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Wu J, Zeng Q, Gui S, Li Z, Miao W, Zeng M, Wang M, Hu L, Zeng G. Construction and evaluation of prediction model for postoperative re-fractures in elderly patients with hip fractures. Int J Med Inform 2025; 195:105738. [PMID: 39644793 DOI: 10.1016/j.ijmedinf.2024.105738] [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: 10/03/2024] [Revised: 11/25/2024] [Accepted: 11/28/2024] [Indexed: 12/09/2024]
Abstract
OBJECTIVE The aim of study was to construct a postoperative re-fracture prediction model for elderly hip fracture patients using an automated machine learning algorithm to provide a basis for early identification of patients with high risk of re-fracture occurrence. METHODS Clinical data were collected and subjected to univariate and multivariate analyses to determine the independent risk factors affecting postoperative re-fracture of hip fracture in the elderly. The collected data were divided into training and validation sets in a ratio of 7:3, AutoGluon was applied to construct LightGBMXT, LightGBM, RandomForestGini, RandomForestEntr, CatBoost, NeuralNetFastAI, XGBoost, NeuralNetTorch, LightGBMLarge and WeightedEnsemble_L2 prediction models, and the constructed models were evaluated using evaluation indicators. The models were externally validated and the model with the best prediction performance was selected. RESULTS The incidence of postoperative re-fracture was about 11.7%, and age, comorbid diabetes mellitus, comorbid osteoporosis, rehabilitation exercise status, and preoperative total protein level were considered as independent risk factors. The top three models in terms of AUC values in the training set were WeightedEnsemble_L2 (0.9671), XGBoost (0.9636), and LightGBM (0.9626), the WeightedEnsemble_L2 (0.9759) was best in the external validation. Based on the AUC and other evaluation indicators, WeightedEnsemble_L2 was considered the model with the best prediction performance. CONCLUSION The constructed model is highly generalizable and applicable, and can be used as an effective tool for healthcare professionals to assess and manage patients' risk of re-fracture.
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Affiliation(s)
- Jingjing Wu
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
| | - Qingqing Zeng
- Jiangbei Campus of The First Affiliated Hospital of Army Medical University (The 958th Hospital of Chinese People's Liberation Army), No. 29 Jianxindong Street, Jiangbei District, Chongqing 400038, China.
| | - Sijie Gui
- Department of Orthopedics and Trauma, the First Affiliated Hospital of University of South China, Hengyang, China.
| | - Zhuolan Li
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
| | - Wanyu Miao
- College of Computer Science And Engineering, Chongqing University of Technology,Chongqing , China.
| | - Mi Zeng
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
| | - Manyi Wang
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
| | - Li Hu
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
| | - Guqing Zeng
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, China; School-Enterprise Cooperative Innovation and Entrepreneurship Education Base, University of South China-Hunan Lantern Medical Technology Co., Ltd, Hengyang, China.
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Nguyen BTT, Huang SW, Kuo YJ, Nguyen TT, Chen YP. The Second Hip Fracture is not an Independent Predictor of Poor Outcomes in Elderly Patients - A Case-Control Study. Geriatr Orthop Surg Rehabil 2024; 15:21514593241293645. [PMID: 39444567 PMCID: PMC11497524 DOI: 10.1177/21514593241293645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 08/19/2024] [Accepted: 10/05/2024] [Indexed: 10/25/2024] Open
Abstract
Introduction Hip fracture is particularly seen in elderly patients with frailty and osteoporosis and leads to diminished functional independence and quality of life. Despite the susceptibility of these patients to a second hip fracture (SHF), the literature insufficiently discussed its impact leading to poor outcomes. This study aims to directly assess the outcomes of elderly patients with initial hip fractures (IHF) vs those experiencing an SHF within a well-matched group with similar characteristics. Materials and Methods This case-control study gathered data from the clinical hip fracture registry at a medical center from 2019 to 2022. Patients with SHF were matched with those with IHF in a 1:2 ratio according to the similarity of age, sex, and Charlson Comorbidity Index classification. Demographics at admission, baseline characteristics, and 1-year postoperative outcome were compared between the SHF and IHF groups. Results Thirty-two SHF patients were matched with 64 IHF patients (81.25% of women, median age of 86 years). Anthropometric measurements and socioeconomic factors were not significantly different between the two groups. No differences in baseline characteristics were observed, except IHF patients had a significantly lower T-score than SHF patients (-3.98 vs. -3.31, P = 0.016). At one-year follow-up, despite a notable decrease in Barthel Index scores and an uptick in EQ-5D measures among the patients, the IHF and SHF groups demonstrated similar quality of life and a high level of activities of daily living. Discussions In this case-control study, after matching for age, sex, and comorbidities, an SHF did not indicate poorer outcomes than an IHF, providing a more optimistic outlook for the patients and healthcare providers. Conclusion Despite the significant challenges presented by hip fracture, the one-year postoperative outcomes did not differ between IHF and SHF patients, suggesting that SHF is not an independent predictor of poor outcomes following hip fracture in the elderly population.
