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Choi JW, Park JW, Choi WJ. Effects of hip joint kinematics on the effective pelvis stiffness and hip impact force during simulated sideways falls. J Biomech 2024; 162:111885. [PMID: 38039920 DOI: 10.1016/j.jbiomech.2023.111885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
Improved understanding is required on how hip fracture risk is influenced by landing configuration. We examined how hip impact dynamics was affected by hip joint kinematics during simulated sideways falls. Twelve young adults (7 males, 5 females) of mean age 23.5 (SD = 1.5) years, participated in pelvis release experiments. Trials were acquired with the hip flexed 15° and 30° for each of three hip rotations: +15° ("external rotation"), 0°, and -15° ("internal rotation"). During falls, force-deformation data of the pelvis were recorded. Outcome variables included the peak hip impact force (Fexperimental) and effective stiffness of the pelvis (k1st, ksecant, and kms) determined with different methods suggested in literature, and predicted hip impact force during a fall from standing height (F1st, Fsecant and Fms). The two-way repeated-measures ANOVA was used to test whether these variables were associated with hip joint angles. The Fexperimental, ksecant and Fsecant were associated with hip rotation (F = 5.587, p = 0.005; F = 9.278, p < 0.0005; F = 5.778, p = 0.004, respectively), and 15 %, 31 % and 17 % smaller in 15° external than internal rotation (848 versus 998 N; 24.6 versus 35.6 kN/m; 2,637 versus 3,170 N, respectively). However, none of the outcome variables were associated with hip flexion (p > 0.05). Furthermore, there were no interactions between the hip rotation and flexion for all outcome variables (p > 0.05). Our results provide insights on hip impact dynamics, which may help improve a hip model to assess hip fracture risk during a fall.
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Affiliation(s)
- J W Choi
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Gangwon-do, South Korea
| | - J W Park
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Gangwon-do, South Korea
| | - W J Choi
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Gangwon-do, South Korea.
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2
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Vlachos C, Ampadiotaki MM, Papagrigorakis E, Galanis A, Zachariou D, Vavourakis M, Rodis G, Vasiliadis E, Kontogeorgakos VA, Pneumaticos S, Vlamis J. Distinctive Geometrical Traits of Proximal Femur Fractures-Original Article and Review of Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2131. [PMID: 38138234 PMCID: PMC10744519 DOI: 10.3390/medicina59122131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson's χ2 criterion was used, while Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur.
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Affiliation(s)
- Christos Vlachos
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | | | - Eftychios Papagrigorakis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - Athanasios Galanis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - Dimitrios Zachariou
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - Michail Vavourakis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - George Rodis
- Department of Radiology, KAT General Hospital, 14561 Athens, Greece;
| | - Elias Vasiliadis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - Vasileios A. Kontogeorgakos
- 1st Orthopedic Department, National and Kapodistrian University of Athens, Attikon General University Hospital, 12462 Chaidari, Greece;
| | - Spiros Pneumaticos
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
| | - John Vlamis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, 14561 Athens, Greece; (E.P.); (A.G.); (D.Z.); (M.V.); (E.V.); (S.P.); (J.V.)
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Robinovitch SN, Onyejekwe C. Research Priorities for Wearable Hip Protectors for Hip Fracture Prevention in Long-Term Care. J Am Med Dir Assoc 2023; 24:1010-1012. [PMID: 37349048 DOI: 10.1016/j.jamda.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Stephen N Robinovitch
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.
| | - Cynthia Onyejekwe
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
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Tarbert R, Zhou J, Manor B. Potential Solutions for the Mitigation of Hip Injuries Caused by Falls in Older Adults: A Narrative Review. J Gerontol A Biol Sci Med Sci 2023; 78:853-860. [PMID: 36194471 PMCID: PMC10172985 DOI: 10.1093/gerona/glac211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hip injuries caused by falling are common and often catastrophic for older adults. There is thus an urgent need to develop solutions designed to mitigate fall injuries to the hip by reducing the forces created on the body by ground impact. METHODS The goal of this narrative review was to synthesize published literature on available products developed with the expressed goal of reducing fall-related hip injuries. RESULTS Three categories were identified: passive wearables (eg, hip protectors), active wearables (eg, instrumented belts with deployable airbags), and compliant flooring. Laboratory studies indicate that each technology can reduce peak forces induced by simulated falls. Considerable preliminary data suggest that passive wearables and compliant flooring may reduce fall-related injuries within long-term care facilities. Controlled trials of specific types of these 2 technologies, however, have produced inconsistent results. While little is known about the effectiveness of active wearables, promising early data indicate the feasibility of an instrumented belt worn around the waist to effectively deploy an airbag to protect the hips prior to ground impact. Important challenges associated with one or more identified technologies included poor adherence to instructed wear as well as the potential for significant physical or time burden to caregivers or health care professionals. CONCLUSIONS Passive wearables, active wearables, and compliant flooring have shown promise in reducing fall-related hip injuries in older adults. Still, each type of product is accompanied by limited real-world data and/or significant challenges that must be overcome to maximize effectiveness and minimize unintended side effects.
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Affiliation(s)
- Rebecca J Tarbert
- ActiveProtective Technologies, Inc, Fort Washington, Pennsylvania, USA
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Brad Manor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Aoshima Y, Murakami S, Mizuno K, Otaka Y, Yamada M, Jinzaki M. Analysis of loading to the hip joint in fall using whole-body FE model. J Biomech 2022; 142:111262. [PMID: 36027638 DOI: 10.1016/j.jbiomech.2022.111262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/28/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Hip fractures caused by falls are important health problems for the elderly. Many studies used finite element (FE) models of the femur and its surroundings to evaluate the hip fracture risk during the impact phase in a fall. In this study, the whole-body human FE model (THUMS) of a small female was applied from the descent to the impact phase in a fall to understand the effect of the whole body. Brosh's material model was used for the soft tissue of the hip. A low-BMI and high-BMI model were developed based on THUMS (middle-BMI). For the middle-BMI model, the torso angle and the pelvis impact velocity were 45.2° and 2.62 m/s at the time of pelvis impact. The effective mass changed with time, and was 18.3 kg when the femoral neck force was maximum. The femoral neck force was 2.11 kN for the low-BMI model. The femoral neck forces when wearing a soft and a hard hip protector, and when falling on an energy-absorbing floor were compared for the FE models of human and a hip protector testing system. Though the force attenuation of the protective devices was 32.0-44.3 % in the testing system, the force attenuation in the middle-BMI was 0.1-22.2 %. In the low-BMI model, the attenuation of the soft protector was limited (4.2 %) because the hip protector protruded from the outer surface, so the contact force was concentrated at the hip region. This research suggests the importance of including the whole body to evaluate the hip fracture risk.
