Post-fracture prescribed calcium and vitamin D supplements alone or, in females, with concomitant anti-osteoporotic drugs is associated with lower mortality in elderly hip fracture patients: a prospective analysis

Adjuvant Vitamin D Injection in Elderly Patients Before Intertrochanteric Fracture Surgery: A Randomised Controlled Trial

Background

There are multiple recommended protocols for Vitamin D (VitD) supplementation in elderly; however, only a few studies achieved to examine the role of VitD supplements before intertrochanteric fracture surgery on mortality and complications after surgery.

Methods

This single-center block-randomized double-blinded trial was conducted on 80 patients with intertrochanteric fractures and a sufficient level of 25 (OH) VitD. The intervention group received an intramuscular 300,000 IU VitD ampule before surgery. The primary outcome was a 6-month mortality rate, and the secondary outcomes were 1- and 2-year mortality rates and Harris Hip Score (HHS) in 6, 12, and 24 months after surgery. Chi-square, t-test, repeated measure ANOVA, and Cox regression survival model was used for statistical analysis.

Results

40 patients were allocated to each group. Demographic, clinical characteristics, and preoperative evaluations were not significantly different between the groups. Mortality rate 6-month after the surgery was 7.5% and 10% for the intervention and placebo groups respectively (P value = .71), 15% and 12.5% at 1-year (P value = .83), and 25% and 27.5% at 2-year (P value = .98). Based on the Cox regression model, only age was significantly associated with mortality (HR = 1.229, P value <.001). Significant HHS changes from baseline through 24 months after surgery were observed within both groups; however, mean differences were not significantly different between groups.

Conclusions

A single preoperative 300,000 IU VitD did not significantly impact 2-year survival and HHS in patients with intertrochanteric fractures and sufficient serum VitD level.

Challenges in osteoporosis treatment initiation in geriatric patients admitted under the hip-fracture pathway

Osteoporosis is often untreated especially in older people. This study found a low prescribing rate of osteoporosis treatment medication of 22.4% in older people admitted under the hip-fracture pathway. Factors associated with greater odds of being prescribed osteoporosis medications are categorized into patient-related, physician-related and system-related factors.

INTRODUCTION

Osteoporosis represents a growing healthcare problem which is often overlooked by healthcare providers and untreated especially in older people. This study aims to assess the rate of osteoporosis treatment initiation and to investigate underlying physician and system-related barriers in geriatric patients admitted for hip fracture.

METHODS

A retrospective study was conducted on patients aged 60 years and older, admitted under the hip-fracture pathway from January 2019 to December 2019. Data collected included demographics, co-morbid conditions and laboratory data. Clinical charts were reviewed for whether bone mineral density (BMD) scan has been ordered, plans for bone health were made and reflected in the discharge summary, and if appropriate memos were written. The primary outcome was the prescription of osteoporosis treatment medications. Prescription lists were also reviewed for prescribing patterns of calcium and vitamin D.

RESULTS

A total of 375 patients older than 60 years old were identified. 281 patients who fit the inclusion and exclusion criteria with complete data were further analysed. Within 1 year of hip fracture admission, 63 (22.4%) of them were prescribed with osteoporosis treatment. Multivariate logistic regression identified milder stage of CKD (p = 0.038, OR = 0.617, 95% CI 0.392-0.973) and BMD scan performed (p &lt; 0.001, OR = 6.515, 95% CI 3.180-13.348) as independent factors associated with the prescription of osteoporosis treatment within 1 year of hip fracture admission.

CONCLUSION

The rate of osteoporosis treatment initiation post-hip fracture is low. Systematic solutions will need to be established to ensure that osteoporosis treatment is addressed prior to discharge.

Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center

PURPOSE

Fragility fractures are a significant source of morbidity and have high associated mortality. Identifying risk factors for poor outcomes is essential for guiding treatment and for setting expectations for patients and their families. Although fragility hip fractures have been abundantly explored, there is a paucity of information regarding proximal humerus fractures (PHFs).

METHODS

We retrospectively review the electronic medical records of 379 patients who presented to a level 1 trauma center with a PHF secondary to a fall. Patient demographics, handedness, comorbidities, treatment, imaging data, follow-up data, and death date (if applicable) were recorded.

RESULTS

Our cohort consisted of 279 females and 100 males with an average age of 71.4 years. Distribution of injuries was 178 left, 141 right, and 7 bilateral. Compared with handedness, 179 were ipsilateral, 141 were contralateral, and 59 were unknown. A total of 81.3% of injuries were treated nonoperatively, whereas 18.7% were managed surgically. One-year mortality was 17.4%, and 2-year mortality was 24.0%.Males demonstrated a 2.28 increased risk of 1-year mortality (P = .004). Patients who died within 1 year of fracture had significantly higher Charlson comorbidity index scores (P < .0001) and age (P = .0003). Risk of death was significantly lower in patients who underwent surgery compared with those who were treated nonoperatively (P = .01). Patients who used an assist device before fracture had 4.2 increased risk of 1-year mortality (P < .0001). Patients who presented from nursing homes or assisted living had a 2.1 increased risk of 1-year mortality (P = .02). Patients with severe liver disease had a 5.5 increased risk of 1-year mortality (P < .0001), and those with metastatic cancer had a 13.7 increased risk of 1-year mortality (P < .0001). Bilateral fractures, side of injury in relation to handedness, rehospitalization, Neer classification, and PCP follow-up within 30 days were not associated with increased mortality.

