The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study

Non-invasive interactive neurostimulation in the post-operative recovery of patients with a trochanteric fracture of the femur. A randomised, controlled trial

We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation. Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.

Five-year survival in a cohort of hip fracture patients: the predictive role of pre-fracture health status

The aim was to assess the outcome of surgery at 5 years after hip fracture. In this prospective study, we analyzed 5-year survival of a cohort of 105 hip fracture patients as a function of preoperative health. The main outcome measurements were the status of the patient, dead or alive, and the SF-36 of their pre-fracture status as recalled during their hospital stay. In the fifth year post-hospitalization 58 patients were alive. There was a significant association between the recall SF-36 general health score and being alive in the fifth year (P = 0.0004) and with survival in general (P = 0.0001). This and prior studies support the concept of stratifying hip fracture patients according to pre-fracture health status when assessing outcomes of fracture repair or other interventions. This study further demonstrates the utility of the SF-36 for this purpose.

Total hip arthroplasty is less painful at 12 months compared with hemiarthroplasty in treatment of displaced femoral neck fracture

OBJECTIVES

The Displaced Femoral (neck fracture) Arthroplasty Consortium for Treatment and Outcomes (DFACTO) study compared total hip arthroplasty (THA) to hemiarthroplasty in the treatment of displaced femoral neck fractures.

DESIGN

This study was designed as a prospective, randomized clinical trial.

SETTING

The study was conducted in five US academic and private medical centers.

PATIENTS

Patients were composed of independent, mentally competent individuals, >50 years old who suffered a displaced femoral neck fracture without existing arthritis at the hip. Forty-one patients were enrolled.

MAIN OUTCOME MEASURES

Functional outcomes and quality of life were assessed at 6 and 12 months post-fracture using the SF-36, Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the Harris Hip Score, and the Timed "Up & Go" Test (TUG test).

RESULTS

Groups were equivalent at baseline in terms of age, comorbid conditions, and functional status. At 6 months, there were no significant differences between the groups using the outcome measures or overall rates of complications. There was one dislocation in the THA group (5.8% of patients). At 12 months, the THA group reported significantly less pain (53.2 +/- 10.2) than the hemiarthroplasty group (42.4 +/- 11.5) using the SF-36 (p = 0.02). Using the TUG Test, we observed a greater proportion of THA patients remain functionally independent 1 year after surgery compared the hemiarthroplasty group (p = 0.08, controlling for age and sex).

CONCLUSIONS

These differences in pain and functional outcomes suggest THA is a viable treatment option for the active elderly displaced femoral neck fracture population.

Explosive force and fractionated reaction time in elderly low- and high-active women

PURPOSE

The purpose of this study was to determine whether muscle power, activation time, and neuromuscular stimulation are related to physical activity patterns in older women.

METHODS

Forty women (65-84 yr) were assigned to high-active (HA) and low-active (LA) groups on the basis of a historical activity questionnaire, and then they performed a series of maximal, voluntary, isometric knee extensions in a visually cued RT task. Fractionated RT measures were taken using three landmarks in the data: the presentation of the visual stimulus, the beginning of the EMG burst, and the initiation of force development. The rate and magnitude of neural stimulation were taken from surface EMG.

RESULTS

Peak torque was 15% greater, rate of torque development was 26% greater, motor time was 17% shorter, rate of EMG rise was 25% faster, and onset EMG magnitude was 15% greater in HA than in LA subjects (P<0.05).

CONCLUSION

These results indicate that older women with a history of vigorous activity can generate greater force, power, and motor output in comparison with their less active peers. The lower-body mass index of the HA subjects and 310% greater volume of physical activity are likely to account for the enhanced neuromuscular function seen. It is plausible that in addition to aging, physical inactivity is responsible for a large portion of the loss of neuromuscular function seen in older adults.

Factors associated with a second hip fracture: a systematic review

OBJECTIVE

To provide a systematic review of factors associated with subsequent hip fracture among individuals who have fractured a hip.

DATA SOURCES

We searched Ageline, CINAHL, EMBASE and MEDLINE, from database inceptions to the week of 5 June 2006.

REVIEW METHODS

Studies were selected if they provided information regarding risk of subsequent hip fracture among individuals who had fractured a hip. Study quality was assessed using the Jadad criteria for randomized controlled trials (RCTs) and a simple scale based on the MOOSE criteria for cohort studies.

RESULTS

Four RCTs and seven cohort studies were identified. Older age, cognitive impairment and lower bone mass appear to increase the risk of subsequent fracture, as did impaired depth perception, impaired mobility, previous falls, dizziness and poor or fair self-perceived health. Pharmacologic treatment for osteoporosis decreased the risk of subsequent fracture. Use of hip protectors by community-dwelling seniors did not appear to protect against a second fracture.

CONCLUSION

A number of easily observed risk factors may help identify those individuals at higher risk for subsequent fracture.

Combining clinical factors and quantitative ultrasound improves the detection of women both at low and high risk for hip fracture

We hypothesized that combining clinical risk factors (CRF) with the heel stiffness index (SI) measured via quantitative ultrasound (QUS) would improve the detection of women both at low and high risk for hip fracture. Categorizing women by risk score improved the specificity of detection to 42.4%, versus 33.8% using CRF alone and 38.4% using the SI alone. This combined CRF-SI score could be used wherever and whenever DXA is not readily accessible.

INTRODUCTION AND HYPOTHESIS

Several strategies have been proposed to identify women at high risk for osteoporosis-related fractures; we wanted to investigate whether combining clinical risk factors (CRF) and heel QUS parameters could provide a more accurate tool to identify women at both low and high risk for hip fracture than either CRF or QUS alone.

METHODS

We pooled two Caucasian cohorts, EPIDOS and SEMOF, into a large database named "EPISEM", in which 12,064 women, 70 to 100 years old, were analyzed. Amongst all the CRF available in EPISEM, we used only the ones which were statistically significant in a Cox multivariate model. Then, we constructed a risk score, by combining the QUS-derived heel stiffness index (SI) and the following seven CRF: patient age, body mass index (BMI), fracture history, fall history, diabetes history, chair-test results, and past estrogen treatment.

RESULTS

Using the composite SI-CRF score, 42% of the women who did not report a hip fracture were found to be at low risk at baseline, and 57% of those who subsequently sustained a fracture were at high risk. Using the SI alone, corresponding percentages were 38% and 52%; using CRF alone, 34% and 53%. The number of subjects in the intermediate group was reduced from 5,400 (including 112 hip fractures) and 5,032 (including 111 hip fractures) to 4,549 (including 100 including fractures) for the CRF and QUS alone versus the combination score.

CONCLUSIONS

Combining clinical risk factors to heel bone ultrasound appears to correctly identify more women at low risk for hip fracture than either the stiffness index or the CRF alone; it improves the detection of women both at low and high risk.

Survival and functional outcome according to hip fracture type: a one-year prospective cohort study in elderly women with an intertrochanteric or femoral neck fracture

We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome and to determine whether outcomes differ by fracture type. The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures were survival and functional outcome, both at hospital discharge and 1 year later. Functional outcome was assessed using the Rapid Disability Rating Scale version-2. Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significant differences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities and prefracture residence at the time of injury. At hospital discharge, intertrochanteric hip fracture patients had a higher mortality (p=0.006) and were functionally more impaired (p=0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (relative risk 2.5; 95% confidence interval: 1.3 to 5.1; p=0.008), but functional outcome among surviving patients was similar in both groups. We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcome differs according to fracture type at hospital discharge, but these differences do not persist over time. These differences cannot be explained by differences in age or comorbidity. To address the mechanism(s) by which intertrochanteric fractures carry excess mortality compared to femoral neck fractures, future studies in hip fracture patients should include a comprehensive assessment of the degree of frailty, vitamin D status, and fall dynamics.