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Affiliation(s)
- Yuhei Aoshima
- Department of Mechanical Systems Engineering, School of Engineering, Nagoya University, Japan
| | - Sotaro Murakami
- Department of Mechanical Systems Engineering, School of Engineering, Nagoya University, Japan
| | - Koji Mizuno
- Department of Mechanical Systems Engineering, School of Engineering, Nagoya University, Japan.
| | - Yohei Otaka
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Minoru Yamada
- Department of Radiology, Keio University School of Medicine, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Japan
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6
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Galliker ES, Laing AC, Ferguson SJ, Helgason B, Fleps I. The Influence of Fall Direction and Hip Protector on Fracture Risk: FE Model Predictions Driven by Experimental Data. Ann Biomed Eng 2022; 50:278-290. [PMID: 35129719 PMCID: PMC8847295 DOI: 10.1007/s10439-022-02917-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/02/2022] [Indexed: 11/25/2022]
Abstract
Hip fractures in older adults, which often lead to lasting impairments and an increased risk of mortality, are a major public health concern. Hip fracture risk is multi-factorial, affected by the risk of falling, the load acting on the femur, and the load the femur can withstand. This study investigates the influence of impact direction on hip fracture risk and hip protector efficacy. We simulated falls for 4 subjects, in 7 different impact directions (15° and 30° anterior, lateral, and 15°, 30°, 60°, and 90° posterior) at two different impact velocities (2.1 and 3.1 m/s), all with and without hip protector, using previously validated biofidelic finite element models. We found the highest number of fractures and highest fragility ratios in lateral and 15° posterior impacts. The hip protector attenuated femur forces by 23–49 % for slim subjects under impact directions that resulted in fractures (30° anterior to 30° posterior). The hip protector prevented all fractures (6/6) for 2.1 m/s impacts, but only 10% of fractures for 3.1 m/s impacts. Our results provide evidence that, regarding hip fracture risk, posterior-lateral impacts are as dangerous as lateral impacts, and they support the efficacy of soft-shell hip protectors for anterior- and posterior-lateral impacts.
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Affiliation(s)
| | - Andrew C Laing
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Canada
| | | | | | - Ingmar Fleps
- Institute for Biomechanics, ETH-Zurich, Zurich, Switzerland.
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Thalmann BH, Latz D, Schiffner E, Jungbluth P, Windolf J, Grassmann J. CCD angle & hip fractures - Predictor of fracture symmetry? J Orthop 2021; 24:1-4. [PMID: 33679019 DOI: 10.1016/j.jor.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hip fracture caused by fall is a common injury of the elderly. The risk of sustaining a contralateral hip fracture has been reported to be 5-10%. Aging society heightens the need of efficient prevention tools. To be able to cope with this demand, understanding of biomechanics of hip fractures are mandatory. Previous studies suggest that geometry of the proximal femur could play an important role for fracture probability and fracture type. Thus, analysis of hip geometry could play an important role in the prediction and prevention of bilateral hip fractures. Aim of this study was to elucidate the influence of caput collum diaphyseal angle on the fracture type of proximal femur. Material and methods In a retrospective analysis, data of patients with an acute hip fracture who underwent surgical treatment within five years were included. Data was separated into two groups: (I) intra capsular femur fracture (femoral neck fractures) and (II) extra capsular femur fracture (inter- and subtrochanteric femur fractures). Occurrence of a bilateral fracture, age, gender, weight, height and caput collum diaphyseal angle (standardized measurement of the opposite joint on preoperative digital x-rays) of each group were further analyzed. Results Data of 448 patients were included ((I): 250 vs. (II): 198 patients). Group (I) showed a significant higher mean caput collum diaphyseal angle of 133.9 ± 7.0° (mean ± standard deviation) compared to group (II) with 127.6 ± 6.1° (F (1, 451) = 106.5, p = 0.00). In group (I) 0 patients had a caput collum diaphyseal angle <120° (varus), 214 patients (86%) 120°-140° and 35 patients (14%) angle>140° (valgus). In contrast, in group (II) 21 patients (10%) had a caput collum diaphyseal angle <120° (varus), 175 patients (86%) 120°-140° and 7 patients (4%) >140° (valgus). 52 patients had a bilateral hip fracture. 36 patients (69%) sustained a bilateral hip fracture of the same fracture type. Conclusion Patients with an intra capsular proximal femur fracture showed a significantly higher caput collum diaphyseal angle compared to patients with an extra capsular proximal femur fracture. Moreover, intra capsular femur fractures are correlated with an indifferent (120-140°) or valgus (>140°) femoral neck configuration. Extra capsular femur fractures correlate with an indifferent (120-140°) or varian femoral neck configuration (<120°). The results support the assumption that the caput collum diaphyseal angle has an influence on fracture type of the proximal femur. This could possibly be a predictor for the fracture type of the contralateral hip (second fracture). Based on this, present data may benefit prosthetists in developing new and more efficient hip protectors. Level of evidence Level III. Retrospective comparative study.
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Affiliation(s)
- Ben Hannes Thalmann
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - David Latz
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Erik Schiffner
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Pascal Jungbluth
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Joachim Windolf
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Jan Grassmann
- Department of Trauma and Hand Surgery, University Hospital, Moorenstrasse 5, 40225, Düsseldorf, Germany
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8
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Lim KT, Choi WJ. The effect of the hip impact configuration on the energy absorption provided by the femoral soft tissue during sideways falls. J Biomech 2021; 117:110254. [PMID: 33493711 DOI: 10.1016/j.jbiomech.2021.110254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/12/2020] [Accepted: 01/10/2021] [Indexed: 12/26/2022]
Abstract
The femoral soft tissue (i.e., skin, muscle, fat) may play a key role in preventing hip fractures during a fall by absorbing the impact energy. We measured the femoral soft tissue deformation and associated compressive force during simulated sideways falls to estimate the energy absorbed by the soft tissue, and then examined how this was affected by the hip impact configuration and gender. Eighteen young adults (9 males and 9 females) participated in the pelvis release experiment. The pelvis was raised through a rope attached to an electromagnet on the ceiling, so the skin surface barely touches the ultrasound probe, which flush to a Plexiglas plate placed on a force plate. The electromagnet was turned off to cause a fall while the soft tissue deformation and associated compressive force were being recorded. Trials were acquired with three hip impact configurations. An outcome variable included the energy absorbed by the femoral soft tissue during a fall. The energy absorbed by the femoral soft tissue ranged from 0.03 to 3.05 J. Furthermore, the energy absorption was associated with the hip impact configuration (F = 4.69, p = 0.016). On average, the absorbed energy was 62% greater in posteriolateral than anteriolateral impact (0.92 versus 0.57 J). However, the energy absorption did not differ between male and female (F = 0.91, p = 0.36). The force-deflection behavior of the femoral soft tissue during a fall has been recorded, providing insights on the potential protective benefits of the soft tissue covering during a fall.