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Affiliation(s)
- Bao Tu Thai Nguyen
- The International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Orthopedics, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Shu-Wei Huang
- Graduate Institute of Health and Biotechnology Law, Taipei Medical University, Taipei, Taiwan
| | - Yi-Jie Kuo
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Deparment of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tan Thanh Nguyen
- Department of Orthopedics, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Yu-Pin Chen
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Deparment of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Chapman PN, Georgiadis GM, Seegert S, Russell B, O'Mara-Gardner K, Bair JM, Tank JC. Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures. Orthopedics 2024; 47:264-269. [PMID: 38810129 DOI: 10.3928/01477447-20240520-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures. MATERIALS AND METHODS This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contralateral hip fracture, with the second treated at our tertiary referral center. RESULTS The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event. CONCLUSION Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 2024;47(5):264-269.].
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Patel R, Judge A, Johansen A, Javaid MK, Griffin XL, Chesser T, Griffin J, Marques EMR, Ben-Shlomo Y, Gregson CL. Following hip fracture, hospital organizational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: a record-linkage study. J Bone Miner Res 2024; 39:1071-1082. [PMID: 38988134 PMCID: PMC11337946 DOI: 10.1093/jbmr/zjae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/20/2024] [Accepted: 07/09/2024] [Indexed: 07/12/2024]
Abstract
Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organizational factors predict prescription of post-hip fracture AOM and refracture risk. A cohort of 178 757 patients aged ≥60 yr who sustained a hip fracture in England and Wales (2016-2019) was examined and followed for 1 yr. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organizational reports. Multilevel models determined organizational factors, independent of patient case-mix, associated with (1) AOM prescription and (2) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) yr old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission, while 50 354 (28%) died during 1-yr follow-up, 12 240 (7%) refractured. Twelve organizational factors were associated with AOM prescription, for example, orthogeriatrician-led care compared to traditional care models (odds ratio [OR] 4.65 [95% CI, 2.25-9.59]); AOM was 9% (95% CI, 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126 d (IQR 59-234). Eight organizational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72 h of admission had an 18% (95% CI, 2%-31%) lower refracture risk, weekend physiotherapy provision had an 8% (95% CI, 3%-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95% CI, 2%-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95% CI, 3%-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist, and occupational therapist involvement in secondary fracture prevention post hip fracture; notably, fracture risk reductions were seen within 12 mo of hip fracture.
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Affiliation(s)
- Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, United Kingdom
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7HE, United Kingdom
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, BS8 2BN, United Kingdom
| | - Antony Johansen
- Division of Population Medicine, School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, CF14 4XN, United Kingdom
- National Hip Fracture Database, Royal College of Physicians, London, NW1 4LE, United Kingdom
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7HE, United Kingdom
| | - Xavier L Griffin
- Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, United Kingdom
- Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, United Kingdom
| | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Jill Griffin
- Clinical & Operations Directorate, Royal Osteoporosis Society, Bath, BA2 3BH, United Kingdom
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, United Kingdom
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, United Kingdom
- Older People’s Unit, Royal United Hospital NHS Foundation Trust Bath, Combe Park, Bath, BA1 3NG, United Kingdom
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Zhang YF, Ren C, Yao MX, Zhao SG, Ding K, Wang HC, Chen W, Zhang Q, Zhang YZ. Biomechanical comparison of the therapeutic effect of a novel proximal femoral bionic intramedullary nail and traditional inverted triangle hollow screw on femoral neck fracture. J Orthop Surg Res 2024; 19:359. [PMID: 38880901 PMCID: PMC11181575 DOI: 10.1186/s13018-024-04770-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/01/2024] [Indexed: 06/18/2024] Open
Abstract