Excess mortality following hip fracture: the role of underlying health status

We evaluated the long-term excess mortality associated with hip fracture, using prospectively collected data on pre-fracture health and function from a nationally representative sample of U.S. elders. Although mortality was elevated for the first six months following hip fracture, we found no evidence of long-term excess mortality.

INTRODUCTION

The long-term excess mortality associated with hip fracture remains controversial.

METHODS

To assess the association between hip fracture and mortality, we used prospectively collected data on pre-fracture health and function from a representative sample of U.S. elders in the Medicare Current Beneficiary Survey (MCBS) to perform survival analyses with time-varying covariates.

RESULTS

Among 25,178 MCBS participants followed for a median duration of 3.8 years, 730 sustained a hip fracture during follow-up. Both early (within 6 months) and subsequent mortality showed significant elevations in models adjusted only for age, sex and race. With additional adjustment for pre-fracture health status, functional impairments, comorbid conditions and socioeconomic status, however, increased mortality was limited to the first six months after fracture (hazard ratio [HR]: 6.28, 95% CI: 4.82, 8.19). No increased mortality was evident during subsequent follow-up (HR: 1.04, 95% CI: 0.88, 1.23). Hip-fracture-attributable population mortality ranged from 0.5% at age 65 among men to 6% at age 85 among women.

CONCLUSIONS

Hip fracture was associated with substantially increased mortality, but much of the short-term risk and all of the long-term risk was explained by the greater frailty of those experiencing hip fracture.

Post-operative considerations in hip fracture management

Hip fractures are among the most important causes for disability, reduced quality of life, and death in older persons. Hip fracture patients are typically characterized by older age and a large complexity in their underlying conditions, comorbidities, and clinical histories. Therefore, large, well-designed studies are difficult to perform and the available evidence for most treatments is limited compared with other disease entities of this magnitude. This paper illuminates the current issues and recommendations for post-operative hip fracture care. Efforts to improve osteoporosis assessment and management, the multidisciplinary team approach, and clinical pathways are areas that have received attention recently.

The costs of fatal and non-fatal falls among older adults

OBJECTIVE

To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged >or=65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury.

METHODS

Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall.

RESULTS

In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled 0.2 billion dollars for fatal and 19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% (12 billion dollars ) were for hospitalizations, 21% (4 billion dollars) were for emergency department visits, and 16% (3 billion dollars) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2-3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs.

CONCLUSIONS

Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

Time trends of mortality after first hip fractures

A register-based study including 2,674 first hip fracture patients from 1987-1996 investigated if the mortality after hip fracture was associated with time trend and fracture type. Despite significantly increasing age at admission no changing time trend of mortality was observed, nor was the mortality linked to the kind of fracture suffered.

INTRODUCTION AND HYPOTHESIS

A retrospective cohort study was performed to investigate if the mortality of first hip fracture patients was associated with time trend and fracture type. The hypotheses were that cumulative mortality would remain unchanged and there would be no difference in mortality between cervical and pertrochanteric patients.

METHODS

Study material was obtained by record linkage of excerpts from two computerized national health registers. First hip fractures were identified indirectly by searching the files ten years before the date of admission. The period 1987-1996 saw inclusion of 2,674 patients aged 50 years and older (average follow-up 2.6 years).

STATISTICS

Weighted regression analysis, chi(2) test, and t test.

RESULTS

Cumulative mortality did not change significantly (P > 0.05). Weighted average cumulative mortality was 9% (95% CI, 7.9-10.1) at 1 month, 15.5% (95% CI, 14.1-16.8) at 3 months, 26.5% (95% CI, 24.7-28.3) at 1 year, and 36.2% (95% CI, 34.1-38.3) at 2 years. Cervical and pertrochanteric first hip fracture patients did not have significantly different mortality rates (P > 0.05).

CONCLUSION

No changing time trend of mortality after first hip fracture was observed despite significantly increasing age at admission, nor was the mortality linked to the kind of fracture suffered.

Risk-adjusted mortality rates of elderly veterans with hip fractures

PURPOSE

The goal of this research was to estimate 12-month survival rates for a large sample of elderly veterans after hip fracture with a risk-adjusted model and to compare the results of men to those of women.

METHODS

The study design was a retrospective, secondary data analysis of national Veterans Health Administration (VHA) Medicare beneficiaries. The study population was 43,165 veterans with hip fracture first admitted to a Medicare-eligible facility during our specified enrollment period of 1999-2002. Measurement was a Cox proportional hazard model or survival analysis of hip fracture patients with an outcome of death over a 1 year period after discharge controlled by age, gender, and selected Elixhauser comorbidities.

RESULTS

The unadjusted, 1 year mortality rates (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%) were slightly higher than the adjusted rates (30 days = 8.9%, 90 days = 15.6%, 180 days = 21.8%, 1 year = 29.9%). The mortality odds for women 12 months after hip fracture were 18%, compared with 32% for men. The comorbidity adjustment suggested that the presence of metastatic cancer increased the risk of death by almost 4 times compared with those patients without this diagnosis. Other particularly high-risk conditions included congestive heart failure, renal failure, liver disease, lymphoma, and weight loss, each of which increased the 1 year mortality risk by approximately two-fold.

CONCLUSIONS

One in 3 elderly male veterans who sustain a hip fracture dies within 1 year. Our work represents the first large study of hip fractures with a predominantly male sample and confirms that men have a higher mortality risk than women, as reported by previous researchers who used smaller samples that were mostly female. Fracture patients with metastatic cancer, renal failure, lymphoma, weight loss, and liver disease have higher mortality risks. The adverse outcomes associated with hip fracture argue for clinical intervention strategies, such as gait and balance testing, and osteoporosis diagnosis that may prevent fractures in both genders.

Implementation of a Mandatory Rheumatology Osteoporosis Consultation in Patients With Low-Impact Hip Fracture

BACKGROUND

Osteoporosis remains an underdiagnosed and undertreated major health problem. The current treatment rate for patients who have experienced at least 1 osteoporotic fracture is 20%-25%. Therefore, the Rheumatology and Internal Medicine Departments of Ochsner Clinic Foundation New Orleans implemented a mandatory rheumatology osteoporosis consult as part of preprinted admission orders for all patients after hip fracture surgery on the Internal Medicine service.

METHODS

We conducted a retrospective study of 78 patients admitted with a low-impact hip fracture between June 2004 and July 2005. These patients were seen by the rheumatology service in the hospital after hip fracture repair (exposed group). Osteoporosis evaluation was performed based on an interview questionnaire. Seventy-eight age-matched patients previously admitted for low-intensity or low-impact hip fracture in 2002-2003 but not exposed to the mandatory rheumatology consult served as our comparison group. Pearson chi2 test was used for statistical analysis.