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Affiliation(s)
- Ki Taek Lim
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, South Korea
| | - Woochol Joseph Choi
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, South Korea.
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9
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Yang Y, Komisar V, Shishov N, Lo B, Korall AM, Feldman F, Robinovitch SN. The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care. J Bone Miner Res 2020; 35:1914-1922. [PMID: 32402136 PMCID: PMC7689902 DOI: 10.1002/jbmr.4048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/19/2020] [Accepted: 05/04/2020] [Indexed: 11/19/2022]
Abstract
Over 95% of hip fractures in older adults are caused by falls, yet only 1% to 2% of falls result in hip fracture. Our current understanding of the types of falls that lead to hip fracture is based on reports by the faller or witness. We analyzed videos of real-life falls in long-term care to provide objective evidence on the factors that separate falls that result in hip fracture from falls that do not. Between 2007 and 2018, we video-captured 2377 falls by 646 residents in two long-term care facilities. Hip fracture was documented in 30 falls. We analyzed each video with a structured questionnaire, and used generalized estimating equations (GEEs) to determine relative risk ratios (RRs) for hip fracture associated with various fall characteristics. All hip fractures involved falls from standing height, and pelvis impact with the ground. After excluding falls from lower than standing height, risk for hip fracture was higher for sideways landing configurations (RR = 5.50; 95% CI, 2.36-12.78) than forward or backward, and for falls causing hip impact (3.38; 95% CI, 1.49-7.67). However, hip fracture risk was just as high in falls initially directed sideways as forward (1.14; 95% CI, 0.49-2.67), due to the tendency for rotation during descent. Falling while using a mobility aid was associated with lower fracture risk (0.30; 95% CI, 0.09-1.00). Seventy percent of hip fractures involved impact to the posterolateral aspect of the pelvis. Hip protectors were worn in 73% of falls, and hip fracture risk was lower in falls where hip protectors were worn (0.45; 95% CI, 0.21-0.99). Age and sex were not associated with fracture risk. There was no evidence of spontaneous fractures. In this first study of video-captured falls causing hip fracture, we show that the biomechanics of falls involving hip fracture were different than nonfracture falls for fall height, fall direction, impact locations, and use of hip protectors. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Yijian Yang
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China
| | - Vicki Komisar
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Nataliya Shishov
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Bryan Lo
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Alexandra Mb Korall
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Fabio Feldman
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,Fraser Health Authority, Surrey, BC, Canada
| | - Stephen N Robinovitch
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,School of Engineering, Simon Fraser University, Burnaby, BC, Canada
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10
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Lim KT, Choi WJ. Effect of fall characteristics on the severity of hip impact during a fall on the ground from standing height. Osteoporos Int 2020; 31:1713-1719. [PMID: 32346772 DOI: 10.1007/s00198-020-05432-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/22/2020] [Indexed: 11/25/2022]
Abstract
UNLABELLED The magnitude of hip impact force during a fall on the ground (i.e., concrete surface) from standing height was determined. We found that this force decreases up to 59%, depending on how they land on the ground. INTRODUCTION We determined the magnitude of hip impact force that humans may experience in the event of a fall from standing height on the ground, in order to examine how the hip impact force was affected by characteristics of a fall. METHODS Twenty subjects mimicked a typical older adults' falls on a mat. Trials were acquired with three initial fall directions: forward, sideways, and backward. Trials were also acquired with three knee positions at the time of hip impact: knee together, knee on the mat, and free knee. During falls, attenuated vertical hip impact forces and corresponding depression of the mat were measured via a force plate placed under the mat and motion capture system, respectively. Using a mass-spring model, actual hip impact force and body stiffness during a fall on the ground were estimated. RESULTS Hip impact force averaged 4.0 kN (SD = 1.7). The hip impact force was associated with knee condition (F = 25.6, p < 0.005), but not with fall direction (F = 0.4, p = 0.599). Compared with "knee on the mat," hip impact force averaged 59% and 45% greater in "free knee" and "knee together," respectively (4.6 versus 2.9 kN, p < 0.005; 4.3 versus 2.9 kN, p < 0.005). However, the hip impact force did not differ between "free knee" and "knee together (4.6 versus 4.3 kN, p = 0.554). CONCLUSION Our results suggest that hip fracture risk during a fall decreases substantially, depending on how they land on the ground, informing the development of safe landing strategies to prevent fall-related hip fractures in older adults.
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Affiliation(s)
- K-T Lim
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, 26493, South Korea
| | - W J Choi
- Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, 1 Yonseidae-gil, Wonju, Gangwon-do, 26493, South Korea.
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11
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Plant D, Leevers P. Injection moldable rate stiffening re‐entrant cell arrays for wearable impact protection. POLYM ENG SCI 2020. [DOI: 10.1002/pen.25400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Daniel Plant
- Department of Mechanical EngineeringImperial College London London UK
| | - Patrick Leevers
- Department of Mechanical EngineeringImperial College London London UK
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12
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What types of injuries did seriously injured pedestrians and cyclists receive in a Swedish urban region in the time period 2003–2017 when Vision Zero was implemented? Public Health 2020; 181:59-64. [DOI: 10.1016/j.puhe.2019.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 11/21/2022]
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13
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Yahaya SA, Ripin ZM, Ridzwan MIZ. Test systems for the biomechanical evaluation of hip protectors: a systematic review. Osteoporos Int 2020; 31:43-58. [PMID: 31446442 DOI: 10.1007/s00198-019-05128-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
Various mechanical and biomechanical test systems to evaluate the effectiveness of hip protectors designed to prevent hip fracture as a result of falls were examined in this review. The articles considered were selected systematically. The effect of differences in design criteria was demonstrated, and it was observed that the impact energy employed during testing dramatically affects the performance of the hip protector. Over the past three decades, researchers have continuously experimented with various systems to determine the efficacy of various hip protectors. The primary aim has been to make informed decisions in optimizing hip protector design. This article provides a systematic review of various test systems employed in the determination of the biomechanical efficacy of hip protectors. A systematic literature search was carried out, and 28 relevant articles were included to demonstrate the effect of test systems in the evaluation of the biomechanical effectiveness of hip protectors. Methodological studies illustrated the appropriate use of impact testing systems for the simulation of hip anatomy and fall dynamics in evaluating the effectiveness of hip protectors in preventing a hip fracture. This systematic review has demonstrated the effect of the variability of test systems on the evaluation of impact attenuation by various hip protectors. The lack of standardized test systems accounts for the inconsistencies in the test results of the efficacy of hip protectors. This has been a major challenge in the efforts of researchers to optimize the interventions. The standardization of test systems may require needed improvements immediately as opposed to the development of new interventions in order to ensure that only hip protectors with adequately proven efficacies are deployed for clinical trials or for the protection of the hips of vulnerable individuals from sideways impact.