CONCLUSIONS

Increased understanding risk factors for mortality after PHF will allow for more informed patient discussions regarding treatment outcomes and risk of death. Our data suggest that mortality at 1 year for fragility PHF is universally high regardless of risk factors. This risk is increased in patients who are older, functionally limited, or who have medical comorbidities. Our data demonstrate the importance of medical optimization of patients with a fragility PHF and underscore the importance of fall prevention in high-risk patients.

The Potential Impact of Inducing a Restriction in Reimbursement Criteria on Vitamin D Supplementation in Osteoporotic Patients with or without Fractures

In October 2019, the Italian Drug Agency (AIFA) restricted reimbursement criteria for vitamin D (VD) use outside the osteoporosis setting (Note 96). However, whether this restriction could also have involved patients at risk for or with osteoporotic fractures has not yet been investigated. We retrospectively analyzed databases from five Italian Local Health Units. Patients aged ≥50 years with either at least one prescription for osteoporosis treatment or with fragility fractures and evidence of osteoporosis from 2011 to 2020 were included. The proportion of subjects with an interruption in VD treatment before and after the introduction of the new reimbursement criteria and predictors of this interruption were analyzed. A total of 94,505 patients (aged 69.4 years) were included. Following the introduction of Note 96, a 2-fold (OR 1.98, 95% CI: 1.92–2.04) increased risk of VD discontinuation was observed. These findings were independent of seasonal variation, osteoporosis treatment patterns, as well as other confounding variables. However, a higher rate of interruption was observed in patients without vertebral/femur fracture (37.8%) vs. those with fracture (32.9%). Rheumatoid arthritis, dyslipidemia and previous fracture were associated with a lower risk of VD interruption, while stroke increased the risk of VD interruption. Our results highlight that a possible misinterpretation of newly introduced criteria for reimbursement restrictions in VD outside of osteoporosis have resulted in an inadequate level of VD supplementation in patients with osteoporosis. This undertreatment could reduce the effect of osteoporosis therapies leading to increased risk of negative outcome.

Changes in Characteristics and Outcomes of Patients Undergoing Surgery for Hip Fractures Following the Initiation of Orthogeriatric Service: Temporal Trend Analysis

The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009-2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC =  - 53.7% (95% CI - 68.3, - 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC =  - 17.9 (95% CI - 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC =  - 7.1 (95% CI - 12.6, - 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC =  - 24.6% (95% CI - 31.2, - 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009-2016 (APC =  - 10.6, 95% CI - 17.2, - 2.7, P = 0.017) and sharply thereafter (APC =  - 47.5%, 95%CI - 71.7, - 2.7, P = 0.043). The rate of patients returning home was decreasing (APC =  - 2.9, 95% CI - 5.1, - 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes.

Assessment of Vitamin D Levels and Its Correlation With Osteoporosis and Fracture Site Comminution in Osteoporotic Hip Fractures in Tertiary Care Hospital

INTRODUCTION

A global concern is vitamin D deficiency and insufficiency. There is a particularly high risk for pregnant women, people of color (Blacks, Hispanics, and those with increased skin melanin pigmentation), obese children and adults, and children and adults who are abstinent from direct sun exposure. The goal of this study was to understand the incidence of vitamin D deficiency in patients with osteoporotic hip fractures in our rural population and also to know its association with osteoporosis and osteoporotic hip fractures in a tertiary care trauma center.

METHODS

This prospective research was performed at our tertiary trauma treatment center in Kolar, Karnataka, India by the Department of Orthopedics from September 2019 and July 2020. The age category was 45-90 years, intertrochanteric fractures were graded using the Boyd and Griffin classification and femoral neck fractures the Garden's staging. The research included all patients with fractures after a trivial trauma such as slip and fall while standing/walking and excluded patients with a serious history of trauma such as road traffic accidents/falls from height and pathological fractures. This study involved 30 patients. Age and gender, type of fracture, vitamin D levels, Singh's index, and comminution of fracture site were reported in patient demographics.

RESULTS

Thirty patients comprised the study population. Most of them were female. Females comprised 18 out of the 30. There were twelve, thirteen, and five persons in our sample population between the ages of 45-60, 61-75, and >75 years. The Singh's index was tabulated. Mean vitamin D levels were 9.64+/-3.23 in the femur fracture group and 13.42+/-5.31 in the intertrochanteric fracture group. Mean levels of vitamin D are included as a graphical representation. The comminution of the fracture site in groups of the femur and intertrochanteric fractures was eight and six, respectively.

CONCLUSION

Early diagnosis and treatment of these patients with vitamin D for osteomalacia and anti-osteoporotic osteoporosis regimens will hopefully enhance bone, muscle, and general health, minimizing falls and fractures.