RESULTS

Mean patient age was 80 years. Of the 78 unexposed patients, 17 (22%) were on treatment (calcium, vitamin D, hormones or antiresorptive agents) before the hip fracture, and 18 (23%) were on treatment after fracture repair. Of the 78 patients exposed to the compulsory rheumatology consultation, 34 (44%) patients were receiving osteoporosis treatment before hip fracture and 75 (96%) patients were receiving treatment after fracture repair. Of the patients not treated before hip fracture repair, there was a significant increase in the percent treated for those patients exposed to the rheumatology consult versus those not exposed (97.6% vs. 2.4%, respectively, P < 0.0001).

CONCLUSIONS

In our institution, we were successful in identifying and initiating appropriate therapy for osteoporosis patients through an automatic rheumatology osteoporosis consultation after hip fracture. The implementation of a mandatory osteoporosis consult resulted in a statistically significant increase in treatment of the exposed group compared with the unexposed group.

Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway

BACKGROUND

Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization.

METHODS

A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization.

RESULTS

Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group.

CONCLUSION

Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Fat mass and skeletal muscle mass in hip-fracture women: a cross-sectional study

OBJECTIVES

To investigate the association between appendicular lean mass (aLM) and age, fat mass (FM), serum levels of Vitamin D, parathyroid hormone, three parameters of the protein nutritional status (total lymphocyte count, serum albumin, and insulin-like growth factor I), levels of independence in activities of daily living (assessed by using Barthel index scores), type both of hip fracture and surgical operation, number of medications in use, and number of concomitant diseases in hip-fracture women.

METHODS

We investigated 299 of 327 hip-fracture women admitted consecutively to a rehabilitation hospital. Soft tissue body composition was assessed by dual-energy X-ray absorptiometry, 22.1+/-7.5 (mean+/-S.D.) days after fracture occurrence. Appendicular LM was calculated as the sum of LM in arms and legs. Because metal implants (prostheses and nails) affect the regional assessment of body composition, aLM was corrected by substituting LM in unfractured leg for LM in fractured leg: corrected aLM=(LM in unfractured leg x 2)+LM in arms. We divided corrected aLM by height squared (aLM/ht(2)), to adjust it for body size.

RESULTS

Four variables were significantly correlated with corrected aLM: age, height, FM, and Barthel index score. FM was the only variable significantly correlated with aLM/ht(2) (r=0.492; p<0.001). This significant correlation was not affected after adjustment for age and Barthel index score.

CONCLUSIONS

FM measured after hip fracture was significantly associated with aLM/ht(2) in women.

Promoting declines in the prevalence of late-life disability: comparisons of three potentially high-impact interventions

Although the prevalence of late-life disability has been declining, how best to promote further reductions remains unclear. This article develops and then demonstrates an approach for comparing the effects of interventions on the prevalence of late-life disability. We review evidence for three potentially high-impact strategies: physical activity, depression screening and treatment, and fall prevention. Because of the large population at risk for falling, the demonstrated efficacy of multi-component interventions in preventing falls, and the strong links between falls and disability, we conclude that, in the short run, multi-component fall-prevention efforts would likely have a higher impact than either physical activity or depression screening and treatment. However, longer-term comparisons cannot be made based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the influences of these interventions on prevalence. Additional research is needed to evaluate longer-term outcomes of interventions, including effects on length and quality of life.

Outcome of bilateral hip hemiarthroplasty for displaced fracture of the hip

Our aim was to evaluate the outcome in patients with bilateral non-simultaneous hip fracture treated with hemiarthroplasty at our institution between 1997 and 2003. We looked for any important modification factor that could change the devastating functional and social results. Twenty-two patients with a mean age of 79 at the initial fracture and 82 at the subsequent fracture were evaluated; all were Garden grade III-IV. The second fracture happened a mean of 28 months after the first one. The outcome measurement was the incidence of hip pain, recovery of pre-injury level of ambulation and activities of daily living at a minimum follow-up of one year. Following the first hemiarthroplasty patients deteriorated in their walking capacity and other activities of daily life, and this happened to an even greater extent after the second operation. With respect to walking ability (measured in metres) we concluded that it improved if a modular hemiarthroplasty was used after both fractures (p<0.05) and that worse functional outcomes were observed when different kinds of hemiarthroplasties were used in the same patient.;

Prediction and discrimination of osteoporotic hip fracture in postmenopausal women

Osteoporotic hip fractures increase dramatically with age and are responsible for considerable morbidity and mortality. Several treatments to prevent the occurrence of hip fracture have been validated in large randomized trials and the current challenge is to improve the identification of individuals at high risk of fracture who would benefit from therapeutic or preventive intervention. We have performed an exhaustive literature review on hip fracture predictors, focusing primarily on clinical risk factors, dual X-ray absorptiometry (DXA), quantitative ultrasound, and bone markers. This review is based on original articles and meta-analyses. We have selected studies that aim both to predict the risk of hip fracture and to discriminate individuals with or without fracture. We have included only postmenopausal women in our review. For studies involving both men and women, only results concerning women have been considered. Regarding clinical factors, only prospective studies have been taken into account. Predictive factors have been used as stand-alone tools to predict hip fracture or sequentially through successive selection processes or by combination into risk scores. There is still much debate as to whether or not the combination of these various parameters, as risk scores or as sequential or concurrent combinations, could help to better predict hip fracture. There are conflicting results on whether or not such combinations provide improvement over each method alone. Sequential combination of bone mineral density and ultrasound parameters might be cost-effective compared with DXA alone, because of fewer bone mineral density measurements. However, use of multiple techniques may increase costs. One problem that precludes comparison of most published studies is that they use either relative risk, or absolute risk, or sensitivity and specificity. The absolute risk of individuals given their risk factors and bone assessment results would be a more appropriate model for decision-making than relative risk. Currently, a group appointed by the World Health Organization and lead by Professor John Kanis is working on such a model. It will therefore be possible to further assess the best choice of threshold to optimize the number of women needed to screen for each country and each treatment.

Past and future: sex and gender in health research, the aging experience, and implications for musculoskeletal health

The statistics about common musculoskeletal disorders describe a few of the many health conditions that affect men and women. For such disorders and conditions, there are differences in incidence, predisposition, and therapeutic and preventive strategies for managing them. Although we have made progress in women's health research, many challenges remain, including those related to conditions and diseases of the musculoskeletal system that may affect women and men differentially. Research is needed to identify genetic, hormonal, environmental, and societal factors that contribute to these sex and gender differences and to understand when appropriate clinical applications should differ or be the same.

The role of pain in the recovery of instrumental and social functioning after hip fracture

OBJECTIVE

It is critical to identify modifiable factors associated with functional recovery from hip fracture. The authors examined the association between pain intensity and two functional endpoints-instrumental activities of daily living and social activity participation-after hip fracture.

METHOD

A total of 270 cognitively intact, community-dwelling persons older than 65 who underwent surgical hip fracture repair in New Haven, Connecticut, were followed for 12 months.

RESULTS

Pain intensity was strongly negatively associated with both instrumental and social functioning (p values < .001). Increases in pain intensity between 6 and 12 months were also associated with concurrent decreases in function (p values < .001). These relationships were partly explained by depressive symptoms and a marker of physical ability-gait speed.

DISCUSSION

Interventions to control pain may enhance functional status after hip fracture; however, pain relief must be maintained to sustain recovery. Attention to the complex relationships among pain, depressive symptoms, and physical impairments should inform intervention development.