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Affiliation(s)
- S A Yahaya
- School of Mechanical Engineering, Engineering Campus, Universiti Sains Malaysia, 14300, Penang, Malaysia.
- Department of Biomedical Engineering, Faculty of Engineering, University of Ilorin, Ilorin, 234001, Nigeria.
| | - Z M Ripin
- School of Mechanical Engineering, Engineering Campus, Universiti Sains Malaysia, 14300, Penang, Malaysia
| | - M I Z Ridzwan
- School of Mechanical Engineering, Engineering Campus, Universiti Sains Malaysia, 14300, Penang, Malaysia
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Post E, Komisar V, Sims-Gould J, Korall A, Feldman F, Robinovitch SN. Development of a stick-on hip protector: A multiple methods study to improve hip protector design for older adults in the acute care environment. J Rehabil Assist Technol Eng 2019; 6:2055668319877314. [PMID: 31839983 PMCID: PMC6896132 DOI: 10.1177/2055668319877314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 08/28/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction Over 90% of hip fractures in older adults result from falls, and hospital patients are at especially high risk. Specific types of wearable hip protectors have been shown to reduce hip fracture risk during a fall by up to 80%, but user compliance has averaged less than 50%. We describe the development and evaluation of a "stick-on" hip protector (secured over the hip with a skin-friendly adhesive) for older patients in acute care. Methods An initial version of the product was evaluated with six female patients (aged 76-91) in a hospital ward, who were asked to wear it for one week. We subsequently refined the product through biomechanical testing and solicited feedback from 43 health professionals on a second prototype. Results The first prototype was worn by five of six patients for the full week or duration of their hospital stay. The second prototype (20 mm thick, surface area 19 × 15.5 cm) provided 36% force attenuation, more than common garment-based models (20-21%). Feedback from patients and health professionals highlighted usability, comfort, cost, and appearance. Conclusions Our results from biomechanical and user testing support the need for further work to determine the value of stick-on hip protectors in acute care.
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Affiliation(s)
- E Post
- Department of Biomedical Physiology and Kinesiology, Injury Prevention and Mobility Laboratory, Simon Fraser University, Burnaby, Canada
| | - V Komisar
- Department of Biomedical Physiology and Kinesiology, Injury Prevention and Mobility Laboratory, Simon Fraser University, Burnaby, Canada
| | - J Sims-Gould
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Amb Korall
- Department of Biomedical Physiology and Kinesiology, Injury Prevention and Mobility Laboratory, Simon Fraser University, Burnaby, Canada
| | - F Feldman
- Department of Biomedical Physiology and Kinesiology, Injury Prevention and Mobility Laboratory, Simon Fraser University, Burnaby, Canada.,Older Adult Program, Fraser Health Authority, Surrey, Canada
| | - S N Robinovitch
- Department of Biomedical Physiology and Kinesiology, Injury Prevention and Mobility Laboratory, Simon Fraser University, Burnaby, Canada
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Korall AM, Feldman F, Yang Y, Cameron ID, Leung PM, Sims-Gould J, Robinovitch SN. Effectiveness of Hip Protectors to Reduce Risk for Hip Fracture from Falls in Long-Term Care. J Am Med Dir Assoc 2019; 20:1397-1403.e1. [DOI: 10.1016/j.jamda.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/22/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
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Fleps I, Fung A, Guy P, Ferguson SJ, Helgason B, Cripton PA. Subject-specific ex vivo simulations for hip fracture risk assessment in sideways falls. Bone 2019; 125:36-45. [PMID: 31071479 DOI: 10.1016/j.bone.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/17/2019] [Accepted: 05/04/2019] [Indexed: 12/18/2022]
Abstract
The risk of hip fracture of a patient due to a fall can be described from a mechanical perspective as the capacity of the femur to withstand the force that it experiences in the event of a fall. So far, impact forces acting on the lateral aspect of the pelvic region and femur strength have been investigated separately. This study used inertia-driven cadaveric impact experiments that mimic falls to the side from standing in order to evaluate the subject-specific force applied to the hip during impact and the fracture outcome in the same experimental model. Eleven fresh-frozen pelvis-femur constructs (6 female, 5 male, age = 77 years (SD = 13 years), BMI = 22.8 kg/m2 (SD = 7.8 kg/m2), total hip aBMD = 0.734 g/cm2 (SD = 0.149 g/cm2)), were embedded into soft tissue surrogate material that matched subject-specific mass and body shape. The specimens were attached to metallic lower-limb constructions with subject-specific masses and subjected to an inverted pendulum motion. Impact forces were recorded with a 6-axis force plate at 10,000 Hz and three dimensional deflections in the pelvic region were tracked with two high-speed cameras at 5000 Hz. Of the 11 specimens, 5 femur fractures and 3 pelvis fractures were observed. Three specimens did not fracture. aBMD alone did not reliably separate femur fractures from non-fractures. However, a mechanical risk ratio, which was calculated as the impact force divided by aBMD, classified specimens reliably into femur fractures and non-fractures. Single degree of freedom models, based on specimen kinetics, were able to predict subject-specific peak impact forces (RMSE = 2.55% for non-fractures). This study provides direct evidence relating subject-specific impact forces and subject-specific strength estimates and improves the assessment of the mechanical risk of hip fracture for a specific femur/pelvis combination in a sideways fall.
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Affiliation(s)
- Ingmar Fleps
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland; Orthopaedics and Injury Biomechanics Group, Departments of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, University of British Columbia, Vancouver, Canada.
| | - Anita Fung
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland; Orthopaedics and Injury Biomechanics Group, Departments of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
| | - Pierre Guy
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | | | | | - Peter A Cripton
- Orthopaedics and Injury Biomechanics Group, Departments of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
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Keenan BE, Evans SL. Biomechanical testing of hip protectors following the Canadian Standards Association express document. Osteoporos Int 2019; 30:1205-1214. [PMID: 30941484 DOI: 10.1007/s00198-019-04914-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/22/2019] [Indexed: 11/25/2022]
Abstract
UNLABELLED A variety of hip protectors are available, but it is not clear which is the most effective and there is no standard test to evaluate their performance. This is the first study that uses a standard mechanical test on hip protectors. Some protectors perform well but others are almost ineffective, providing little to no protection to the wearer during a fall. INTRODUCTION Each year, over 70,000 patients are admitted to hospital in the UK with hip fractures. There are a variety of commercial hip protectors currently available. However, it is not explicitly clear which is the most effective with regard to maximum force attenuation, whilst still being both comfortable for the user and providing reasonable force reduction if misplaced from the intended position. The numerous test methods reported in the literature have given conflicting results, making objective comparison difficult for users, researchers, and manufacturers alike. The Canadian Standards Association (CSA) has therefore published an express document (EXP-08-17) with a draft standard test method. This paper presents initial results for a range of hip protectors. METHODS Eighteen commercially available hip protectors were tested according to EXP-08-17. Each hip protector was impacted five times in correct anatomical alignment over the greater trochanter and once at 50 mm displacements in the anterior, posterior, and lateral directions. RESULTS Considerable differences were identified between individual hip protectors in their ability to reduce impact forces on the femur (between 3% and 36% reduction in peak force). The performance was reduced when misplaced in many cases (maximum reduction only 20%). CONCLUSIONS This is the first study that uses a standard mechanical test on hip protectors. Previous studies have used a variety of methods, making it difficult to interpret results. We hope that these results using a standard test method will facilitate the effective comparison of results, as well as providing useful data for clinicians, users, and purchasers.