Characteristics and outcomes of osteoporotic hip fractures: treatment gaps in a tertiary care center in Riyadh, Saudi Arabia

BACKGROUND

Hip fracture is the most clinically devastating and economically important complication of osteoporosis. Pain, suffering, loss of mobility and independence are some of the devastating consequences of hip fractures. The present study aimed to determine the main characteristics and outcomes of patients with osteoporotic hip fracture and treatment gaps at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.

METHODS

This is a single-center, retrospective cohort study analyzing charts of patients > 45 years who were admitted for hip fracture secondary to low-grade trauma from 2008 to 2012.

RESULTS

A total of 264 patients (50.4% males and 49.6% females) were included. The most common fracture types were trochanter (49%) and femoral neck (46%). History of falls was documented in 115 (43.6%) patients. Bone mineral density (BMD) was assessed in only 41 (15.5%) patients. Majority underwent surgery (92%). Surgical complications occurred in 15 (5.7%) patients and medical complications in 21 (7.9%) patients. Vitamin D and calcium were the most common medications, but given only to 45 (17%) patients. Bone mineral density (BMD) assessment was significantly more frequent post-surgery than pre-surgery (p = 0.03). Very few patients received osteoporosis-specific therapy. F ollow-up revealed that 62 (23.5%) patients died 1 year after surgery.

CONCLUSION

These present findings warrant urgent reassessment of clinical care and treatments provided to patients with osteoporotic hip fractures to prevent recurrent fractures. The introduction of Fracture Liaison Service (FLS) in institutions caring for patients with hip fractures as internationally recommended will definitely change the current status of care.

Self-emulsifying formulation of Spinacia oleracea reduces the dose and escalates bioavailability of bioactive compounds to accelerate fracture repair in rats

Background

Spinach (Spinacia oleracea) is a rich source of flavonoids and therefore widely used therapeutically as an antioxidant agent in traditional medicine. The present study was undertaken to study the bone regenerating property of dried Spinacia oleracea extract (DSE) and self-emulsifying formulation of the extract (FDSE) on drill-hole model of fracture repair in rats.

Methods

0.8 mm hole was drilled in the diaphyseal region of femur in adult SD rats. DSE and formulated extract (FDSE) was administered orally and fractured femur was collected after treatment regimen. Micro-CT, transcriptional analysis and measurement of calcein intensity of callus formed at the injured site was performed to study the efficacy of the extract and formulation on bone regeneration. Further, compounds from extract were assessed for in-vitro osteoblast activity.

Results

Micro-architecture of the regenerated bone at injured site exhibited 26% (p < 0.001) and 35% (p < 0.01) increased BV/TV (bone volume /tissue volume) and Tb.N. (trabecular number) for DSE (500 mg.kg− 1). Further, FDSE exhibited similar augmentation in BV/TV (p < 0.01) and Tb. N (p < 0.01) parameters at dose of 250 mg.kg− 1. Analogous results were obtained from transcriptional analysis and calcein intensity at the fractured site. 3-O-Methylpatuletin, one of the compound isolated from the extract stimulated the differentiation and mineralization of primary osteoblast and depicted concentration dependent antagonizing effect of H2O2 in osteoblast apparently, minimizing ROS generation thus affectivity in fracture repair.

Conclusions

The present study showed that bone regenerating property of spinach was augmented by formulating extract to deliverable form and can be further studied to develop as therapeutic agent for fracture repair.

Graphical abstract

Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study

Background

We investigated the association of anti-osteoporosis medication with mortality risk in older adults with hip fractures and evaluated the influence of medication adherence on mortality.

Methods

We conducted a population-based cohort study and identified a total of 13,123 patients aged 65 years or older with hip fracture from the Taiwan National Health Insurance Database during the period 2001–2010. Individuals with (n = 2092) and without (n = 2092) receiving anti-osteoporosis medication were matched using propensity score matching (1:1 ratio). The 1-, 3- and 5-year survival rates after the index fracture were compared between patients with and without treatment. In the treated group, survival rate was compared between those with good and non-adherence. Good adherence was defined as the medication possession ratio of ≥80% and non-adherence as a ratio < 80%.

Results

The 1-, 3- and 5-year mortality rates were significantly lower in the treated vs. the non-treated group (all p < 0.0001). In the treated group, the estimated 1-, 3- and 5-year survival rates were higher in those with good adherence than in those with non-adherence (all p < 0.0001). Regarding all-cause mortality, the adjusted hazard ratio in the treated vs. the non-treated group was 0.63 (95% confidence interval 0.58–0.68, p < 0.0001). The good adherence subgroup showed a significantly lower mortality risk than that in the non-adherence subgroup (hazard ratio 0.41, 95% confidence interval 0.32–0.51, p < 0.0001).

Conclusions

The 1-, 3- and 5-year survival rates were significantly higher in patients receiving anti-osteoporosis medication than in the untreated group. All-cause mortality rates were lower in patients with good adherence to anti-osteoporosis medication.

