tool to identify older hip fracture patients at-risk of fracture-related readmissions and mortality. This study examined hip fracture hospitalisation temporal trends and explore the role of frailty risk in fracture-related readmission and mortality.

METHODS

This retrospective cohort study was conducted using linked hospital admission and mortality data in New South Wales, Australia. Patients aged ≥65 years were admitted after a hip fracture between 2014 and 2021 for temporal trends and those admitted and discharged after a hip fracture in 2014-2018 for fracture-related readmission. The Hospital Frailty Risk Score was estimated, and patients were followed for at least 36 months after discharge. A semi-competing risk analysis was used to examine the associations of frailty with fracture-related readmission and/or mortality.

RESULTS

Hip fracture hospitalisation rate was 472 per 100,000 and declined by 2.9 % (95 % confidence intervals (CI): -3.7 to -2.1) annually. Amongst 28,567 patients, 9.8 % were identified with low frailty risk, 39.4 %, intermediate frailty risk, and 50.6 % with high frailty risk. Patients with intermediate or high frailty risk had a higher chance of fracture-related readmission (Hazard ratios (HR): 1.33, 95 %CI: 1.21-1.47, HR: 1.65, 95 %CI: 1.49-1.83), death (HR: 1.50, 95 %CI: 1.38-1.63, HR: 1.80, 95 %CI: 1.65-1.96) and death post fracture-related readmission (HR: 1.32, 95 %CI: 1.12-1.56, HR: 1.56, 95 %CI: 1.32-1.84) than those with low frailty risk.

CONCLUSIONS

It appears that frailty risk estimated using hospital administrative data can contribute to identify patients who could benefit from targeted interventions to prevent further fractures.

Bone health in rural Australia: a mixed methods study of consumer needs

This mixed methods study explores osteoporosis among adults living in a regional area of Victoria, Australia. Three major themes emerged from interviews, which reflected the findings of surveys, concerns regarding the adequacy of care in rural areas, a desire for tailored, local care, and a desire for hybrid telemedicine or in-person services.

PURPOSE

Osteoporosis or osteopenia affects over half of adults aged over 50 years. People living outside major cities in Australia have higher hip fracture rates than people living in cities, along with reduced access to bone densitometry and osteoporosis specialists. This study explores osteoporosis risk factors, knowledge, experiences of and preferences for care in people living in a regional area, to inform development of osteoporosis care programs.

METHODS

Adults living in a large non-metropolitan region of Australia were invited to participate in a mixed methods study: a survey (phase 1) followed by semi-structured interviews (phase 2) with triangulation of results. Data collected included osteoporosis diagnosis, risk factors, management, knowledge, preferences for care and experience using telemedicine. Surveys were analysed quantitatively, with linear and logistic regression used to assess factors related to osteoporosis knowledge or satisfaction with telemedicine. Interview transcripts were analysed using thematic analysis by two researchers, with in-depth discussion to identify themes.

RESULTS

Sixty-two participants completed the survey, and 15 completed interviews. The mean (SD) age of survey participants was 62.2 (14.1) years, 57% had a screening test for osteoporosis, and 12 (19%) had a diagnosis of osteoporosis. The mean osteoporosis knowledge score was 8.4 / 19 and did not differ with age, education, or history of osteoporosis. The majority wanted access to more information about osteoporosis but preferred method differed, and the majority preferred in-person medical consultations to telemedicine. Interview participants were aged between 57 and 87 years, and included 8 with osteoporosis or osteopenia. Three major themes emerged: concerns regarding the adequacy of care in rural areas, a desire for tailored local car and a desire for hybrid telemedicine or in-person services.

CONCLUSION

Gaps exist in rural osteoporosis care, including knowledge, screening and management. People have differing experiences of care, access to services and preferences for care. High-quality care, tailored to their needs, was preferred. Improving osteoporosis services for regional Australia will require a flexible, multi-faceted approach, addressing needs of the local community and providers.

Denosumab versus zoledronic acid in elderly patients after hip fracture

BACKGROUND

Two injectable anti-osteoporosis medications, denosumab and zoledronic acid, have been widely used to treat patients with severe osteoporosis. The purpose of this study was to evaluate the real-world effectiveness and adherence of denosumab compared to zoledronic acid in geriatric patients after a hip fracture.