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Affiliation(s)
- B E Keenan
- School of Engineering, Cardiff University, Queens Buildings, 14-17 The Parade, Cardiff, Wales, CF24 3AA, UK.
| | - S L Evans
- School of Engineering, Cardiff University, Queens Buildings, 14-17 The Parade, Cardiff, Wales, CF24 3AA, UK
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Hughes D, Nabhani F. Comparison of impact energy absorbance by various combinations of hip protector and flooring material. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fleps I, Vuille M, Melnyk A, Ferguson SJ, Guy P, Helgason B, Cripton PA. A novel sideways fall simulator to study hip fractures ex vivo. PLoS One 2018; 13:e0201096. [PMID: 30040858 PMCID: PMC6057661 DOI: 10.1371/journal.pone.0201096] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/09/2018] [Indexed: 11/19/2022] Open
Abstract
Falls to the side are the leading cause of hip fractures in the elderly. The load that a person experiences during a fall cannot be measured with volunteers for ethical reasons. To evaluate injurious loads, while considering relevant energy input and body posture for a sideways fall, a subject-specific cadaveric impact experiment was developed. Full cadaveric femur-pelvis constructs (N = 2) were embedded in surrogate soft tissue material and attached to metallic surrogate lower limbs. The specimens were then subjected to an inverted pendulum motion, simulating a fall to the side with an impact to the greater trochanter. The load at the ground and the deformation of the pelvis were evaluated using a 6-axis force transducer and two high-speed cameras. Post-test, a trauma surgeon (PG) evaluated specimen injuries. Peak ground contact forces were 7132 N and 5641 N for the fractured and non-fractured specimen, respectively. We observed a cervical fracture of the femur in one specimen and no injuries in a second specimen, showing that the developed protocol can be used to differentiate between specimens at high and low fracture risk.
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Affiliation(s)
- Ingmar Fleps
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
- * E-mail:
| | - Muriel Vuille
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | - Angela Melnyk
- Orthopaedics and Injury Biomechanics Group, Department of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
| | | | - Pierre Guy
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Benedikt Helgason
- Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
- School of Science and Engineering, Reykjavik University, Reykjavik, Iceland
| | - Peter A. Cripton
- Orthopaedics and Injury Biomechanics Group, Department of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, University of British Columbia, Vancouver, Canada
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Martel DR, Levine IC, Pretty SP, Laing AC. The influence of muscle activation on impact dynamics during lateral falls on the hip. J Biomech 2018; 66:111-118. [DOI: 10.1016/j.jbiomech.2017.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 09/28/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Watabe T, Suzuki H, Konuki Y, Aoki K, Nagashima J, Sako R. Beneficial falls in stroke patients: evaluation using a mixed method design. Top Stroke Rehabil 2017; 25:137-144. [PMID: 29073830 DOI: 10.1080/10749357.2017.1394631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose To use a mixed method design to evaluate how clinicians judge falls in stroke patients as a beneficial event, and to identify patient-specific characteristics associated with beneficial falls. Methods The definition of beneficial falls was based on interviews with six experienced clinicians in stroke rehabilitation. Interview data were analyzed using the grounded theory approach, with outcomes used to develop a checklist to judge falls as beneficial. We subsequently used the checklist to identify falls sustained by patients in our rehabilitation unit as beneficial events. The characteristics of beneficial fallers were investigated in this retrospective study. Results According to experienced clinicians, beneficial falls result from patient-specific factors and level of independence. Beneficial falls are not associated with after-effects or a diagnosis of cognitive impairment, do not result in physical injury and post-fall syndrome, and do not alter the course of rehabilitation. These falls are considered to enhance patients' self-awareness of their physical status and abilities. Among the 123 stroke patients who experienced a fall in our study group, 23 patients (18.7%) were identified as beneficial fallers according to our checklist. The majority had a left hemiplegia and perceptual impairments, and were at low risk of recurrent falls and made functional gains during rehabilitation. Conclusions Based on our results, we created a 10-item checklist to differentiate beneficial from adverse falls. This differentiation is important to target fall prevention programs to adverse fallers in rehabilitation units.
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Affiliation(s)
- Takayuki Watabe
- a Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences , Showa University , Yokohama, Japan.,b Rehabilitation Center , Showa University Fujigaoka Rehabilitation Hospital , Yokohama, Japan
| | - Hisayoshi Suzuki
- a Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences , Showa University , Yokohama, Japan
| | - Yusuke Konuki
- b Rehabilitation Center , Showa University Fujigaoka Rehabilitation Hospital , Yokohama, Japan
| | - Keiichiro Aoki
- a Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences , Showa University , Yokohama, Japan.,c Rehabilitation Division , Showa University Koto Toyosu Hospital , Tokyo , Japan
| | - Jun Nagashima
- a Department of Occupational Therapy, School of Nursing and Rehabilitation Sciences , Showa University , Yokohama, Japan.,b Rehabilitation Center , Showa University Fujigaoka Rehabilitation Hospital , Yokohama, Japan
| | - Rikitaro Sako
- b Rehabilitation Center , Showa University Fujigaoka Rehabilitation Hospital , Yokohama, Japan
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Nasiri Sarvi M, Luo Y. Sideways fall-induced impact force and its effect on hip fracture risk: a review. Osteoporos Int 2017; 28:2759-2780. [PMID: 28730547 DOI: 10.1007/s00198-017-4138-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/21/2017] [Indexed: 01/12/2023]
Abstract
UNLABELLED Osteoporotic hip fracture, mostly induced in falls among the elderly, is a major health burden over the world. The impact force applied to the hip is an important factor in determining the risk of hip fracture. However, biomechanical researches have yielded conflicting conclusions about whether the fall-induced impact force can be accurately predicted by the available models. It also has been debated whether or not the effect of impact force has been considered appropriately in hip fracture risk assessment tools. This study aimed to provide a state-of-the-art review of the available methods for predicting the impact force, investigate their strengths/limitations, and suggest further improvements in modeling of human body falling. METHODS We divided the effective parameters on impact force to two categories: (1) the parameters that can be determined subject-specifically and (2) the parameters that may significantly vary from fall to fall for an individual and cannot be considered subject-specifically. RESULTS The parameters in the first category can be investigated in human body fall experiments. Video capture of real-life falls was reported as a valuable method to investigate the parameters in the second category that significantly affect the impact force and cannot be determined in human body fall experiments. CONCLUSIONS The analysis of the gathered data revealed that there is a need to develop modified biomechanical models for more accurate prediction of the impact force and appropriately adopt them in hip fracture risk assessment tools in order to achieve a better precision in identifying high-risk patients. Graphical abstract Impact force to the hip induced in sideways falls is affected by many parameters and may remarkably vary from subject to subject.