Bisphosphonates and mortality: confounding in observational studies?

Numerous observational studies suggest that bisphosphonates reduce mortality. This study showed that bisphosphonate use is associated with lower mortality within days of treatment, although the association was not significant until the second week. Such an early association is consistent with confounding, although an early treatment effect cannot be ruled out.

INTRODUCTION

The purpose of this study was to examine whether confounding explains why numerous observational studies show that bisphosphonate use is associated with lower mortality. To this end, we examined how soon after treatment initiation a lower mortality rate can be observed. We hypothesized that, due to confounding, the association would be observed immediately.

METHODS

This was a retrospective cohort study of hip fracture patients discharged from Swedish hospitals between 1 July 2006 and 31 December 2015. The data covered 260,574 hip fracture patients and were obtained from the Swedish Hip Fracture Register and national registers. Of the 260,574 patients, 49,765 met all eligibility criteria and 10,178 were pair matched (bisphosphonate users to controls) using time-dependent propensity scores. The matching variables were age, sex, diagnoses, prescription medications, type of hip fracture, type of surgical procedure, known or suspected dementia, and physical functioning status.

RESULTS

Over a median follow-up of 2.8 years, 2922 of the 10,178 matched patients died. The mortality rate was 7.9 deaths per 100 person-years in bisphosphonate users and 9.4 deaths in controls, which corresponded to a 15% lower mortality rate in bisphosphonate users (hazard ratio 0.85, 95% confidence interval 0.79-0.91). The risk of death was lower in bisphosphonate users from day 6 of treatment, although the association was not significant until the second week.

CONCLUSION

Bisphosphonate use was associated with lower mortality within days of treatment initiation. This finding is consistent with confounding, although an early treatment effect cannot be ruled out.

A 10-Year Retrospective Study of 490 Hip Fracture Patients: Reoperations, Direct Medical Costs, and Survival

BACKGROUND AND AIMS

Reoperations after operative treatment of hip fracture patients may be associated with higher costs and inferior survival. We examined the acute hospital costs, long-term reoperation rates, and survival of patients with a new hip fracture.

MATERIALS AND METHODS

A total of 490 consecutive new hip fracture patients treated at a single center between 31 December 2004 and 6 December 2006 were analyzed retrospectively. Fractures were classified according to Garden and AO. All medical records were checked manually. The costs of reoperations were calculated using the diagnosis-related groups (DRG)-based prices. Survival analysis was performed using the life-table method. The follow-up time was 10 years.

RESULTS

In all, 70/490 patients (14.3%) needed reoperations. Of all reoperations, 34.2% were performed during the first month and 72.9% within 1 year after the primary operation. The hemiarthroplasty dislocation rate was 8.5%, and mechanical failures of osteosynthesis occurred in 6.2%. Alcohol abuse was associated with a heightened risk of reoperation. The mean direct costs of primary fracture care were lower than the mean costs of reoperations (€7500 vs €9800). The mortality rate at 10 years was 79.8% among non-reoperated patients and 62.9% among reoperated patients.

CONCLUSIONS

According to our hypothesis, the cost per patient of reoperation in acute care was 31% higher than the corresponding cost of a primary operation. Reoperations increased the overall immediate costs of index fractures by nearly 20%. One-third of all reoperations were performed during the first month and almost 75% within 1 year after the primary operation.

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.

Association of gastrointestinal events and osteoporosis treatment initiation in newly diagnosed osteoporotic Israeli women

BACKGROUND

The objective was to examine the association of gastrointestinal (GI) events and osteoporosis treatment initiation patterns among postmenopausal women following an osteoporosis diagnosis from an Israeli health plan.

METHODS

This retrospective analysis of claims records included women aged ≥ 55 years with ≥ 1 osteoporosis diagnosis (date of first diagnosis was index date). Osteoporosis treatment initiation was defined as use of osteoporosis therapy (oral bisphosphonates or other) during 12 months postindex. GI events (diagnosis of GI conditions) were reported for 12 months preindex and postindex (from index to treatment initiation or 1 year postindex, whichever occurred first). The association of postindex GI events (yes/no) with the initiation of osteoporosis treatment (yes/no) and with type of therapy initiated (oral bisphosphonate vs. other) were examined with logistic regression and Cox proportional hazard regression (as sensitivity analysis).

RESULTS

Among 30,788 eligible patients, 17.5% had preindex GI events and 13.0% had postindex GI events. About 70.6% of patients received no osteoporosis therapy within 1 year of diagnosis, 24.9% received oral bisphosphonates and 4.5% received other medications. Postindex GI events were associated with lower odds of osteoporosis medication initiation (85-86% reduced likelihood; p < 0.01). Upon treatment initiation, postindex GI was not significantly associated with the type of osteoporosis therapy initiated, controlling for baseline GI events and patient characteristics.

CONCLUSIONS

Among newly diagnosed osteoporotic women from a large Israeli health plan, 70.6% did not receive osteoporosis treatment within 1 year of diagnosis. The presence of GI events was associated with reduced likelihood of osteoporosis treatment initiation.