METHODS

A total of 282 patients treated with osteoporotic hip fracture between March 2014 and Aug 2022 were retrospectively reviewed. The patients were asked to select the anti-osteoporosis medication after surgery. Treatment persistence was monitored by follow-up visit to the outpatient clinic at postoperative 2 years.

RESULTS

Of 282 individuals with baseline data, 162 patients took subcutaneous denosumab and 120 patients took intravenous zoledronic acid. At postoperative 2 years, the change in bone mineral density (BMD) from baseline was greater in the denosumab group compared with the zoledronic acid group (p < 0.001). The rate of persistence to denosumab was significantly higher than that for 12-months zoledronic acid (p = 0.01). Serious adverse events were similar in the two groups.

CONCLUSIONS

Our study revealed the effectiveness and patients' persistence for two commonly used anti-osteoporosis agents after hip fracture. In this frail, elderly population, half-yearly denosumab was superior to yearly zoledronic acid in BMD and demonstrated significant higher persistence rate, indicating a potential therapeutic advantage that warrants further validation.

Improving osteoporosis treatment rates in inpatients admitted with hip fracture: A healthcare improvement initiative in a tertiary referral hospital

Objective

This healthcare improvement initiative was designed to increase inpatient osteoporosis treatment after hip fracture.

Methods

A new protocol was developed by Geriatric Medicine and Endocrinology departments at a tertiary care hospital in Sydney. Its aim was to standardize assessment and treatment of osteoporosis in patients admitted with hip fracture. Eligible inpatients would receive intravenous zoledronic acid during their admission. A 6-month sample of hip fracture patients admitted after the protocol's implementation was compared to a group admitted before. Data collected included demographics, biochemistry, treatment rates, adverse effects, and admission survival.

Results

There was a considerable increase in osteoporosis treatment after introducing the protocol. Before the protocol's introduction, none of 36 eligible patients received treatment. After the intervention 79% (23 out of 29) of eligible patients were treated.All treated patients had renal function and serum calcium levels checked post-infusion with no adverse outcomes. Eight patients developed flu-like symptoms within 24 h of the infusion. There were no instances of arrhythmias, ocular inflammation, or death. The cost per patient treated was AUD $87.

Conclusion

Adopting a standardized protocol for osteoporosis treatment in patients admitted for hip fracture was effective in improving treatment rates whilst being relatively safe and inexpensive.

Pharmacological management, and potentially inappropriate prescriptions in patients with osteoporosis

BACKGROUND

The treatment of osteoporosis involves medications that reduce the risk of fractures, but some medications can decrease bone density. The aim was to identify the treatments, comorbidities, and prescriptions related to reducing bone mineral density in patients with osteoporosis.

RESEARCH DESIGN AND METHODS

A cross-sectional study that identified patterns of anti-osteoporotic drug prescriptions for outpatient use and potentially inappropriate prescriptions for patients with osteoporosis based on the drug-dispensing database of 8.5 million people in Colombia. All patients ≥65 years with a diagnosis of osteoporosis were included.

RESULTS

A total of 16,362 patients with osteoporosis were identified. They had a median age of 74.4 years, and 47.9% received anti-osteoporotic therapy, especially bisphosphonates (41.6%), and 86.5% received calcium and/or vitamin D supplement. 41.6% of those who had a history of bone fractures were prescribed anti-osteoporotic drugs. Potentially inappropriate prescriptions, especially corticosteroids at doses greater than 5mg prednisolone equivalent (4.4%), were found in 41.4% of cases and were more common in older patients and those with a history of fractures or with cardiovascular, digestive, neurological, psychiatric or neoplastic comorbidities.

CONCLUSIONS

A significant proportion of patients had potentially inappropriate prescriptions, especially older patients, those with certain comorbidities, and those receiving comedication with antirheumatic drugs.

Multivariable prediction models for long-term outcomes after hip fracture: A protocol for a systematic review