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Affiliation(s)
- M Nasiri Sarvi
- Department of Mechanical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, R3T 5V6, Canada.
- AI Incorporated, Toronto, Canada.
| | - Y Luo
- Department of Mechanical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, R3T 5V6, Canada
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
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Ogihara N, Ito K. The use of shear thickening polymer as a hip protecter. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:1633-1635. [PMID: 29060196 DOI: 10.1109/embc.2017.8037152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
External hip protectors are used by the elderly in preventing hip fracture due to sideway falls. There are some commercial hip protectors which has both energy absorbing and energy shunting properties. In this study, a novel hip protector using shear thickening polymer (STP) is studied. The purpose of this work is to determine the optimal thickness of STP needed for maximum force attenuation. A mechanical test rig to simulate a person falling with sufficient impact energy to fracture the greater trochanter if unprotected was used together with biofidelic femur model which simulates the layer of flesh with skin. 8mm of STP together with 5mm foam gives the best force attenuation. When comparing the overall thickness with commercial hip protectors, STP hip protectors tested have much less thickness. Reduced thickness increases the compliance and comfort of STP hip protectors.
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Ryen L, Svensson M. Modelling the cost-effectiveness of impact-absorbing flooring in Swedish residential care facilities. Eur J Public Health 2015; 26:407-11. [DOI: 10.1093/eurpub/ckv197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Cianferotti L, Fossi C, Brandi ML. Hip Protectors: Are They Worth it? Calcif Tissue Int 2015; 97:1-11. [PMID: 25926045 DOI: 10.1007/s00223-015-0002-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/11/2015] [Indexed: 01/04/2023]
Abstract
Hip fractures are one of the most serious conditions in frail elderly subjects, greatly increasing morbidity and mortality, and decreasing healthy life years. Since their first introduction on the market, hip protectors have been revealed to be a potential preventive measure for hip fractures, in addition to other well-known recognized medical interventions and rehabilitation procedures. However, randomized controlled trials have given contradictory results regarding their efficacy. Moreover, little data are available on the cost effectiveness of hip protectors. Adherence is a major problem in assessing the effectiveness of hip protectors in preventing fractures. Indeed, there is a lack of general consensus on a standard definition and quantitative objective estimation of adherence to hip protectors, along with still scarce evidence on specific interventions on how to ameliorate it. From what is known so far, it seems reasonable to advise the use of hip protectors in aged care facilities, since recent pooled analyses have suggested their efficacy in this setting. The introduction of sensors combined with hip protectors will probably address this issue, both for monitoring and optimizing compliance, especially in elderly people. In the meantime, new, well-designed studies following specific guidelines are strongly encouraged and needed. In particular, studies in community-dwelling elderly individuals at high risk of first or further fragility fractures are required. The optimization of the tested devices in a preclinical setting according to international standard biomechanical testing is necessary.
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Affiliation(s)
- Luisella Cianferotti
- Department of Surgery and Translational Medicine, Section of Endocrinology, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy,
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Choi W, Wakeling J, Robinovitch S. Kinematic analysis of video-captured falls experienced by older adults in long-term care. J Biomech 2015; 48:911-20. [DOI: 10.1016/j.jbiomech.2015.02.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/10/2015] [Accepted: 02/15/2015] [Indexed: 10/23/2022]
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Lee JK, Robinovitch SN, Park EJ. Inertial Sensing-Based Pre-Impact Detection of Falls Involving Near-Fall Scenarios. IEEE Trans Neural Syst Rehabil Eng 2015; 23:258-66. [DOI: 10.1109/tnsre.2014.2357806] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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28
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Levine IC, Minty LE, Laing AC. Factors that influence soft tissue thickness over the greater trochanter: Application to understanding hip fractures. Clin Anat 2014; 28:253-61. [DOI: 10.1002/ca.22499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/21/2014] [Accepted: 11/24/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Iris C. Levine
- Injury Biomechanics and Aging Laboratory; Department of Kinesiology; University of Waterloo; Waterloo Ontario Canada
| | - Lauren E. Minty
- Injury Biomechanics and Aging Laboratory; Department of Kinesiology; University of Waterloo; Waterloo Ontario Canada
| | - Andrew C. Laing
- Injury Biomechanics and Aging Laboratory; Department of Kinesiology; University of Waterloo; Waterloo Ontario Canada
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29
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Bhan S, Levine IC, Laing AC. Energy absorption during impact on the proximal femur is affected by body mass index and flooring surface. J Biomech 2014; 47:2391-7. [PMID: 24837217 DOI: 10.1016/j.jbiomech.2014.04.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 03/03/2014] [Accepted: 04/11/2014] [Indexed: 11/17/2022]
Abstract
Impact mechanics theory suggests that peak loads should decrease with increase in system energy absorption. In light of the reduced hip fracture risk for persons with high body mass index (BMI) and for falls on soft surfaces, the purpose of this study was to characterize the effects of participant BMI, gender, and flooring surface on system energy absorption during lateral falls on the hip with human volunteers. Twenty university-aged participants completed the study with five men and five women in both low BMI (<22.5 kg/m(2)) and high BMI (>27.5 kg/m(2)) groups. Participants underwent lateral pelvis release experiments from a height of 5 cm onto two common floors and four safety floors mounted on a force plate. A motion-capture system measured pelvic deflection. The energy absorbed during the initial compressive phase of impact was calculated as the area under the force-deflection curve. System energy absorption was (on average) 3-fold greater for high compared to low BMI participants, but no effects of gender were observed. Even after normalizing for body mass, high BMI participants absorbed 1.8-fold more energy per unit mass. Additionally, three of four safety floors demonstrated significantly increased energy absorption compared to a baseline resilient-rolled-sheeting system (% increases ranging from 20.7 to 28.3). Peak system deflection was larger for high BMI persons and for impacts on several safety floors. This study indicates that energy absorption may be a common mechanism underlying the reduced risk of hip fracture for persons with high BMI and for those who fall on soft surfaces.
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Affiliation(s)
- Shivam Bhan
- Injury Biomechanics and Aging Laboratory, Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1
| | - Iris C Levine
- Injury Biomechanics and Aging Laboratory, Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1
| | - Andrew C Laing
- Injury Biomechanics and Aging Laboratory, Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1.