Nutritional guidelines for older people in Finland

BACKGROUND

Ageing is associated with an increased risk of malnutrition, decreased nutrient intake, unintentional weight loss and sarcopenia, which lead to frailty, functional disabilities and increased mortality. Nutrition combined with exercise is important in supporting older people's health, functional capacity and quality of life.

OBJECTIVE

To identify nutritional needs in various groups of older individuals and to present the nutritional guidelines for older people in Finland.

DESIGN

A review of the existing literature on older people's nutritional needs and problems. The draft guidelines were written by a multidisciplinary expert panel; they were then revised, based on comments by expert organisations. The guidelines were approved by the National Nutritional Council in Finland.

RESULTS

The heterogeneity of the older population is highlighted. The five key guidelines are: 1. The nutritional needs in different age and disability groups should be considered. 2. The nutritional status and food intake of older individuals should be assessed regularly. 3. An adequate intake of energy, protein, fiber, other nutrients and fluids should be guaranteed. 4. The use of a vitamin D supplement (20 μg per day) recommended. 5. The importance of physical activity is highlighted. In addition, weight changes, oral health, constipation, obesity, implementing nutritional care are highlighted.

CONCLUSIONS

Owing to the impact that good nutrition has on health and well-being in later life, nutrition among older people should be given more attention. These nutritional guidelines are intended to improve the nutrition and nutritional care of the older population.

Fracture mortality: associations with epidemiology and osteoporosis treatment

The rates of incident osteoporotic fractures seem to be stabilizing; however, fragility fractures are still associated with considerable disability, costs and an increased risk of mortality, which is particularly the case for fractures of the hip and vertebra. Mortality is usually highest during the first year after fracture; however, a notably increased mortality risk might persist for several years after the event. In addition to its efficacy in the prevention of new and recurrent osteoporotic fractures, medical treatment has been associated with improved survival after osteoporotic fractures. Observational studies and randomized controlled clinical trials have reported increased survival in patients with a fracture who are treated with bisphosphonates. Rates of medical treatment in patients with osteoporosis remain low, and although the rationale for the putative increase in survival is unclear, this emerging evidence might help further justify the use of medical treatment after fracture. However, further work is needed before medical therapy for mortality prevention in patients with osteoporotic fractures is accepted.

An 8-year follow-up study of 221 consecutive hip fracture patients in Finland: analysis of reoperations and their direct medical costs

BACKGROUND

Some hip fracture patients need one or more reoperations because of complications following initial operative treatment.

AIMS

The aim of this study was to identify all further surgical interventions in a cohort of patients with hip fractures over a period of 8 years after index fracture. Immediate direct costs of these reoperations were also calculated.

MATERIAL AND METHODS

This retrospective study investigated 221 consecutive patients with hip fractures operated on at two different hospitals in southeastern Finland. The study period in hospital A was from 1 February 2003 to 31 January 2004, and in hospital B from 1 February 2003 to 30 April 2004. About 50% were femoral neck fractures, 41% trochanteric fractures, and 9% subtrochanteric fractures. Patients' medical records were checked from the hospital records and confirmed manually. Short- and long-term complications were recorded. Survival analysis was performed using a life-table method. The actual costs for reoperations and other further procedures for each patient were calculated using diagnosis-related groups-based costs for both hospitals in 2012.

RESULTS

A total of 20 patients (9%) needed reoperations. Overall, 10 patients (8.9%) with a femoral neck fracture (n = 112), 8 patients (8.7%) with trochanteric fracture (n = 92), and 2 patients (10.5%) with subtrochanteric fracture (n = 19) were reoperated on. The median interval between the primary operation of the acute hip fracture (n = 20) and the first reoperation was about 300 days (range: 2 weeks to 82 months). Among the women reoperated on, the excess mortality was lower than among those undergoing a single operation. The median costs of treatment per patient with one or more reoperations were €13,422 in hospital A (range: €1616-€61,755), €11,076 in hospital B (range: €1540-€17,866), and €12,850 in the total study group (p = 0.43). In the case of infections (3 patients), the mean costs per patient were €28,751 (range: €11,076-€61,755).

CONCLUSIONS

Almost 10% of hip fracture patients required reoperations, and these reoperations caused significant direct costs to health care. However, direct costs account for only approximately 25% of the first year's total costs. These costs should be taken into account when evaluating the economics of hip fractures and the burden of health care.

Screening for osteoporosis reduced new fracture incidence by almost half: a 6-year follow-up of 592 fracture patients from an osteoporosis screening program

BACKGROUND AND PURPOSE

Fractures can be prevented if osteoporosis is identified and treated. In 2002, we initiated a screening program at our orthopedics department, in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and encouraged to see their doctor for decision on treatment regarding osteoporosis. The patients receive written documents containing information, DEXA results, and a letter to their doctor with suggestions regarding blood tests and treatment. In this 6-year follow-up study, we compared the fracture recurrence in 2 groups: patients screened for osteoporosis after fracture as described, and a historical control group with fracture patients who presented at our department 1 year before we started the screening intervention.