Background: Hip fracture results in high mortality and, for many survivors, long-term functional limitations. Multivariable prediction models for hip fracture outcomes have the potential to aid clinical-decision making as well as risk-adjustment in national audits of care. The aim of this study is to identify, critically appraise and synthesise published multivariable prediction models for long-term outcomes after hip fracture. Protocol: The systematic review will include a literature search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) for journal articles. Search terms related to hip fracture, prognosis and outcomes will be included. Study selection criteria includes studies of people with hip fracture where the study aimed to predict one or more long-term outcomes through derivation or validation of a multivariable prediction model. Studies will be excluded if they focus only on the predictive value of individual factors, or only include patients with periprosthetic fractures, fractures managed non-surgically or younger patients. Covidence software will be used for data management. Two review authors will independently conduct study selection, data extraction and appraisal. Data will be extracted based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist. Risk of bias assessment will be conducted using the Prediction model Risk of Bias Assessment Tool (PROBAST). Characteristics and results of all studies will be narratively synthesised and presented in tables. Where the same model has been validated in multiple studies, a meta-analysis of discrimination and calibration will be conducted. Conclusions: This systematic review will aim to identify multivariable models for hip fracture outcome prognosis that have been derived using high quality methods. Results will highlight if current models have the potential for further assessment for use in both clinical decision making and improving methods of national hip fracture audits. PROSPERO registration: CRD42022330019 (25th May 2022).

Long-term persistence of treatment after hip fracture in a fracture liaison service

Long-term adherence to antiosteoporosis medication (AOM) in the setting of a fracture liaison service (FLS) are not well known. Patients ≥ 50 with hip fracture seen in an FLS and recommended for treatment to prevent new fractures were analyzed. Baseline data included demographics, identification mode, previous treatment and FRAX items. Patient records were reviewed 3-8 years later, and these data were collected: (1) survival; (2) major refracture; (3) initiation of treatment, proportion of days covered (PDC) and persistence with AOM. 372 patients (mean age, 79 years; 76% women) were included. Mean follow-up was 47 months, 52 patients (14%) had a refracture (22 hip) and 129 (34.5%) died. AOM was started in 283 patients (76.0%). Factors associated with initiation of AOM were previous use of bisphosphonate (OR 9.94; 95% CI 1.29-76.32) and a lower T-score lumbar (OR 0.80; 95% CI 0.65-0.99). Persistence decreased to 72.6%, 60% and 47% at 12, 36 and 60 months. A PDC > 80% was confirmed in 208 patients (55.7%) and associated with previous use of bisphosphonate (OR 3.38; 95% CI 1.34-8.53), treatment with denosumab (OR 2.69; 95% CI:1.37-5.27), and inpatient identification (OR 2.26; 95% CI 1.18-4.34). Long-term persistence with AOM was optimal in patients with hip fracture seen at an FLS. A PDC > 80% was associated with inpatient identification and prescription of denosumab.

Safety climate, leadership and patient views associated with hip fracture care quality and clinician perceptions of hip fracture care performance

BACKGROUND

Hip fracture is a major public health concern for older adults, requiring surgical treatment for patients presenting at hospitals across Australia. Although guidelines have been developed to drive appropriate care of hip fracture patients in hospitals, data on health outcomes suggest these are not well-followed.

OBJECTIVE

This study aims to examine whether clinician measures of safety, teamwork and leadership, and patient perceptions of care are associated with key indicators of hip fracture care and the extent to which there is agreement between clinician perceptions of hip fracture care performance and actual hospital performance of hip fracture care.

METHODS

Retrospective analysis was performed on a series of questionnaires used to assess hospital department- and patient-level measures from the Deepening our Understanding of Quality in Australia study. Data were analysed from 32 public hospitals that encompassed 23 leading hip fracture clinicians, 716 patient medical records and 857 patients from orthopaedic public hospital wards.

RESULTS

Aggregated across all hospitals, only 5 of 12 of the key hip fracture indicators had ≥50% adherence. Adherence to indicators requiring actions to be performed within a recommended time period was poor (7.2-25.6%). No Patient Measure of Safety or clinician-based measures of teamwork, safety climate or leadership were associated with adherence to key indicators of hip fracture care. Simple proportionate agreement between clinician perceptions and actual hospital performance was generally strong, but few agreement coefficients were compelling.

CONCLUSION

The development of strong quality management processes requires ongoing effort. The findings of this study provide important insights into the relationship between hospital care and outcomes for hip fracture patients and could drive the design of targeted interventions for improved quality assurance of hip fracture care.

Development of an Early Activation Hip Fracture Care Bundle and Implementation Strategy to Improve Adherence to the National Hip Fracture Clinical Care Standard

Objective

To develop and implement a multidisciplinary early activation mechanism and bundle of care (eHIP) to improve adherence to ACSQHC standards in a regional trauma centre.

