[Osteoporosis in traumatology. Prevalence and management]

[Development of the inpatient quality of care of surgically treated patients with a proximal femoral fracture in North Rhine-Westphalia : Analysis of 61,249 treatment courses based on data from external inpatient quality assurance]

BACKGROUND AND OBJECTIVE

Every year in Germany over 100,000 people, mostly of older age, suffer a proximal femoral fracture. Increasing case numbers in connection with an aging population and a relatively large number of concomitant diseases requiring treatment make everyday care more difficult. It is therefore of great importance to observe the quality of care for these patients using relevant quality parameters in order to be able to derive implications for everyday treatment practice.

MATERIAL AND METHODS

The data of the external inpatient quality assurance from North Rhine-Westphalia for the years 2007-2008 and 2017-2018 were analyzed and the time periods compared. In addition, based on the documented secondary diagnosis and other influencing parameters, a risk adjustment was carried out with the aid of a logistic regression model with respect to the outcomes of general and surgical complications and mortality. Both osteosynthetically and endoprosthetically treated patients were taken into account. A total of 61,249 cases were included in the study.

RESULTS

Positive developments could be observed in the area of surgical complications and wound infections with decreases of 1.2% and 0.8%, respectively. Patients with cardiovascular diseases had a particularly poor outcome. Here, improvements in the subcategory of cardiovascular events were found for general complications. The mortality remained unchanged at 6%. Operative activity on the weekends increased significantly. Patients whose hospital admission was related to the weekend did not show an increased risk of complications or mortality. Although the proportion of patients who were operated on after more than 48 h was reduced from 11.4% to 8.2%, the operation (> 24 h) was still delayed in 26.8% of cases.

CONCLUSION

Against the background of increasing performance demands on the healthcare system, the results document improvements in some central areas of inpatient treatment. Nevertheless, the development of strategies for the further reduction of the preoperative waiting times in a medically justifiable manner is required. Internal concomitant diseases have a decisive influence on patient outcome. Thus, an adequate treatment of the multimorbid patient collective is to be established in everyday practice on the basis of close cooperation between geriatric traumatology and geriatric internal medicine departments.

Investigation and management of osteoporosis in aged trauma patients: a treatment algorithm adapted to the German guidelines for osteoporosis

BACKGROUND

Osteoporosis-associated fractures are of increasing importance in trauma surgery. Systematic diagnostics and treatment of osteoporosis during a hospital stay, however, remain inadequate. Therefore, a specific algorithm for diagnosing and treating osteoporosis in trauma surgery patients was developed based on the DVO (German Osteology Society) guideline for osteoporosis from 2014.

METHODS

In a first step, the individuals' age and risk profile for osteoporosis is identified considering specific fractures indicating osteoporosis and risk factors assessed by a specific questionnaire. In addition, physical activity, risk of falls, dietary habits and the individuals' medication are considered. Basic osteoporosis laboratory tests, a bone densitometry by dual-energy X-ray absorptiometry (DXA) and, if needed, X-rays of the spine are carried out to identify prevalent vertebral body fractures.

RESULTS

Based on the treatment algorithm adapted to the new guidelines for osteoporosis in the majority of proximal femoral fractures, treatment of osteoporosis could already be indicated without prior DXA. In case of preexisting glucocorticoid therapy, a history of previous fractures or other risk factors according to the risk questionnaire, the threshold of treatment has to be adjusted given the table of T-scores.

CONCLUSIONS

The treatment algorithm for diagnosing and treating osteoporosis in in-patient trauma surgery patients can help identify high-risk patients systematically and efficiently. As a result, osteoporosis-associated fractures or failure of osteosynthesis could be reduced, yet a prospective validation of the algorithm has to be completed.

[Prevalence and management of osteoporosis in trauma surgery. Implementation of national guidelines during inpatient fracture treatment]

BACKGROUND

Osteoporosis-associated fractures represent a risk factor for developing further fragility fractures. Therefore, guideline-oriented osteoporosis intervention is of utmost importance during inpatient fracture treatment.

PATIENTS AND METHODS

Women >50 years and men >60 years with fractures of the lumbar or thoracic spine, proximal femur, proximal humerus and distal radius were included in a prospective study. We analyzed the initiation of diagnosis and treatment of osteoporosis during the inpatient stay.

RESULTS

A total of 455 patients were included and bone mineral density measurement (DXA) was carried out in 65.9 %. Women underwent DXA in 69.5 % and men significantly less frequently in 52.1 %. Osteoporosis was diagnosed in 56.6 %, where women were affected in 56.2 % and men in 59 % of cases. In 83.8 % osteoporosis had been previously unknown. Treatment according to the guidelines of the Organisation of German Scientific Osteology-related Societies (DVO) was initiated in 86.7 % and 77.1 % of women >70 years and men >80 years required anti-resorptive treatment after DXA.

CONCLUSIONS

The majority of elderly patients with fractures also suffer from osteoporosis, independent of gender. Even nowadays, osteoporosis is predominantly not diagnosed until the incidence of a fracture. Therefore, the trauma surgeon is in a key position to initiate diagnosis and treatment of osteoporosis.

[The Ludwigshafen Osteoporosis Screening Questionnaire (LOS Questionnaire): result of the evaluation of anamnestic risk factors in osteoporosis diagnostics]

BACKGROUND

Osteoporosis is a major health problem worldwide and is included in the WHO list of the top ten major diseases. However, it is often undiagnosed until the first fracture occurs, due to inadequate patient education and lack of insurance coverage for screening tests.