Cross-sectional and longitudinal risk factors for falls, fear of falling, and falls efficacy in a cohort of middle-aged African Americans

PURPOSE

The purpose of this study is to cross-sectionally and longitudinally identify risk factors for falls, fear of falling, and falls efficacy in late-middle-aged African Americans.

DESIGN AND METHODS

We performed in-home assessments on a probability sample of 998 African Americans and conducted two annual follow-up interviews. Multiple logistic regression modeled the associations with falls (any fall or injurious fall) during 2 years prior to the baseline interview, and baseline fear of falling and falls efficacy with 2-year prospective risks for falling and fear of falling.

RESULTS

The most consistent association for all outcomes was depressive symptoms. Age was associated with increased risk of prior and prospective falls. Lower-body functional limitations were associated with prior falls, baseline fear of falling, and low falls efficacy, whereas low ability with one-leg stands prospectively predicted fear of falling. The greatest prospective risk for incident falls was having had a prior fall (odds ratio = 2.51), and the greatest prospective risk for fear of falling was having been afraid of falling at baseline (odds ratio = 8.14).

IMPLICATIONS

Falls, fear of falling, and low falls efficacy are important issues for late-middle-aged as well as older persons. Interventions should focus on younger adults and attend especially to lower-body function and depressive symptoms as well as building self-efficacy for safe exercise, dealing with falls risks, and managing falls themselves.

Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures

BACKGROUND

The research on hip fractures has been focused on surgical procedures for hip fracture repair; little is known about the contribution of nursing interventions to outcomes.

OBJECTIVES

To investigate factors, including nursing interventions, associated with the discharge destination of an older patient population hospitalized for a fractured hip or an elective hip procedure. Nursing interventions used during the hospitalized period are identified.

METHODS

A design model composed of patient characteristics; clinical conditions; nursing unit characteristics; and medical, pharmacy, and nursing interventions related to the outcome of discharge disposition was tested using generalized estimating equations analysis. A total of 116 variables were examined in a sample of 569 hospitalizations from 524 patients aged 60 years and older admitted for treatment of a hip fracture or elective hip procedure in one tertiary care agency over a 4-year period. Data were obtained retrospectively from five clinical databases.

RESULTS

Fifty-four percent of the population was discharged to a location other than to home. The predictors of discharge to home were a younger age, admission from home, and having a spouse, as well as receipt of intravenous solutions, diagnostic ultrasound, a lower number of medications, and moderate use of the nursing intervention of bathing. The identification of nursing interventions indicates that those who received routine nursing care for this condition returned home while those who required interventions for complications or prevention of complications were discharged to an institution.

DISCUSSION

Using a standardized nursing language with the hospital's information system can provide nurses and others with information that demonstrates the contribution of nursing care to outcomes, including the outcome of discharge to home.

Patients with femoral or distal forearm fracture in Germany: a prospective observational study on health care situation and outcome

Background

Distal radius and proximal femoral fractures are typical injuries in later life, predominantly due to simple falls, but modulated by other relevant factors such as osteoporosis. Fracture incidence rates rise with age. Because of the growing proportion of elderly people in Western industrialized societies, the number of these fractures can be expected to increase further in the coming years, and with it the burden on healthcare resources. Our study therefore assessed the effects of these injuries on the health status of older people over time. The purpose of this paper is to describe the study method, clinical parameters of fracture patients during hospitalization, mortality up to one and a half years after discharge in relation to various factors such as type of fracture, and to describe changes in mobility and living situation.

Methods

Data were collected from all consecutive patients (no age limit) admitted to 423 hospitals throughout Germany with distal radius or femoral fractures (57% acute-care, femoral and forearm fractures; 43% rehabilitation, femoral fractures only) between January 2002 and September 2003. Polytrauma and coma patients were excluded. Demographic characteristics, exact fracture location, mobility and living situation, clinical and laboratory parameters were examined. Current health status was assessed in telephone interviews conducted on average 6–7 months after discharge. Where telephone contact could not be established, at least survival status (living/deceased/date of death) was determined.

Results

The study population consisted of 12,520 femoral fracture patients (86.8% hip fractures), average age 77.5 years, 76.5% female, and 2,031 forearm fracture patients, average age 67.6 years, 81.6% female. Women's average age was 6.6 (femoral fracture) to 10 years (forearm fracture) older than men's (p < 0.0001). Only 4.6% of femoral fracture patients experienced changes in their living situation post-discharge (53% because of the fracture event), although less than half of subjects who were able to walk without assistive devices prior to the fracture event (76.7%) could still do so at time of interview (34.9%). At time of interview, 1.5% of subjects were bed-ridden (0.2% before fracture). Forearm fracture patients reported no change in living situation at all. Of the femoral fracture patients 119 (0.95%), and of the forearm fracture patients 3 (0.15%) died during hospital stay. Post-discharge (follow-up one and a half years) 1,463 femoral fracture patients died (19.2% acute-care patients, 8.5% rehabilitation patients), but only 60 forearm fracture patients (3.0%). Ninety percent of femoral fracture deaths happened within the first year, approximately 66% within the first 6 months. More acute-care patients with a pertrochanteric fracture died within one year post-discharge (20.6%) than patients with a cervical fracture (16.1%).

Conclusion

Mortality after proximal femoral fracture is still alarmingly high and highest after pertrochanteric fracture. Although at time of interview more than half of femoral fracture patients reported reduced mobility, most patients (96%) attempt to live at home. Since forearm fracture patients were on average 10 years younger than femoral fracture patients, forearm fractures may be a means of diagnosing an increased risk of later hip fractures.

Risk factors correlated with post-operative mortality for hip fracture surgery in the elderly: a population-based approach

OBJECTIVES

To estimate the effect of waiting time for surgery and volume of surgical activity on mortality in patients with hip fracture and to compare risk-adjusted outcomes between hospitals providing surgery for such patients.

DESIGN

Retrospective cohort study.

SETTING

Friuli Venezia Giulia, Italy.

PARTICIPANTS

A total of 6,629 elderly people who underwent surgery for hip fracture between 1st January 1996 and 31th December 2000.

MAIN OUTCOME MEASURES

In-hospital, 6-month and 1-year mortality rate.

RESULTS

In-hospital mortality rate was 5.4%. At six months, the mortality rate was 20.0%, and at 1 year 25.3%. Age, male sex, and comorbidity were significant predictors of mortality. Logistic regression analysis indicated that, after controlling for main patients risk factors and taking into account the hospital level variability, there was no significant association between increase in mortality rate and more than 1 day of waiting time for surgery (OR 0.90; 95% CI 0.58-1.40 for in-hospital mortality). One hospital had a significantly higher mortality rate than the others; high hospital volume for hip fracture surgery was associated with worse outcomes (OR 1.57; 95% CI 1.38-1.78 for in-hospital mortality). Mortality after hip fracture decreased significantly from 1996 to 2000 (OR 0.85; 95% CI 0.80-0.90).

CONCLUSIONS

Longer waiting time for surgery was not associated with mortality after adjusting for patient risk factors, and taking into account hospital level variability. Hospital level variability was statistically significant, and was partially explained by the total volume of hospital surgical activity. The decrease in mortality between 1996 and 2000 was confirmed by multivariate models.

Secondary prevention of hip fractures among the hospitalized elderly: are we doing enough?