Methods

Barriers to implementation were categorised using the Theoretical Domains Framework, then linked to specific strategies guided by the Behaviour Change Wheel and Behaviour Change Technique Taxonomy (BCTT). The resulting implementation strategies were assessed using Affordable, Practical, Effective, Acceptable, had Side-effects (APEASE) criteria.

Results

Eighty-three barriers to implementation of the hip fracture care bundle were identified. The behaviour change wheel process resulted in the identification of 41 techniques to address these barriers. The predominant mechanisms to achieve this were development and implementation of 1) formal policy that outlines eHIP roles; 2) video promotion; 3) pager group; 4) fascia iliaca block enabling; 5) eMR modifications; 6) face-to-face reinforcement and modelling; 7) communication and prompts; 8) environmental restructuring.

Conclusion

We applied behaviour change theory through a pragmatic evidence-based process. This resulted in a codesigned strategy to overcome staff and organisational barriers to the implementation of a multidisciplinary early activation mechanism and bundle of care (eHIP). Future work will include evaluation of the uptake and clinical impact of the care bundle.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study

PURPOSE

Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures.

PATIENTS AND METHODS

Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications.

RESULTS

Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality.

CONCLUSIONS

Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics

BACKGROUND

Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes.

METHODS

This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used.

FINDINGS

314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare.

INTERPRETATION

This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.

Radiographer advanced and consultant practice and community diagnostic hubs - a vision for the future

OBJECTIVES

This article combines a brief narrative review of the Richards Report with an overview of current radiographer advanced and consultant clinical practice (ACCP) to provide suggestions for future ACCP within radiography.

KEY FINDINGS

The 'Diagnostics: Recovery and Renewal' report by Professor Sir Mike Richards, published in 2020, has identified a need for improvements to be made to diagnostic services. His recommendations include the introduction of Community Diagnostic Hubs (CDHs) that would provide quicker and easier access to diagnostic tests for patients⁽¹⁾ A narrative review around the concept of Advanced and Consultant Clinical Practice (ACCP) for radiographers demonstrates the capability of the radiographers to expand their role. The article concludes with a vision of how CDHs could potentially provide multiple career pathways for radiographers working at this level of practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It is acknowledged that some of these concepts are a combination of visionary and aspirational in outlook rather than being entirely based on current practice. The intention of this article, and the implications for practice, are to support on-going discussions to enable radiography, as a profession, to seek ways and opportunities to do things differently whilst ensuring that the patient remains at the centre of the services delivered.

Patients' first-year adherence to different anti-osteoporotic therapy after hip fractures

BACKGROUND

Osteoporosis medication treatment is recommended after geriatric fractures. However, the percentage of patients receiving anti-osteoporotic treatment after a hip fracture is extremely low.

OBJECTIVES

The aim of this study was to evaluate the adherence to different anti-osteoporotic medications in elderly patients following hip fracture.

METHODS

This retrospective study included 520 patients treated with osteoporotic hip fracture between March 2014 and June 2019. The patients were asked to choose the medication for osteoporosis treatment at discharge. Adherence was monitored by follow-up visits to the outpatient clinic at 1 year following surgery.

RESULTS

Of 520 patients with baseline data, osteoporosis medications were prescribed to 250 (48.1%) patients. Of these patients, 110 (44.0%) took subcutaneous denosumab, 69 (27.6%) took oral selective estrogen receptor modulator, 55 (21.0%) took intravenous bisphosphonate. At 12 months, we followed up 178 (71.2%) patients. Of those prescribed a bone protection medication, only 85 patients (34.0%) reported still taking their medication 1 year later. The rate of adherence to 6-month subcutaneous denosumab injection was significantly higher than that for quarterly intravenous bisphosphonates (p = 0.024) or daily oral tablets (p = 0.028).

CONCLUSIONS

This study revealed patients' adherence for osteoporosis treatments after hip fracture. 6-month subcutaneous denosumab injection was preferred over 3-month intravenous injection or daily oral tablets in this elderly population and exhibited significant lower discontinuation rates. However, because of the limited power of the study, further research is required to identify the reasons behind non-adherence and to improve adherence to anti-osteoporosis medications.

Effect of patient-led cooperative follow-up by general practitioners and community pharmacists on osteoporosis treatment persistence

AIM

Osteoporosis is a major risk factor for fractures. Poor persistence with osteoporosis medication hampers outcomes. This study assessed whether encouraging the formation of patient-led follow-up cooperatives between general practitioners (GPs) and community pharmacists improved medication persistence.