METHODS

A questionnaire was sent to the 2 groups of fracture patients, those from before the time that we started the screening in 2002 and those who participated in the initial screening study in 2003. The questionnaire included questions on whether they had sustained further fractures, whether they had seen a doctor, and whether treatment had been initiated.

RESULTS

239 of the 306 unscreened patients (68%) and 219 of the 286 screened patients (77%) answered the questionnaire. In the unscreened group, 69 new fractures had occurred, in contrast to 39 in the screened group. The fracture risk was 42% lower in the screened group. Answers regarding treatment were incomplete in the unscreened group.

INTERPRETATION

Screening of fracture patients for osteoporosis reduced fracture recurrence, which indicates that the screening procedure has resulted in treatment that prevents fractures.

Osteoporosis in the community: Sensitivity of self-reported estimates and medication use of those diagnosed with the condition

Objectives

To assess the sensitivity and specificity of self-reported osteoporosis compared with dual energy X-ray absorptiometry (DXA) defined osteoporosis, and to describe medication use among participants with the condition.

Methods

Data were obtained from a population-based longitudinal study and assessed for the prevalence of osteoporosis, falls, fractures and medication use. DXA scans were also undertaken.

Results

Overall 3.8% (95% confidence interval (CI) 3.2 to 4.5) of respondents and 8.8% (95% CI 7.5 to 10.3) of those aged ≥ 50 years reported that they had been diagnosed with osteoporosis by a doctor. The sensitivity (those self-reporting osteoporosis and having low bone mineral density (BMD) on DXA) was low (22.7%), although the specificity was high (94.4%). Only 16.1% of those aged ≥ 50 years and with DXA-defined osteoporosis were taking bisphosphonates.

Conclusions

The sensitivity of self-reporting to identify osteoporosis is low. Anti-osteoporotic medications are an important part of osteoporosis treatment but opportunities to use appropriate medications were missed and inappropriate medications were used.

Exposure to medicines among patients admitted for hip fracture and the case-fatality rate at 1 year: a longitudinal study

PURPOSE

To describe the demographic and clinical characteristics and the pre-fracture exposure to medicines of patients admitted for a hip fracture, and to explore their association with fatal outcome 1 year after the fracture.

METHODS

All patients ≥ 65 years old admitted for a hip fracture in a tertiary hospital in Barcelona between January 1 and December 31 2007 were included. Data on the patients' clinical characteristics before and during hospital admission and on pre-fracture exposures to medicines were collected from the clinical records. One-year mortality was checked by approaching the patients and their families and was cross-checked with the national mortality statistics database. A Cox proportional hazards analysis was carried out.

RESULTS

Four hundred and fifty-six patients [mean age (SD) 82.9 (7.2) years, 73.5 % female], were admitted with hip fracture during the study period. Almost 80 % of the patients (363, 79.6 %) had three or more associated conditions, and 41.7 % received pre-fracture treatment with five or more drugs. The case-fatality rate during hospital admission was 4.6 % (21 patients). One hundred and seven patients died within 1 year (23.5 %). Advanced age, male gender, two or more associated chronic conditions, cancer, severe cognitive impairment, and treatment with opiates before fracture were significantly associated with the risk of dying. An inverse association was recorded between mortality and pre-hospital exposure to medicines for osteoporosis.

CONCLUSIONS

One-quarter of patients admitted for hip fracture died within 1 year after the fracture. Exposure to opiates before hip fracture was associated with an increased 1-year death rate, whereas treatment with drugs for osteoporosis was associated with a decrease in death rate. These results should be confirmed in studies with detailed prospective collection of information on exposure to medicines.

Calcium and vitamin D controversies

Controversies regarding appropriate use of vitamin D and calcium are predominately related to the extraskeletal effects. Calcium and vitamin D are essential for bone health. The concerns regarding calcium and cardiovascular complications are inconclusive at best, and do not warrant a change in our approach to supplementation at this time. A growing body of literature exists suggesting that additional vitamin D may have numerous benefits, although more study needs to be done. Further prospective trials would provide insight into the potential advantages that increased vitamin D supplementation could provide.

Impact of guideline implementation by a fracture nurse on subsequent fractures and mortality in patients presenting with non-vertebral fractures

INTRODUCTION

Systematic implementation of guidelines in patients presenting with a fracture increases identification of patients at high risk for subsequent fractures and contributes to a decreased fracture risk. Its effect on prevention of subsequent fractures and on mortality has not been documented. The aim of this study was to determine the impact of the implementation of specific guidelines on the risk of subsequent fractures and mortality in patients presenting with a non-vertebral fracture (NVF).

PATIENTS AND METHODS

Before-after impact analysis in consecutive patients older than 50 years who were admitted to the hospital with a NVF during 2 periods: pre-intervention group (n = 1,920, enrolled in 1999-2001) and intervention group (n = 1,335, enrolled in 2004-2006). The intervention consisted of a dedicated fracture nurse who systematically offered fracture risk evaluation and treatment according to available guidelines. The 2-year absolute risk (AR) and hazard ratio's (HR, with 95% confidence interval (CI)) of subsequent NVFs and mortality were analysed between both groups after adjustment for age, sex and baseline fracture location by multivariable Cox regression and by intention-to-treat.