BACKGROUND

Older individuals with hip fractures almost always have osteoporosis. Such individuals are at increased risk of experiencing other osteoporotic fractures, including recurrent hip fractures. The management of such patients should include assessing bone mineral density and treating osteoporosis.

OBJECTIVE

The objective of this study was to investigate if elderly (> or =65 years) patients with hip fractures were assessed and treated for osteoporosis.

METHODS

A retrospective chart review was conducted of all elderly patients who underwent hip fracture surgery at a university teaching hospital during the calendar years 1997 to 1999.

RESULTS

A total of 95 subjects were identified (29% males and 71% females). Subjects' age ranged from 65 to 96 years with a mean (+/-standard deviation) 81 +/- 7 years. Femoral neck fractures were the most common (51%), followed by intertrochanteric (43%) and subtrochanteric fractures (3%). Two subjects (2%) had fractures at multiple sites. The most common cause of a hip fracture was a fall (87%). Other causes included motor vehicle accidents (6%) as well as other trauma (4%). One subject had a spontaneous hip fracture. A history of hip fractures was obtained in 8% of subjects. Osteoporosis was diagnosed in 17% of subjects before admission. On admission, 9% of subjects were receiving calcium, 3% were receiving vitamin D, none were receiving alendronate, and 1 subject was receiving calcitonin. Approximately 3% of female subjects were receiving estrogen on admission. On discharge, 11% of subjects were prescribed calcium, 6% were prescribed vitamin D, none were prescribed alendronate, and 2% were on calcitonin. None of the female subjects were discharged on estrogen. During hospitalization, 88% of subjects who were admitted to nonmedical services were seen by either a geriatric or a general internal medicine consult. Obtaining a medical and/or geriatric consult did not have an apparent effect on the frequency of treating osteoporosis in this high-risk group of subjects.

CONCLUSION

Older adults with hip fractures are not adequately treated for osteoporosis. This places them at increased risk of other osteoporotic fractures, including recurrent hip fractures.

Does standardized rehabilitation and discharge planning improve functional recovery in elderly patients with hip fracture?

OBJECTIVE

To determine whether standardized early rehabilitation and discharge planning increase risk-adjusted function and reduce risk-adjusted institutionalization in the first 6 months after hip fracture.

DESIGN

Pre-post study of 2 independent population-based inception cohorts.

SETTING

Two tertiary hospitals in an urban health region.

PARTICIPANTS

Patients with hip fracture (N=919) 65 years and older.

INTERVENTION

Subjects were enrolled before (control) and after (intervention) implementation of standardized rehabilitation and discharge planning.

MAIN OUTCOME MEASURES

Function and institutionalization status were assessed at time of fracture and 3 and 6 months postfracture. Administrative databases provided length of stay (LOS) data.

RESULTS

After risk-adjustment, the Barthel Index score was significantly lower 3 months postfracture in control patients with low social support compared with those with higher social support (P<.05). Social support did not affect 3-month function in the intervention cohort. Control subjects with low social support were also significantly more likely to reside in long-term care by 6 months postfracture than intervention subjects with similar social support or those with higher social support (odds ratio=3.3; 95% confidence interval, 1.4-7.5). Total LOS did not change between cohorts.

CONCLUSIONS

Overall, standardized rehabilitation and discharge planning did not affect postoperative function or institutionalization in elderly patients with hip fracture. In intervention patients with low social support, function improved and institutionalization was reduced.

Body mass index and functional recovery after hip fracture: a survey study of 510 women

BACKGROUND AND AIMS

Low body mass index (BMI) is associated with high risk of osteoporosis and fractures, but its impact on functional recovery after fractures is unknown. Our aim was to investigate the association between BMI and both functional recovery and period of rehabilitation in hip-fractured women.

METHODS

510 out of 580 Caucasian women with hip fracture, admitted consecutively to a rehabilitation hospital, were investigated in this retrospective study. Functional recovery was assessed using the Barthel index score.

RESULTS

In the 510 women, BMI was 22.8 +/- 4.1 kg/m2 (mean +/- SD). After adjustment for age, femur bone mineral density, and the Barthel index assessed on admission to rehabilitation, a significant negative association was found between BMI and both the Barthel index score after rehabilitation and changes in it resulting from rehabilitation (p < 0.001). After adjustment for age and the Barthel index assessed on admission to rehabilitation, a significant positive association was found between BMI and period of rehabilitation (p < 0.001). The results were similar when BMI was evaluated either as individual values or after categorization according to World Health Organization criteria.

CONCLUSIONS

In a sample of hip-fractured women, BMI was negatively associated with Barthel index scores and positively associated with period of rehabilitation. BMI may affect function after hip fracture, apart from hip fracture risk: subjects with higher BMI and low hip fracture risk may have poorer functional recovery in case of hip fracture, despite prolonged rehabilitation. Conversely, subjects with lower BMI and high hip fracture risk may have better functional recovery in case of hip fracture.

Cost-effectiveness Strategies to Treat Osteoporosis in Elderly Women

BACKGROUND

Comparing the cost-effectiveness of various antiosteoporotic drugs has not been defined.

METHODS

We determined the cost-effectiveness of calcitonin, raloxifene, bisphosphates and PTH in a base-case cohort of women aged 65 or older with osteoporosis. After bone densitometry, women were stratified into groups of treatment or no treatment. Our outcome goal was a value of dollars 100,000 or less per quality-adjusted life years (QALY). A sensitivity analysis varied nonvertebral fracture reduction and compliance between the two most effective strategies to test various cost per QALY thresholds.

RESULTS

Bisphosphonates displayed the most favorable incremental cost saving and prevented more fractures in our base-case analysis. In a sensitivity analysis, virtually all values of bisphosphonates were under dollars 100,000 per QALY and parathyroid hormone (PTH) was between dollars 100,000 and dollars 200,000 per QALY.

CONCLUSIONS

Only bisphosphonates are cost-effective for fracture prevention in osteoporotic women aged 65 or older and this economic advantage is also maintained in subsets who have a lower relative risk of future fracture.

Morbimortalidade por causas externas na população idosa residente em município da região sul do Brasil

A morbimortalidade por causas externas foi analisada para idosos residentes em Município do Sul do Brasil. Os óbitos, de 1979 a 1998, e as internações, de 1995 a 1998, foram obtidos do Sistema de Informação de Mortalidade, do Sistema de Informações Hospitalares do SUS e a população, dos Anuários do IBGE. O coeficiente de mortalidade por causas externas decresceu 16,2%, mas observaram-se valores crescentes com a idade, maiores no sexo feminino. As quedas, atropelamentos e outros acidentes de transporte foram as causas mais freqüentes. O coeficiente de mortalidade no sexo masculino, no último triênio, foi maior por atropelamentos e no feminino por quedas (64,8 e 58,3 óbitos por 100.000 habitantes, respectivamente). As internações por lesões e envenenamentos decresceram no período e entre as 146 ocorridas em 1998, 45,9% foram por quedas. A comunidade deve reconhecer que o idoso está exposto aos acidentes, sendo necessário que medidas preventivas sejam adotadas.

Women with hip fracture have a greater rate of decline in bone mineral density than expected: another significant consequence of a common geriatric problem

INTRODUCTION

Hip fracture is a major public health problem, annually affecting over 350,000 persons in the United States and 1.6 million worldwide. Consequences include decreased survival, loss of independence, and increased risk of subsequent fractures. A substantial decline in bone mineral density (BMD) also occurs, yet the magnitude of the decline specifically attributable to hip fracture has not been documented.