OBJECTIVE A novel Proximal Femoral Bionic Nail (PFBN) has been developed by a research team for the treatment of femoral neck fractures. This study aims to compare the biomechanical properties of the innovative PFBN with those of the conventional Inverted Triangular Cannulated Screw (ITCS) fixation method through biomechanical testing. METHODS Sixteen male femoral specimens preserved in formalin were selected, with the donors' age at death averaging 56.1 ± 6.3 years (range 47-64 years), and a mean age of 51.4 years. The femurs showed no visible damage and were examined by X-rays to exclude diseases affecting bone quality such as tumors, severe osteoporosis, and deformities. The 16 femoral specimens were randomly divided into an experimental group (n = 8) and a control group (n = 8). All femurs were prepared with Pauwels type III femoral neck fractures, fixed with PFBN in the experimental group and ITCS in the control group. Displacement and stress limits of each specimen were measured through cyclic compression tests and failure experiments, and vertical displacement and strain values under a 600 N vertical load were measured in all specimens through vertical compression tests. RESULTS In the vertical compression test, the average displacement at the anterior head region of the femur was 0.362 mm for the PFBN group, significantly less than the 0.480 mm for the ITCS group (p < 0.001). At the fracture line area, the average displacement for the PFBN group was also lower than that of the ITCS group (0.196 mm vs. 0.324 mm, p < 0.001). The difference in displacement in the shaft area was smaller, but the average displacement for the PFBN group (0.049 mm) was still significantly less than that for the ITCS group (0.062 mm, p = 0.016). The situation was similar on the posterior side of the femur. The average displacements in the head area, fracture line area, and shaft area for the PFBN group were 0.300 mm, 0.168 mm, and 0.081 mm, respectively, while those for the ITCS group were 0.558 mm, 0.274 mm, and 0.041 mm, with significant differences in all areas (p < 0.001). The average strain in the anterior head area for the PFBN group was 4947 μm/m, significantly less than the 1540 μm/m for the ITCS group (p < 0.001). Likewise, in the fracture line and shaft areas, the average strains for the PFBN group were significantly less than those for the ITCS group (p < 0.05). In the posterior head area, the average strain for the PFBN group was 4861 μm/m, significantly less than the 1442 μm/m for the ITCS group (p < 0.001). The strain conditions in the fracture line and shaft areas also showed the PFBN group was superior to the ITCS group (p < 0.001). In cyclic loading experiments, the PFBN fixation showed smaller maximum displacement (1.269 mm vs. 1.808 mm, p < 0.001), indicating better stability. In the failure experiments, the maximum failure load that the PFBN-fixated fracture block could withstand was significantly higher than that for the ITCS fixation (1817 N vs. 1116 N, p < 0.001). CONCLUSION The PFBN can meet the biomechanical requirements for internal fixation of femoral neck fractures. PFBN is superior in biomechanical stability compared to ITCS, particularly showing less displacement and higher failure resistance in cyclic load and failure experiments. While there are differences in strain performance in different regions between the two fixation methods, overall, PFBN provides superior stability.
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Affiliation(s)
- Yi-Fan Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Chuan Ren
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Meng-Xuan Yao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shu-Guang Zhao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Kai Ding
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Hai-Cheng Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Ying-Ze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.
- Chinese Academy of Engineering, Beijing, People's Republic of China.
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Tang N, Gao L, Song J, Li Y, Song M, Qiu C, Shao M, Chen J, Li S, Wang Q, Su Q, Gao Y. Risk analysis for subsequent fracture of osteoporotic fractures in Chinese women over age 60: a nationwide cross-sectional study. Sci Rep 2024; 14:13319. [PMID: 38858454 PMCID: PMC11164976 DOI: 10.1038/s41598-024-64170-w] [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: 03/22/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024] Open
Abstract
Prevention of subsequent fracture is a major public health challenge in the field of osteoporosis prevention and treatment, and older women are at high risk for osteoporotic fractures. This study aimed to examine factors associated with subsequent fracture in older Chinese women with osteoporosis. We collected data on 9212 older female patients with osteoporotic fractures from 580 medical institutions in 31 provinces of China. Higher odds of subsequent fractures were associated with age of 70-79 years (OR 1.218, 95% CI 1.049-1.414), age ≥ 80 (OR 1.455, 95% CI 1.222-1.732), index fracture site was vertebrae (OR 1.472, 95% CI 1.194-1.815) and hip (OR 1.286, 95% CI 1.041-1.590), index fracture caused by fall (OR 1.822, 95% CI 1.281-2.591), strain (OR 1.587, 95% CI 1.178-2.139), no inducement (OR 1.541, 95% CI 1.043-2.277), and assessed as high risk of fracture (OR 1.865, 95% CI 1.439-2.416), BMD T-score ≤ -2.5 (OR 1.725, 95% CI 1.440-2.067), history of surgery (OR 3.941, 95% CI 3.475-4.471) and trauma (OR 8.075, 95% CI 6.941-9.395). Low risk of fall (OR 0.681, 95% CI 0.513-0.904), use of anti-osteoporosis medication (AOM, OR 0.801, 95% CI 0.693-0.926), and women who had received fall prevention health education (OR 0.583, 95% CI 0.465-0.730) associated with lower risk. The areas under the curve of the prediction model was 0.818. The sensitivity was 67.0% and the specificity was 82.0%. The prediction model showed a good ability to predict the risk of subsequent fracture in older women with osteoporotic fractures and are suitable for early self-measurement which may benefit post-fracture management.