RESULTS

The AR of subsequent fracture was 9.9% before and 6.7% after intervention, indicating a decrease of 35% in the risk of subsequent fracture (HR 0.65; CI: 0.51-0.84, after adjustment for age, sex and baseline fracture location) and 17.9% and 11.6%, respectively, for subsequent mortality, indicating a decrease of 33% in the risk of subsequent mortality (HR: 0.67; CI: 0.55-0.81, after adjustment for age, sex and baseline fracture location).

CONCLUSIONS

Systematic implementation of guidelines for fracture prevention by a dedicated fracture nurse immediately after a NVF is associated with a significant reduction of the 2-year risk of subsequent NVF and mortality.

Post-hip fracture use of prescribed calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs is associated with lower mortality: a nationwide study in Finland

We previously found a positive association between calcium plus vitamin D and antiosteoporotic drugs and survival among hip fracture patients. Our aim was to verify this observation using a nationwide database. A retrospective cohort of home-discharged hip fracture patients aged 50 years or older (n = 23,615) was enrolled from the national database. Primary exposure was medical treatment for osteoporosis, and the outcome was all-cause mortality. Cumulative mortalities were calculated using the Kaplan-Meier estimator. The relationship between mortality and medication purchases was modeled using Cox's proportional hazards regression with time-dependent covariates for medication use. One in 4 women and 1 in 10 men with a hip fracture were treated for osteoporosis in Finland. Unadjusted 1-year mortality was lower among patients who purchased calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs than among those who did not purchase these medications [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.67-0.81]. The difference in unadjusted cumulative mortality remained in favor of the drug users for at least 5 years. Among men, the use of calcium plus vitamin D or vitamin D supplements was associated with lower 1-year mortality even after adjustments for observed confounders (HR = 0.74, 95% CI 0.56-0.97). Among women, the use of antiosteoporotic drugs was associated with lower mortality (HR = 0.79, 95% CI 0.67-0.93). There was a tendency to even better survival in both genders if calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs were used simultaneously, the HR being 0.72 (95% CI 0.50-1.03) in men and 0.62 (95% CI 0.50-0.76) in women.

Osteoporosis medication and reduced mortality risk in elderly women and men

CONTEXT

Osteoporotic fractures are associated with premature mortality. Antiresorptive treatment reduces refracture but mortality reduction is unclear.

OBJECTIVE

The objective of the study was to examine the effect of osteoporosis treatment [bisphosphonates (BP), hormone therapy (HT), and calcium ± vitamin D only (CaD)] on mortality risk.

DESIGN

This was a prospective cohort study (April 1989 to May 2007).

SETTING

The study was conducted with community-dwelling elderly (aged 60+ yr) subjects in Dubbo, a semiurban city, Australia.

SUBJECTS

Subjects included 1223 and 819 women and men in the Dubbo Osteoporosis Epidemiology Study.

MAIN OUTCOME MEASURE

Mortality according to treatment group was recorded.

RESULTS

There were 325 (BP, n = 106; HT, n = 77; CaD, n = 142) women and 37 men (BP, n = 15; CaD, n = 22) on treatment. In women, mortality rates were lower with BP 0.8/100 person-years (0.4, 1.4) and HT 1.2/100 person-years (0.7, 2.1) but not CaD 3.2/100 person-years (2.5, 4.1) vs. no treatment 3.5/100 person-years (3.1, 3.8). Accounting for age, fracture occurrence, comorbidities, quadriceps strength, and bone mineral density, mortality risk remained lower for women on BP [hazard ratio (HR) 0.3 (0.2, 0.6)] but not HT [HR 0.8 (0.4, 1.8)]. For 429 women with fractures, mortality risk was still reduced in the BP group [adjusted HR 0.3 (0.2, 0.7)], not accounted for by a reduction in subsequent fractures. In men, lower mortality rates were observed with BP but not CaD [BP 1.0/100 person-years (0.3, 3.9) and CaD 3.1/100 person-years (1.5, 6.6) vs. no treatment 4.3/100 person-years (3.9, 4.8)]. After adjustment, mortality was similar, although not significant [HR 0.5 (0.1, 2.0)].

CONCLUSIONS

Osteoporosis therapy appears to reduce mortality risk in women and possibly men.

Oral bisphosphonates are associated with reduced mortality after hip fracture

Intravenous bisphosphonates reduce mortality following hip fracture. We determined whether new use of oral bisphosphonates was also associated with reductions in mortality in 209 hip fracture patients. Oral bisphosphonate exposure led to relative reduction of 8% per month of use (p = 0.001) or about a 60% reduction in mortality per year of use.

INTRODUCTION

Intravenous bisphosphonates reduce mortality following hip fracture. Using prospectively collected long-term data from a randomized trial of osteoporosis quality improvement for hip fracture, we determined whether new use of oral bisphosphonates was associated with reductions in mortality or the composite outcome of death or new fracture.