METHODS

To determine the amount of BMD decline attributable to hip fracture, the rate of decline in BMD in a cohort of hip fracture patients was compared with that in a cohort of women of similar age and BMD but without hip fracture. All subjects were community dwelling when enrolled. Hip fracture patients in the Baltimore Hip Studies (BHS) came from two hospitals in Baltimore, Maryland, from 1992 through 1995; comparison subjects came from the Study of Osteoporotic Fracture (SOF) enrolled in four areas of the United States during the same period. Eighty-four white, female hip fracture patients 65 years and older from the BHS were compared with 168 SOF participants matched on age, race, and BMD at baseline. BMD of the femoral neck and total hip was measured by dual-energy x-ray absorptiometry.

RESULTS

Hip fracture patients had a greater decline in BMD during the 12-month postfracture follow-up than that expected on the basis of the nonfracture cohort: 4.9% vs. 0.4% at the femoral neck and 3.5% vs. 0.7% for the total hip. The decline in BMD in hip fracture patients was 11.8 times the amount expected at the femoral neck (matched on age and baseline BMD and adjusted for between-cohort differences in smoking prevalence) and 4.9 times that expected for the total hip at the end of 1 year after the hip fracture.

CONCLUSION

In this sample of older women, bone loss over the year following hip fracture far exceeded that expected and is an important clinical management concern.

Chemoprevention: Drug pricing and mortality

BACKGROUND

Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness.

METHODS

A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements.

RESULTS

Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached > or =2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%.

CONCLUSIONS

Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

Quality of life, morbidity, and mortality after low trauma hip fracture in men

BACKGROUND

Osteoporotic hip fractures have been extensively studied in women, but they have been relatively ignored in men.

OBJECTIVE

To study the mortality, morbidity, and impact on health related quality of life of male hip fractures.

METHODS

100 consecutive men aged 50 years and over, with incident low trauma hip fracture, admitted to Royal Cornwall Hospital, UK during 1995-97, were studied. 100 controls were recruited from a nearby general practice. Mortality and morbidity, including health status assessed using the SF-36, were evaluated over a 2 year follow up period.

RESULTS

Survival after 2 years was 37% in fracture cases compared with 88% in controls (log rank test 62.6, df = 1, p = 0.0001). In the first year 45 patients died but only one control. By 2 years 58 patients but only 8 controls had died. Patients with hip fracture died from various causes, the most common being bronchopneumonia (21 cases), heart failure (9 cases), and ischaemic heart disease (8 cases). Factors associated with increased mortality after hip fracture included older age, residence before fracture in a nursing or residential home, presence of comorbid diseases, and poor functional activity before fracture. Patients with fracture were often disabled with poor quality of life. By 24 months 7 patients could not walk, 12 required residential accommodation, and the mean SF-36 physical summary score was 1.7SD below the normal standards.

CONCLUSIONS

Low trauma hip fracture in men is associated with a significant increase in mortality and morbidity. Impaired function before fracture is a key determinant of mortality after fracture.

Survival after hip fracture

Although it is known that overall mortality is increased after hip fracture, the influence of hip fracture risk factors on the subsequent mortality and cause of death has not been well studied. The objective of this study was to establish the survival after hip fracture in women and to assess the impact of comorbidity on mortality. We identified a complete population-based set of 2,245 incident hip fracture cases and 4,035 randomly selected population-based controls among women 50-81 years old in Sweden and followed these subjects for an average of 5 years through the Swedish National Inpatient and Cause-of-Death Registers. Information on factors related to hip fracture was obtained through linkage to hospital discharge data and through a mailed questionnaire. We studied excess mortality of hip fracture patients compared to controls using survival curves and proportional hazard regression models. During follow-up, 896 hip fracture patients (40%) and 516 (13%) controls died. The relative risk (RR) of death, adjusted for age and previous hospitalization for serious disease, was 2.3 (95% CI 2.0-2.5). Although the highest mortality risks were in the 1st 6 months post-fracture, RRs for fractures versus controls were increased for at least 6 years. Increased mortality was apparent both in those with evidence of comorbidity and those without. Hip fracture patients have a substantially increased risk of death that persists for at least 6 years post-fracture. The relative excess mortality is independent of comorbidity and known hip fracture risk factors.

Hip fracture: family caregivers' burden and related factors for older people in Taiwan

AIMS

The purpose of this study was to explore the burden experienced by caregivers during the transition from hospital to home.

BACKGROUND

With a growing older population, home-based care has gradually gained more recognition. Most older people with hip fracture in Taiwan have to be discharged at a relatively early stage. Therefore, the caregiving tasks falls on the families.

METHODS

A total of 98 older people with hip fracture and their caregivers were interviewed. The sample was selected from three medical centres in Taipei, and questionnaires were collected at one week and one month following hospital discharge.

RESULTS

(i) Family caregivers were usually women (63.3%) with spouses being the primary caregivers in most cases (30.6%). About one-third of caregivers took care of other family members on top of their responsibilities caring for the sick elders at home, and 77.6% shared the care tasks with others. (ii) The caregivers experienced moderate burdens. About 91.8% of caregivers reported 'I feel sad watching the elder's health deteriorating', 84.9% reported 'I must keep an eye on the elder constantly' and 56.7% reported 'Taking care of the sick elder at home makes me feel exhausted'. (iii) Caregiver burden and the functional level of older people were adversely correlated. (iv) Caregivers who were unable to access other resources for help and/or had provided care to the older person prior to the fracture resulting in hospitalization experienced a higher burden.

CONCLUSIONS

These findings should be helpful in the formulation of evidence-based discharge planning and home health care services.

RELEVANCE TO CLINICAL PRACTICE

Comprehensive discharge planning and developing social support systems for family caregivers to reduce caregivers burden are needed.

Gender differences for non-fatal unintentional fall related injuries among older adults

OBJECTIVES

To quantify gender differences for non-fatal unintentional fall related injuries among US adults age 65 years and older treated in hospital emergency departments (EDs).

METHODS

The authors analyzed data from a nationally representative sample of ED visits for January 2001 through December 2001, available through the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP). For each initial ED visit, coders record one principal diagnosis (usually the most severe) and one primary part of the body affected.

RESULTS

Based on 22,560 cases, an estimated 1.64 million older adults were treated in EDs for unintentional fall injuries. Of these, approximately 1.16 million, or 70.5%, were women. Fractures, contusions/abrasions, and lacerations accounted for more than three quarters of all injuries. Rates for injury diagnoses were generally higher among women, most notably for fractures which were 2.2 times higher than for men. For all parts of the body, women's injury rates exceeded those of men. Rate ratios were greatest for injuries of the leg/foot (2.3), arm/hand (2.0), and lower trunk (2.0). The hospitalization rate for women was 1.8 times that for men.

CONCLUSIONS

Among older adults, non-fatal fall related injuries disproportionately affected women. Much is known about effective fall prevention strategies. We need to refine, promote, and implement these interventions. Additional research is needed to tailor interventions for different populations and to determine gender differences in the underlying causes and/or circumstances of falls. This information is vital for developing and implementing targeted fall prevention strategies.