METHODS

All consecutive patients who attended an osteoporosis patient education program were invited to participate. They were given a logbook containing questionnaires they would bring to 6-monthly visits to their GP and pharmacist. The effect of this 3-year cooperative follow-up on persistence with medication and lifestyle changes was assessed.

RESULTS

In total, 121 patients (average age, 67 years; 93% female) participated. Poor cooperation between GPs and pharmacists was noted. Nevertheless, medication persistence ranged from 83% to 91% over the 6 visits. However, since patient drop-out rates were high and questionnaire return rates were low, a post-study medical chart review was performed. This confirmed that persistence was high (74%-83%) at 3 years post-enrollment, even for oral bisphosphonate-treated patients (73%-76%). However, adoption of anti-osteoporosis lifestyle changes was poor throughout the study: one- to two-thirds of the patients did not alter their diet, physical activity, or surroundings to prevent falls.

CONCLUSION

One study goal, namely, to encourage GPs and pharmacists to cooperate in patient follow-up, was not achieved. However, high medication persistence was observed. This may reflect the education program, patient empowerment, personalized attention from study personnel, and being in a study. Patient-centered approaches can thus significantly increase medication persistence in osteoporosis. Ongoing education may be needed to improve patient adoption of and persistence with lifestyle changes.

The role of gut microbiota in bone homeostasis

Aims

The effect of the gut microbiota (GM) and its metabolite on bone health is termed the gut-bone axis. Multiple studies have elucidated the mechanisms but findings vary greatly. A systematic review was performed to analyze current animal models and explore the effect of GM on bone.

Methods

Literature search was performed on PubMed and Embase databases. Information on the types and strains of animals, induction of osteoporosis, intervention strategies, determination of GM, assessment on bone mineral density (BMD) and bone quality, and key findings were extracted.

Results

A total of 30 studies were included, of which six studies used rats and 24 studies used mice. Osteoporosis or bone loss was induced in 14 studies. Interventions included ten with probiotics, three with prebiotics, nine with antibiotics, two with short-chain fatty acid (SCFA), six with vitamins and proteins, two with traditional Chinese medicine (TCM), and one with neuropeptide Y1R antagonist. In general, probiotics, prebiotics, nutritional interventions, and TCM were found to reverse the GM dysbiosis and rescue bone loss.

Conclusion

Despite the positive therapeutic effect of probiotics, prebiotics, and nutritional or pharmaceutical interventions on osteoporosis, there is still a critical knowledge gap regarding the role of GM in rescuing bone loss and its related pathways.

Cite this article: Bone Joint Res 2021;10(1):51–59.

Baseline quality of life in people with hip fracture: results from the multicentre WHiTE cohort study

Aims

To assess the variation in pre-fracture quality of life (QoL) within the UK hip fracture population, and quantify the nature and strength of associations between QoL and other routinely collected patient characteristics and treatment choices.

Methods

The World Hip Trauma Evaluation (WHiTE) study, an observational cohort study of UK hip fracture patients, collects a range of routine data and a health-related QoL score (EuroQol five-dimension questionnaire (EQ-5D)). Pre-fracture QoL data are summarized and statistical models fitted to understand associations between QoL, patient characteristics, fracture types, and operations.

Results

Fitting a multiple linear regression model indicated that 36.5% of the variance in pre-fracture EQ-5D scores was explained by routinely collected patient characteristics: sex (0.14%), age (0.17%), American Society of Anesthesiologists (ASA) score (0.73%), Abbreviated Mental Test Score (AMTS; 1.3%), pre-fracture mobility (11.2%), and EQ-5D respondent (participant, relative, or carer; 23.0%). There was considerable variation in pre-fracture EQ-5D scores between operations within fracture types. Participants with trochanteric fractures reported statistically significant but not clinically relevant lower pre-fracture QoL than those with intracapsular fractures. Participants with intracapsular fractures treated with internal fixation or total hip arthroplasty (THA) reported better QoL than those treated with hemiarthroplasty with the overall fittest group receiving THA.

Conclusion

Pre-fracture QoL varies considerably between hip fracture patients; it is generally higher in younger than older patients, patients with better mobility, and those patients who live more independently. Pre-fracture QoL is significantly associated with a range of patient characteristics (e.g. age, mobility, residency). These data explain ~35% of the variation in QoL.