METHODS

Originally, 220 hip fracture patients were randomized to case manager (n = 110) or usual care followed by facilitated bone mineral density (BMD) testing (n = 110) interventions. All were eligible for bisphosphonate treatment. Post-randomization, we followed patients for 3 years and ascertained bisphosphonate treatment, medication adherence and persistence, all-cause mortality, and new clinical fractures. Proportional hazards analyses with time-varying treatment status were undertaken.

RESULTS

The final study cohort included 209 patients: 136 (65%) females, 104 (50%) older than 75 years, 90 (43%) with poor self-reported health, and 38 (18%) underweight. Of these, 76 (36%) had a previous fracture before hip fracture and 132 (81%) had low BMD. A total of 101 (46%) patients started oral bisphosphonates and 65 (64%) remained on treatment at the final evaluation. Overall, 24 (11%) patients died, 19 (9%) had new fractures, and 42 (20%) reached the composite outcome of death or fracture. Compared to no treatment, bisphosphonate exposure was independently associated with reduced mortality (17[16%] vs. 7[7%]; adjusted hazard ratio (aHR) = 0.92 per month treated; 95%CI, 0.88-0.97) and composite endpoints (28[26%] vs. 5[15%]; aHR = 0.94 per month treated; 95%CI, 0.91-0.97).

CONCLUSION

Like intravenous bisphosphonates after hip fracture, our study suggests that oral bisphosphonates may be associated with reductions in all-cause mortality.

Closing the osteoporosis care gap in hip fracture patients: an opportunity to decrease recurrent fractures and hospital admissions

Background. Falls and hip fractures are an increasing health threat to older people who often never return to independent living. This study examines the management of bone health in an acute care setting following a hip fracture in patients over age 65. Methods. Retrospective chart review of all patients admitted to a tertiary health facility who suffered a recent hip fracture. Results. 420 charts of patients admitted over the course of a year (May 1, 2007-April 31, 2008) were reviewed. Thirty-seven percent of patients were supplemented with calcium on discharge, and 36% were supplemented with vitamin D on discharge. Thirty-one percent were discharged on a bisphosphonate. Conclusion. A significant care gap still exists in how osteoporosis is addressed despite guidelines on optimal management. A call to action is required by use of multifaceted approaches to bridge the gap, ensuring that fracture risk is minimized for the aging population.

Is excess calcium harmful to health?

Most current guidelines recommend that older adults and the elderly strive for a total calcium intake (diet and supplements) of 1,000 to 1,300 mg/day to prevent osteoporosis and fractures. Traditionally, calcium supplements have been considered safe, effective and well tolerated, but their safety has recently been questioned due to potential adverse effects on vascular disease which may increase mortality. For example, the findings from a meta-analysis of randomized controlled trials (currently published in abstract form only) revealed that the use of calcium supplements was associated with an ~30% increased risk of myocardial infarction. If high levels of calcium are harmful to health, this may alter current public health recommendations with regard to the use of calcium supplements for preventing osteoporosis. In this review, we provide an overview of the latest information from human observational and prospective studies, randomized controlled trials and meta-analyses related to the effects of calcium supplementation on vascular disease and related risk factors, including blood pressure, lipid and lipoprotein levels and vascular calcification.

Incidence and mortality of hip fracture among the elderly population in South Korea: a population-based study using the national health insurance claims data

Background

The lack of epidemiologic information on osteoporotic hip fractures hampers the development of preventive or curative measures against osteoporosis in South Korea. We conducted a population-based study to estimate the annual incidence of hip fractures. Also, we examined factors associated with post-fracture mortality among Korean elderly to evaluate the impact of osteoporosis on our society and to identify high-risk populations.

Methods

The Korean National Health Insurance (NHI) claims database was used to identify the incidence of hip fractures, defined as patients having a claim record with a diagnosis of hip fracture and a hip fracture-related operation during 2003. The 6-month period prior to 2003 was set as a 'window period,' such that patients were defined as incident cases only if their first record of fracture was observed after the window period. Cox's proportional hazards model was used to investigate the relationship between survival time and baseline patient and provider characteristics available from the NHI data.

Results

The age-standardized annual incidence rate of hip fractures requiring operation over 50 years of age was 146.38 per 100,000 women and 61.72 per 100,000 men, yielding a female to male ratio of 2.37. The 1-year mortality was 16.55%, which is 2.85 times higher than the mortality rate for the general population (5.8%) in this age group. The risk of post-fracture mortality at one year is significantly higher for males and for persons having lower socioeconomic status, living in places other than the capital city, not taking anti-osteoporosis pharmacologic therapy following fracture, or receiving fracture-associated operations from more advanced hospitals such as general or tertiary hospitals.

Conclusion

This national epidemiological study will help raise awareness of osteoporotic hip fractures among the elderly population and hopefully motivate public health policy makers to develop effective national prevention strategies against osteoporosis to prevent hip fractures.