Predictors of functional outcome following intracapsular hip fracture in elderly women. A one-year prospective cohort study

OBJECTIVES

To explore potential predictors of functional outcome one year after the injury in elderly women who sustained a displaced intracapsular hip fracture and who were treated with internal fixation, hemiarthroplasty, or total hip arthroplasty.

PARTICIPANTS AND METHODS

Eighty-four women aged > or =50 years were enrolled on a consecutive basis in this one-year prospective cohort study reflecting standard day-to-day clinical practice. The main outcome measure was the rapid disability rating scale version-2 (RDRS-2) applied at hospital discharge and one year later.

RESULTS

At hospital discharge, the total hip arthroplasty group was younger and had a better functional status than the internal fixation or hemiarthroplasty groups. One year later, the best function was still observed in the total arthroplasty group, but the differences were small and failed to achieve the level of statistical significance. During that one-year period, walking ability or mobility did not change significantly after total hip arthroplasty, but a significant proportion of the women developed cognitive impairment, including mental confusion, uncooperativeness, and depression. Overall, the most significant predictors of poor functional status one year after fracture were increasing age, living in an institution at time of injury, and poor functional status at discharge.

CONCLUSIONS

In elderly women with a displaced intracapsular hip fracture, total hip arthroplasty is associated with a functional benefit within the first months after surgery. However, the extent to which this functional benefit is maintained over time, is less clear. These results support the need for randomised studies to quantify the extent to which, in elderly women, the early functional benefit of total hip arthroplasty is maintained in the long run or compromised by progressive cognitive impairment and other negative determinants of functional outcome.

Factors affecting ambulatory status and survival of patients 90 years and older with hip fractures

This study was done to assess the long-term functional outcome of very elderly patients with hip fractures, to determine whether bone mineral density and prevalent vertebral fractures could affect mortality and ambulatory status, and to examine which patient characteristics reported in the literature are predictive of patient mortality and ambulatory status. Seventy-four patients 90 years and older with hip fractures were analyzed and followed up for at least 4 years or until death. The mean age of the patients was 92.8 years and all were treated surgically. Walking ability before injury was better than at discharge; walking ability decreased during the first year after discharge, but thereafter reached a plateau. The predictors of survival were the preoperative American Society of Anesthesiologists score, walking ability, fracture type, type of surgery, and the number of prevalent vertebral fractures on admission. Dementia and the number of prevalent vertebral fractures were predictors of the recovery of walking ability. Type of surgery and fracture type are collinear variables, and because it is difficult to separate the effects of one versus the other, additional well-designed, randomized studies on the effect of the type of surgery and fracture type on outcome are needed.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Outpatient Medications and Hip Fractures in the US

BACKGROUND

Certain medications have been linked to falls. One of the most severe fall-related injuries in the elderly is a hip fracture.

OBJECTIVE

The objective of this study was to examine the use of medications known to increase fall risk that were prescribed on an outpatient basis to veterans prior to hospital admission for hip fracture.

METHODS

We identified and analysed the use of outpatient fall-related medications in 2212 unique patients with hip fractures admitted in fiscal year 2003 to Veterans Health Administration hospitals compared with that for matched controls (exact match for age and sex) admitted for acute myocardial infarction (MI) or pneumonia. We analysed the medications selected from the three drug categories most often linked with an increased risk for falls. These categories included medications that affected the cardiovascular (CVS), CNS or the musculoskeletal system (MSS). The unit of analysis was the hip fracture linked with outpatient medications in the study group compared with matched control groups of patients with hospitalisations for an acute MI or pneumonia.

RESULTS

Of the 2212 hip-fracture patients, 70% had fall-related medications prior to hospitalisation for hip fracture. The most notable differences in usage were seen in the drug classes antiepileptics/barbiturates, antidepressants (2-fold difference in use of selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]), and antiparkinson's drugs (nearly 4-fold difference between cases and controls). There were also notable differences in usage of antipsychotics (3-fold difference for hip-fracture cases compared with acute MI) and cholinesterase inhibitors (nearly 2-fold difference for hip-fracture cases compared with pneumonia or acute MI). The most notable differences in polypharmacy combinations were CVS and CNS categories with differences of 9.44% (absolute) and 43% (relative) for hip-fracture patients over acute MI, and 4.83% (absolute) and 18% (relative) for hip-fracture patients over pneumonia patients.

CONCLUSIONS

This is the first national Veterans Health Administration hip fracture hospitalisation study that temporally linked outpatient fall-related medications in hip-fracture patients with matched controls. We found that of veterans with hip-fracture hospitalisations, 70% were prescribed outpatient medications from selected major drug categories that may potentially increase fall risk. Moreover, over one-third of hip-fracture patients received concomitant prescriptions of drugs from multiple selected drug categories. Hip-fracture patients, compared with matched controls of acute MI and pneumonia, had the largest pronounced differences in prescribed medications in the antiepileptics, antidepressants, antipsychotics and antiparkinson's drug classes. Although a randomised clinical trial is the 'gold standard' for determining causation issues, exposing patients, particularly the elderly, to the potential risk of injurious falls would raise serious patient safety research approval issues. If the relationship between selected drugs and falls is indeed to some extent causative, future retrospective multivariate analyses could quantify the magnitude of these effects.

Serum levels of 25-Hydroxyvitamin D and functional recovery after hip fracture

OBJECTIVE

To evaluate the association between serum levels of 25-hydroxyvitamin D (25[OH]D(3)) and functional recovery after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 350 white hip-fracture patients consecutively admitted to a rehabilitation hospital. Thirty-five patients were excluded because their hip fracture was caused by major trauma or cancer affecting the bone or they could not complete rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients underwent 25(OH)D(3) assessment at a mean +/- standard deviation of 21.3+/-8.1 days after the hip fracture. Functional recovery was evaluated by using Barthel Index scores.

RESULTS

Low levels of 25(OH)D(3) were found (median, 6.9 ng/mL). By using the Spearman rank correlation test, a significant positive correlation was observed between serum 25(OH)D(3) and Barthel Index score assessed on admission (rho=.218, P <.001) and discharge (rho=.198, P <.001), but not with the change in Barthel Index score attributable to rehabilitation. Linear multiple regression showed that the association between 25(OH)D(3) and Barthel Index score was independent of 11 confounding variables: age, sex, hip-fracture type, pressure ulcers, cognitive impairment, neurologic impairment, infections, time between fracture occurrence and 25(OH)D(3) evaluation, comorbidity, surgical procedure type, and previous hip fractures.

CONCLUSIONS

In the study population, serum 25(OH)D(3) was an independent predictor of functional recovery assessed by Barthel Index score after hip fracture but not of the change in the functional score resulting from rehabilitation.

Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial

BACKGROUND

Treatment of osteoporosis following a hip fracture has been notoriously poor. Many efforts have been made to improve treatment rates. The purpose of this study was to determine whether a perioperative inpatient intervention program, involving patient education and providing a list of questions for the primary care physician, increased the percentage of patients in whom osteoporosis was addressed following a hip fracture.

METHODS

A prospective, randomized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted. During their hospitalization, the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures, the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment, and the importance of medical follow-up for osteoporosis management. These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician, and they were reminded about the questions during a follow-up telephone call six weeks later. The patients in the control group received a brochure describing methods for preventing falls. Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed. Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy.

RESULTS

The average age in each group was eighty-two years, and 78% of the patients were female. Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial. Fifteen (42%) of the thirty-six patients who had been randomized to the study group, compared with only seven (19%) of the thirty-six patients in the control group, had their osteoporosis addressed by their primary physician. This difference between the groups was significant (p = 0.036).