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30
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Sims-Gould J, McKay HA, Feldman F, Scott V, Robinovitch SN. Autonomy, choice, patient-centered care, and hip protectors: the experience of residents and staff in long-term care. J Appl Gerontol 2014; 33:690-709. [PMID: 24652886 DOI: 10.1177/0733464813488658] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to examine long-term care (LTC) resident and staff perceptions on the decision to use hip protectors and identify the factors that influence attitudes toward hip protector use. Staff (N = 39) and residents (N = 27) at two residential care facilities in British Columbia, Canada were invited to participate in focus groups on fall prevention and hip protector use. A total of 11 focus groups were conducted. Using framework analysis results show that residents and staff shared concerns on aesthetic and comfort issues with hip protectors. Residents also generally felt they did not need, or want to use, hip protectors. However, they also had desire to be cooperative within the LTC environment. Staff underscored their role in advocating for hip protector use and their desire to protect residents from harm. Practice considerations for facilities wishing to promote hip protectors within a patient centered framework are highlighted.
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Gilchrist S, Guy P, Cripton PA. Development of an Inertia-Driven Model of Sideways Fall for Detailed Study of Femur Fracture Mechanics. J Biomech Eng 2013; 135:121001. [DOI: 10.1115/1.4025390] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/12/2013] [Indexed: 11/08/2022]
Abstract
A new method for laboratory testing of human proximal femora in conditions simulating a sideways fall was developed. Additionally, in order to analyze the strain state in future cadaveric tests, digital image correlation (DIC) was validated as a tool for strain field measurement on the bone of the femoral neck. A fall simulator which included models for the body mass, combined lateral femur and pelvis mass, pelvis stiffness, and trochanteric soft tissue was designed. The characteristics of each element were derived and developed based on human data from the literature. The simulator was verified by loading a state-of-the-art surrogate femur and comparing the resulting force-time trace to published, human volunteer experiments. To validate the DIC, 20 human proximal femora were prepared with a strain rosette and speckle paint pattern, and loaded to 50% of their predicted failure load at a low compression rate. Strain rosettes were taken as the gold standard, and minimum principal strains from the DIC and the rosettes were compared using descriptive statistics. The initial slope of the force-time curve obtained in the fall simulator matched published human volunteer data, with local peaks superimposed in the model due to internal vibrations of the spring used to model the pelvis stiffness. Global force magnitude and temporal characteristics were within 2% of published volunteer experiments. The DIC minimum principal strains were found to be accurate to 127±239μɛ. These tools will allow more biofidelic laboratory simulation of falls to the side, and more detailed analysis of proximal femur failure mechanisms using human cadaver specimens.
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Affiliation(s)
- Seth Gilchrist
- Department of Mechanical Engineering, University of British Columbia, Vancouver, BC V6T-1Z4, Canada e-mail:
| | - Pierre Guy
- Department of Orthopeadics, University of British Columbia, Vancouver, BC V5Z-1M9, Canada e-mail:
| | - Peter A Cripton
- Department of Mechanical Engineering, University of British Columbia, Vancouver, BC V6T-1Z4, Canada e-mail:
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Li N, Tsushima E, Tsushima H. Comparison of impact force attenuation by various combinations of hip protector and flooring material using a simplified fall-impact simulation device. J Biomech 2013; 46:1140-6. [DOI: 10.1016/j.jbiomech.2013.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/19/2012] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
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Glinka MN, Karakolis T, Callaghan JP, Laing AC. Characterization of the protective capacity of flooring systems using force-deflection profiling. Med Eng Phys 2013; 35:108-15. [DOI: 10.1016/j.medengphy.2012.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 02/01/2012] [Accepted: 04/22/2012] [Indexed: 11/24/2022]
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Palacios S, Christiansen C, Sánchez Borrego R, Gambacciani M, Hadji P, Karsdal M, Lambrinoudaki I, Lello S, O'Beirne B, Romao F, Rozenberg S, Stevenson JC, Ben-Rafael Z. Recommendations on the management of fragility fracture risk in women younger than 70 years. Gynecol Endocrinol 2012; 28:770-86. [PMID: 22558997 DOI: 10.3109/09513590.2012.679062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The risk for fragility fracture represents a problem of enormous magnitude. It is estimated that only a small fraction of women with this risk take the benefit of preventive measures. The relationship between estrogen and bone mass is well known as they are the other factors related to the risk for fracture. There are precise diagnostic methods, including a tool to diagnose the risk for fracture. Yet there continues to be an under-diagnosis, with the unrecoverable delay in instituting preventive measures. Women under the age of 70 years, being much more numerous than those older, and having risk factors, are a group in which it is essential to avoid that first fragility fracture. Today it is usual not to differentiate between the treatment and the prevention of osteoporosis since the common aim is to prevent fragility fractures. Included in this are women with osteoporosis or with low bone mass and increased risk for fracture, for whom risk factors play a primary role. There is clearly controversy over the type of treatment and its duration, especially given the possible adverse effects of long-term use. This justifies the concept of sequential treatment, even more so in women under the age of 70, since they presumably will need treatment for many years. Bone metabolism is age-dependent. In postmenopausal women under 70 years of age, the increase in bone resorption is clearly predominant, related to a sharp drop in estrogens. Thus a logical treatment is the prevention of fragility fractures by hormone replacement therapy (HRT) and, in asymptomatic women, selective estradiol receptor modulators (SERMs). Afterwards, there is a period of greater resorption, albeit less intense but continuous, when one could utilise anti-resorptive treatments such as bisphosphonates or denosumab or a dual agent like strontium ranelate. Bone formation treatment, such as parathyroid hormone (PTH), in women under 70 years will be uncommon. That is because it should be used in cases where the formation is greatly diminished and there is a high risk for fracture, something found in much older women.
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Affiliation(s)
- Santiago Palacios
- Instituto Palacios, Salud y Medicina de la Mujer, C/ Antonio Acuña, Madrid, Spain
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2011 Up-Date of the Consensus Statement of the Spanish Society of Rheumatology on Osteoporosis. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.reumae.2011.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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[2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis]. ACTA ACUST UNITED AC 2011; 7:357-79. [PMID: 22078694 DOI: 10.1016/j.reuma.2011.05.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 05/16/2011] [Accepted: 05/20/2011] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis. METHODS Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used. RESULTS We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis. CONCLUSIONS We present the SER recommendations related to the biologic therapy risk management.