Cite this article: Bone Joint Res 2020;9(8):468–476.

miR-205 regulates bone turnover in elderly female patients with type 2 diabetes mellitus through targeted inhibition of Runx2

The present study aimed to explore the expression of microribonucleic acid (microRNA) (miR)-205 in bone tissues and serum of elderly female patients with type 2 diabetes mellitus (T2DM) complicated with osteoporosis (OP), and to investigate the effect of miR-205 on osteogenesis/adipogenesis of bone marrow mesenchymal stem cells (BMSCs) and its mechanism in elderly female mice with T2DM + OP. The bone tissues and serum of 24 female patients with T2DM + OP at the Third Affiliated Hospital of Qiqihar Medical University were collected as the research group, while those of 24 healthy people were collected as the control group. The expression level of miR-205 was detected in both groups via reverse transcription-polymerase chain reaction (RT-PCR). Then the elderly female mouse model of T2DM + OP was established as a model group, while normal mice of the same age were used as the control group. The mice in the model and control groups were transfected with miR-205 mimic, negative control (NC)-mimic, miR-205-inhibitor and NC-inhibitor. Alizarin red S (ARS) staining and RT-PCR were conducted after osteogenic induction for 21 days, and oil red O (ORO) staining and RT-PCR were performed after adipogenic induction for 24 days. The overexpression of miR-205 inhibited osteogenic differentiation and promoted adipogenic differentiation of BMSCs in elderly female mice with T2DM + OP, while knockdown of miR-205 promoted osteogenic differentiation and inhibited adipogenic differentiation of BMSCs in elderly female mice with T2DM + OP. In addition, miR-205 was able to directly suppress the expression of its target gene RUNX family transcription factor 2 (Runx2). The expression level of miR-205 was obviously increased in female patients with T2DM + OP and the elderly female mouse model of T2DM + OP. In addition, miR-205 was able to regulate the osteogenic/adipogenic differentiation of BMSCs, and miR-205/Runx2 may be a new method and target for the treatment of female patients with T2DM + OP.

Complications following hip fracture: Results from the World Hip Trauma Evaluation cohort study

INTRODUCTION

Hip fractures are common in people over 60 years of age, and are associated with significant disability, morbidity and mortality. The aim of this study was to record the incidence of complications in the first 120 days following hip fracture.

METHODS

The World Hip Trauma Evaluation (WHiTE) study is a multicentre, prospective cohort study conducted in National Health Service (NHS) hospitals in England and Wales. Participants are 60 years and older who received operative treatment for a hip fracture. We report the incidence of complications recorded by hospital staff until discharge from hospital and by participants at 120-days post-surgery.

RESULTS

An analysis of 8673 consecutive participants enrolled in the WHiTE study revealed the following risks of complications within the first 120 days: signs of wound infection (3.1%); dislocation (0.5%); failure of fixation (0.6%); peri‑prosthetic fracture (0.3%); overall revision surgery (0.9%); blood loss requiring transfusion (6.1%); chest infection (6.3%); urinary tract infection (5.0%); deep vein thrombosis/pulmonary embolus (1.8%); cerebrovascular accident (0.6%); acute coronary syndrome/myocardial infarction (0.6%); acute kidney injury (1.3%).

CONCLUSION

The rates of complications reported here provide a reference range against which future studies might be assessed. Registration: ISRCTN63982700.

Development of Algorithm for Clinical Management of Sickle Cell Bone Disease: Evidence for a Role of Vertebral Fractures in Patient Follow-up

Sickle-cell disease (SCD) is a worldwide distributed hemoglobinopathy, characterized by hemolytic anemia associated with vaso-occlusive events. These result in acute and chronic multiorgan damage. Bone is early involved, leading to long-term disability, chronic pain and fractures. Here, we carried out a retrospective study to evaluate sickle bone disease (SBD) in a cohort of adults with SCD. We assessed bone density, metabolism and turnover. We also evaluated the presence of fractures and the correlation between SCD severity and skeletal manifestations. A total of 71 patients with SCD were analyzed. The mean age of population was 39 ± 10 years, 56% of which were females. We found osteoporosis in a range between 7% and 18% with a high incidence of vertebral fractures. LDH and AST were predictive for the severity of vertebral fractures, while bone density was not. Noteworthy, we identified -1.4 Standard Deviations T-score as the cutoff for detecting the presence of fractures in patients with SCD. Collectively our data allowed us to develop an algorithm for the management of SBD, which may be useful in daily clinical practice to early intersect and treat SBD.