CONCLUSIONS

Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions. Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management.

Comparing wound complication rates following closure of hip wounds with metallic skin staples or subcuticular vicryl suture: a prospective randomised trial

PURPOSE

To compare 2 methods of wound closure-metallic staples or 3-0 undyed vicryl-according to postoperative wound complication rates.

METHODS

Patients who underwent surgery for proximal femoral fractures were randomised to have wound closure with metallic staples or with subcuticular vicryl suture. Wounds were regularly examined postoperatively and only those with positive wound swabs were regarded as wound infections.

RESULTS

Five infections and one superficial wound dehiscence occurred in the patients who had wound closure with metallic staples. The complication rate was significantly higher for this group compared with the group who had wound closure with subcuticular vicryl suture (p<0.025).

CONCLUSION

Superficial wound complication rates are higher for wounds closed with metallic staples compared to wounds closed with subcuticular vicryl.

Development and validation of the osteoporosis prescreening risk assessment (OPERA) tool to facilitate identification of women likely to have low bone density

Osteoporosis and its consequent increase in fracture risk is a major health concern for postmenopausal women and older men and has the potential to reach epidemic proportions. The "gold standard" for osteoporosis diagnosis is bone densitometry. However, economic issues or availability of the technology may prevent the possibility of mass screening. The goal of this study was to develop and validate a clinical scoring index designed as a prescreening tool to help clinicians identify which women are at increased risk of osteoporosis [bone mineral density (BMD) T-score -2.5 or less] and should therefore undergo further testing with bone densitometry. Records were analyzed for 1522 postmenopausal females over 50 years of age who had undergone testing with dual-energy X-ray absorptiometry (DXA). Osteoporosis risk index scores were compared to bone density T-scores. Hologic QDR 4500 technology was used to measure BMD at the femoral neck and lumbar spine (L1-L4). Participants who had a previous diagnosis of osteoporosis or were taking bone-active medication were excluded. Receiver-operating characteristic (ROC) analysis was used to identify the specific cutpoint value that would identify women at increased risk of low BMD. A simple algorithm based on age, weight, history of previous low impact fracture, early menopause, and corticosteroid therapy was developed. Validation of this five-item osteoporosis prescreening risk assessment (OPERA) index showed that the tool, at the recommended threshold (or cutoff value) of two, had a sensitivity that ranged from 88.1 [95% confidence interval (CI) for the mean: 86.2-91.9%] at the femoral neck to 90% (95% CI for the mean: 86.1-93.1%) at the lumbar spine area. Corresponding specificity values were 60.6 (95% CI for the mean: 57.9-63.3%) and 64.2% (95% CI for the mean: 61.4-66.9%), respectively. The positive predictive value (PPV) ranged from 29 at the femoral neck to 39.2% at the lumbar spine, while the corresponding negative predictive values (NPVs) reached 96.5 and 96.2%, respectively. Based on this cutoff value, the area under the ROC curve was 0.866 (95% CI for the mean: 0.847-0.882) for the lumbar spine and 0.814 (95% CI for the mean: 0.793-0.833) for the femoral neck. We conclude that the OPERA is a free and effective method for identifying Italian postmenopausal women at increased risk of osteoporosis. Its use could facilitate the appropriate and more cost-effective use of bone densitometry in developing countries.

Hip fracture-related changes in health ratings of older patients with cognitive impairment

A hip fracture is traumatic for many older adults, often leading to declines in both health and health perception. Although health ratings often decrease from pre- to post-fracture, nothing is known about what influences cognitively impaired patients to assess their post-fracture health as they do. We developed a causal model of health perception following a hip fracture and previously reported this causal model for older hip fracture patients of high mental status. This study evaluates the same causal model on 145 patients of low mental status. We found a substantial reorganization of relative health and functional ratings, indicative of the highly disruptive impact of the hip fracture. Our findings suggest physical rehabilitation may aid in recovery from hip fracture and this merits further study.

Comparison of logistic regression and neural network analysis applied to predicting living setting after hip fracture

PURPOSE

Describe and compare the characteristics of artificial neural networks and logistic regression to develop prediction models in epidemiological research.

METHODS

The sample included 3708 persons with hip fracture from 46 different states included in the Uniform Data System for Medical Rehabilitation. Mean age was 75.5 years (sd=14.2), 73.7% of patients were female, and 82% were non-Hispanic white. Average length of stay was 17.0 days (sd=10.6). The primary outcome measure was living setting (at home vs. not at home) at 80 to 180 days after discharge.

RESULTS

Statistically significant variables (p <.05) in the logistic model included follow-up therapy, sphincter control, self-care ability, marital status, age, and length of stay. Areas under the receiver operating characteristic curves were 0.67 for logistic regression and 0.73 for neural network analysis. Calibration curves indicated a slightly better fit for the neural network model.

CONCLUSIONS

Follow-up therapy and independent bowel and/or bladder function were strong predictors of living at home up to 6 months after hospitalization for hip fracture. No practical differences were found between the predictive ability of logistic regression and neural network analysis in this sample.

Functional recovery and length of stay after hip fracture in patients taking corticosteroids

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients receiving corticosteroids.

DESIGN

A total of 796 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 36 of 796 were currently treated with either oral (n = 23) or inhaled (n = 13) corticosteroids.

RESULTS

No significant differences were shown between corticosteroid users and controls for Barthel index score at admission or discharge, change in Barthel index score resulting from rehabilitation, and length of stay. Multiple regression, including 11 confounding variables, showed that several factors, but not the treatment with corticosteroids, were significantly associated with the Barthel index score or the length of stay. The results were similar when the two subgroups of patients receiving corticosteroids were evaluated separately. In the subgroup of the patients receiving oral corticosteroids, no meaningful correlations were observed between the daily dose (milligrams of prednisone equivalent) and the Barthel index score, the change in the Barthel index score attributable to rehabilitation, or the length of stay.

CONCLUSIONS

After hip fracture, neither the functional recovery nor the length of stay were significantly affected by the current treatment with corticosteroids.

Functional outcomes and mortality vary among different types of hip fractures: a function of patient characteristics

A review of prospectively collected data was done to compare functional outcomes and mortality among patients with different hip fracture types. Five hundred thirty-seven elderly patients who sustained a hip fracture were followed up prospectively. Orthopaedists blinded to treatment and outcome radiographically classified the fractures as either: (1) nondisplaced or impacted femoral neck; (2) displaced femoral neck; (3) stable intertrochanteric; or (4) unstable intertrochanteric fracture. Functional independence measure scores were calculated for preinjury function and at 2- and 6- month follow-ups. Comorbidities, operative details, postoperative complications, and deaths were recorded. Six-month mortality was lowest for patients with nondisplaced femoral neck fractures (5.7%) and highest for patients with displaced femoral neck fractures (15.8%), but multivariate analysis only identified preinjury function as an independent predictor of mortality. All preinjury and followup functional independence measure scores were greatest for patients with nondisplaced femoral neck fractures and least for patients with unstable intertrochanteric fractures. However, multivariate analysis identified only patient age and preinjury functional independence measure scores as independent predictors of functional outcome. These data show differences in mortality and functional outcomes among fracture types that can be attributed to differences in functional status before injury.