METHODS AND MATERIAL

In our study of 78 patients with metaphyseal long bone fractures, we searched for a correlation between anamnestic risk factors, bone-specific laboratory values, and the bone morphogenic density (BMD). Each indicator was examined as a possible diagnostic instrument for osteoporosis. The secondary aim of this study was to demonstrate the high prevalence of osteoporosis in patients with metaphyseal fractures.

RESULTS

Of our fracture patients 76.9% had decreased bone density and 43.6% showed manifest osteoporosis in DXA (densitometry) measurements. Our modified LOS Questionnaire, identifying anamnestic risk factors, correlated highly significantly (p=0.01) with reduced BMD, whereas seven bone-specific laboratory values (p=0.046) correlated significantly.

CONCLUSION

Anamnestic risk factors correlate with pathological BMD more than bone-specific laboratory values. The LOS Questionnaire used in this study would therefore function as a cost-effective primary diagnostic instrument for identification of osteoporosis patients.

Anamnestic risk factor questionnaire as reliable diagnostic instrument for osteoporosis (reduced bone morphogenic density)

Background

Osteoporosis is a major health problem worldwide, and is included in the WHO list of the top 10 major diseases. However, it is often undiagnosed until the first fracture occurs, due to inadequate patient education and lack of insurance coverage for screening tests. Anamnestic risk factors like positive family anamnesis or early menopause are assumed to correlate with reduced BMD.

Methods

In our study of 78 patients with metaphyseal long bone fractures, we searched for a correlation between anamnestic risk factors, bone specific laboratory values, and the bone morphogenic density (BMD). Each indicator was examined as a possible diagnostic instrument for osteoporosis. The secondary aim of this study was to demonstrate the high prevalence of osteoporosis in patients with metaphyseal fractures.

Results

76.9% of our fracture patients had decreased bone density and 43.6% showed manifest osteoporosis in DXA (densitometry) measurements. Our questionnaire, identifying anamnestic risk factors, correlated highly significantly (p = 0.01) with reduced BMD, whereas seven bone-specific laboratory values (p = 0.046) correlated significantly.

Conclusions

Anamnestic risk factors correlate with pathological BMD. The medical questionnaire used in this study would therefore function as a cost-effective primary diagnostic instrument for identification of osteoporosis patients.

Osteoporosis prevalence and fracture characteristics in elderly female patients with fractures

PURPOSE

The aim of this study was to characterize the features of fractures that occur in female patients with osteoporosis in the setting of a typical trauma hospital.

METHODS

Observational study was conducted on 233 women aged 50 years and above reporting to a trauma center with a fracture. Fracture location, fracture classification and cause of fracture were obtained and compared with bone mineral status assessed by DXA at the spine.

RESULTS

Our findings indicate that with increasing patient age, the majority of fractures occur after a minor traumatic event. In more than one-third of all fractures after minor trauma, the patients were diagnosed with osteoporosis. The overall prevalence of osteoporosis in patients older than 50 years with fractures was more than 30% and was increasing with age. Most strikingly, one-third of the patients have had a previous fracture at a location that should have triggered the assessment of bone health status, but only 25% of them had received any form of osteoporosis treatment.

CONCLUSION

For patients older than 50 years reporting to a trauma unit with a fracture, osteoporosis has a considerable prevalence. The large number of patients who have had a previous fracture emphasizes the necessity for an effective implementation of treatment algorithms for elderly patients with osteoporosis in the setting of a trauma hospital.

[Reality of treatment of osteoporotic fractures in German trauma departments. A contribution for outcome research]

The implementation of clinical pathways has a proven positive effect on the diagnostic workup and initiation of therapy in osteoporotic fracture patients. Unlike in most countries, fracture care in Germany is provided by so-called trauma surgeons. Therefore, it is essential to focus on the trauma surgeon for correct diagnostic workup and therapy initiation after a fragility fracture. A questionnaire was mailed to 409 departments of traumatology inquiring about the existence of a standardized clinical pathway for diagnosis and treatment of patients with fragility fractures. One of the central issues of the survey was whether those pathways comply with national guidelines. Only institutions that stated that they followed a clinical pathway were analyzed. 80% of institutions took part in our survey, 35% of which reported following a defined clinical pathway. Diagnostic workup is in concordance with the national guidelines in 30%, and therapy is guideline-based in 51%, with 12% basing both diagnostic workup and therapy on the guidelines. Thus, the vast majority of German traumatology departments do not follow national guidelines regarding osteoporosis diagnostics and therapy in patients with fragility fractures, leading to a great opportunity to improve fragility fracture care by means of both education and interdisciplinary cooperation.

[Osteoporosis and falls in Germany: health care for the elderly with an increased risk for fractures]

Fractures are a considerable risk, especially in older patients. The fracture of the proximal femur is of particular relevance. Functional deficiency, an increased need for care and assistance and a limitation of the quality of life after a fracture lead to an increase in morbidity and mortality among patients who lived independently prior to the event in most cases. The risk of suffering a femoral fracture mainly depends on two risk factors: osteoporosis and falls. Both can be influenced and are therefore suitable for interventions. National and international guidelines for diagnosis and treatment have so far separately addressed deficiencies in bone stability and neuromuscular function. The current German DVO guideline is the first to consider both aspects simultaneously and develop an individual concept for diagnosis and therapy depending on a risk prediction of a fracture within the following 10 years. The evaluation of the current quality of health care in the field of osteoporosis and falls both nationally and internationally seems to be hardly possible. Merely the delivery of DXA measurements and medication for osteoporosis are assessable. In these sectors a deficiency in the delivery of care is apparent. Standardized evaluations of the implementation of guidelines are needed to assess deficiencies and reveal options for improving quality of care in the future.