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Laing AC, Feldman F, Jalili M, Tsai CMJ, Robinovitch SN. The effects of pad geometry and material properties on the biomechanical effectiveness of 26 commercially available hip protectors. J Biomech 2011; 44:2627-35. [PMID: 21899845 DOI: 10.1016/j.jbiomech.2011.08.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 08/16/2011] [Accepted: 08/19/2011] [Indexed: 10/17/2022]
Abstract
Wearable hip protectors (padded garments) represent a promising strategy to decrease impact force and hip fracture risk during falls, and a wide range of products are currently marketed. However, little is known about how design features of hip protectors influence biomechanical effectiveness. We used a mechanical test system (simulating sideways falls) to measure the attenuation in femoral neck force provided by 26 commercially available hip protectors at three impact velocities (2, 3, and 4m/s). We also used a materials testing machine to characterize the force-deflection properties of each device. Regression analyses were performed to determine which geometric (e.g., height, width, thickness, volume) and force-deflection properties were associated with force attenuation. At an impact velocity of 3m/s, the force attenuation provided by the various hip protectors ranged between 2.5% and 40%. Hip protectors with lower stiffness (measured at 500N) provided greater force attenuation at all velocities. Protectors that absorbed more energy demonstrated greater force attenuation at the higher impact velocities (3 and 4m/s conditions), while protectors that did not directly contact (but instead bridged) the skin overlying the greater trochanter attenuated more force at velocities of 2 and 3m/s. At these lower velocities, the force attenuation provided by protectors that contacted the skin overlying the greater trochanter increased with increasing pad width, thickness, and energy dissipation. By providing a comparison of the protective value of a large range of existing hip protectors, these results can help to guide consumers and researchers in selecting hip protectors, and in interpreting the results of previous clinical trials. Furthermore, by determining geometric and material parameters that influence biomechanical performance, our results should assist manufacturers in designing devices that offer improved performance and clinical effectiveness.
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Affiliation(s)
- Andrew C Laing
- Injury Biomechanics and Aging Laboratory, Department of Kinesiology, University of Waterloo, 200 University Ave West, Waterloo, Ontario, Canada N2L 3G1.
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Laing AC, Robinovitch SN. Characterizing the effective stiffness of the pelvis during sideways falls on the hip. J Biomech 2010; 43:1898-904. [PMID: 20398905 DOI: 10.1016/j.jbiomech.2010.03.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 03/15/2010] [Accepted: 03/16/2010] [Indexed: 11/16/2022]
Abstract
The force applied to the proximal femur during a fall, and thus hip fracture risk, is dependent on the effective stiffness of the body during impact. Accurate estimates of pelvis stiffness are required to predict fracture risk in a fall. However, the dynamic force-deflection properties of the human pelvis have never been measured in-vivo. Our objectives were to (1) measure the force-deflection properties of the pelvis during lateral impact to the hip, and (2) determine whether the accuracy of a mass-spring model of impact in predicting peak force depends on the characterization of non-linearities in stiffness. We used a sling and electromagnet to release the participant's pelvis from heights up to 5 cm, simulating low-severity sideways falls. We measured applied loads with a force plate, and pelvis deformation with a motion capture system. In the 5 cm trials peak force averaged 1004 (SD 115)N and peak deflection averaged 26.3 (5.1)mm. We observed minimal non-linearities in pelvic force-deflection properties characterized by an 8% increase in the coefficient of determination for non-linear compared to linear regression equations fit to the data. Our model consistently overestimated peak force (by 49%) when using a non-linear stiffness equation, while a piece-wise non-linear fit (non-linear for low forces, linear for loads exceeding 300 N) predicted peak force to within 1% at our highest drop height. This study has important implications for mathematical and physical models of falls, including mechanical systems that assess the biomechanical effectiveness of protective devices aimed at reducing hip fracture risk.
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Affiliation(s)
- Andrew C Laing
- Injury Prevention and Mobility Laboratory, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia V5A1S6, Canada.
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Choi W, Hoffer J, Robinovitch S. The effect of positioning on the biomechanical performance of soft shell hip protectors. J Biomech 2010; 43:818-25. [DOI: 10.1016/j.jbiomech.2009.11.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 11/15/2009] [Accepted: 11/20/2009] [Indexed: 10/20/2022]
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Choi WJ, Hoffer JA, Robinovitch SN. Effect of hip protectors, falling angle and body mass index on pressure distribution over the hip during simulated falls. Clin Biomech (Bristol, Avon) 2010; 25:63-9. [PMID: 19766363 DOI: 10.1016/j.clinbiomech.2009.08.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 07/16/2009] [Accepted: 08/18/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND We examined how a soft shell hip protector affects the magnitude and distribution of force to the hip during simulated falls, and how the protective effect depends on the fall direction and the amount of soft tissue padding over the hip. METHODS Fourteen young women with either high or low body mass index participated in a "pelvis release experiment" that simulated falls resulting in either lateral, anterolateral or posterolateral impact to the pelvis with/without a soft shell hip protector. Outcome variables were the magnitude and location of peak pressure (d, theta) with respect to the greater trochanter, total impact force, and percent force applied to four defined hip regions. FINDINGS The soft shell hip protector reduced peak pressure by 70%. The effect was two times greater in low than high body mass index individuals. The protector shunted the peak pressure distally along the shaft of the femur (d=52 mm (SD 22), theta=-21 degrees (SD 49) in the unpadded trials versus d=81 mm (SD 23), theta=-10 degrees (SD 35) in the padded trials). Peak force averaged 12% greater in posterolateral and 17% lower in anterolateral than lateral falls. INTERPRETATION Our results indicate that the hip protector we tested had a much stronger protective benefit for low than high body mass index individuals. Next generation protectors might be developed for improved shunting of pressure away from the femur, improved protection during posterolateral falls, and greater force attenuation for low body mass index individuals.
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Affiliation(s)
- W J Choi
- Injury Prevention and Mobility Laboratory, School of Kinesiology, Simon Fraser University, Burnaby, BC, Canada.
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Cameron ID, Robinovitch S, Birge S, Kannus P, Khan K, Lauritzen J, Howland J, Evans S, Minns J, Laing A, Cripton P, Derler S, Plant D, Kiel DP. Hip protectors: recommendations for conducting clinical trials--an international consensus statement (part II). Osteoporos Int 2010; 21:1-10. [PMID: 19806284 PMCID: PMC5407461 DOI: 10.1007/s00198-009-1055-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION While hip protectors are effective in some clinical trials, many, including all in community settings, have been unable to demonstrate effectiveness. This is due partly to differences in the design and analysis. The aim of this report is to develop recommendations for subsequent clinical research. METHODS In November of 2007, the International Hip Protector Research Group met to address barriers to the clinical effectiveness of hip protectors. This paper represents a consensus statement from the group on recommended methods for conducting future clinical trials of hip protectors. RESULTS AND CONCLUSIONS Consensus recommendations include the following: the use of a hip protector that has undergone adequate biomechanical testing, the use of sham hip protectors, the conduct of clinical trials in populations with annual hip fracture incidence of at least 3%, a run-in period with demonstration of adequate adherence, surveillance of falls and adherence, and the inclusion of economic analyses. Larger and more costly clinical trials are required to definitively investigate effectiveness of hip protectors.
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Affiliation(s)
- I D Cameron
- Rehabilitation Studies Unit, University of Sydney, Sydney, New South Wales, Australia.
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