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Affiliation(s)
- Nan Tang
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Ling Gao
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Jie Song
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Yeyuan Li
- Beijing Haidian District Wanshou Road Community Health Service Center, Beijing, 100017, China
| | - Mi Song
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Chen Qiu
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China
| | - Mengqi Shao
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Jingru Chen
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Shan Li
- PLA Medical School, PLA General Hospital, Beijing, 100853, China
| | - Qingmei Wang
- Central Patient Management Department, 1th Medical Center, PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
| | - Qingqing Su
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China.
| | - Yuan Gao
- Department of Nursing, 1th Medical Center, PLA General Hospital, Beijing, 100853, China.
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Kay RS, Ho L, Clement ND, Duckworth AD, Hall AJ. The incidence of subsequent contralateral hip fracture and factors associated with increased risk: the IMPACT Contralateral Fracture Study. Osteoporos Int 2024; 35:903-909. [PMID: 38448782 DOI: 10.1007/s00198-024-07039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
Patients who sustain a contralateral hip fracture experience significantly inferior outcomes; however, the incidence and predictors of contralateral hip fracture remain poorly understood. In the present study, 2.5% of patients sustained a contralateral hip fracture within 12 months, and socioeconomic deprivation was associated with reduced risk of contralateral hip fracture. INTRODUCTION Hip fractures are associated with high morbidity and mortality, and patients that sustain a subsequent contralateral fracture experience inferior outcomes. The risk of contralateral fracture is highest within the first year; however, the incidence and associated factors remain poorly understood. The aims were to investigate (i) the incidence of a subsequent contralateral hip fracture within the first year, (ii) identify factors associated with an increased risk of contralateral fracture and (iii) compare early mortality risk after index versus contralateral hip fracture. METHODS This study included all patients aged over 50 years admitted to NHS hospitals in Scotland between 1st March 2020 and 31st December 2020 (n = 5566) as routine activity of the Scottish Hip Fracture Audit (SHFA). Multivariate logistic regression was used to examine factors associated with 30-day mortality, and cox regression was used to identify factors associated with a contralateral fracture. RESULTS During the study period 2.5% (138/5566) of patients sustained a contralateral hip fracture within 12 months of the index hip fracture. Socioeconomic deprivation was inversely associated with increased risk of contralateral fracture (odds ratio 2.64, p < 0.001), whilst advancing age (p = 0.427) and sex (p = 0.265) were not. After adjusting for significant cofounders, there was no significant difference in 30-day mortality following contralateral fracture compared to index fracture (OR 1.22, p = 0.433). CONCLUSION One in 40 (2.5%) hip fracture patients sustained a contralateral fracture within 12 months of their index fracture, and deprivation was associated with a reduced risk of contralateral fracture. No difference in 30-day mortality was found.
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Affiliation(s)
- Robert S Kay
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Lucas Ho
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Scottish Hip Fracture Audit, Edinburgh, UK
- Scottish Centres for Orthopaedic Treatment & Innovation in Surgery & Healthcare (SCOTTISH) Network, St Andrews, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew J Hall
- Scottish Hip Fracture Audit, Edinburgh, UK
- School of Medicine, University of St Andrews, St Andrews, UK
- Scottish Centres for Orthopaedic Treatment & Innovation in Surgery & Healthcare (SCOTTISH) Network, St Andrews, UK
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Liang J, Zhang J, Lou Z, Tang X. Development and validation of a predictive nomogram for subsequent contralateral hip fracture in elderly patients within 2 years after hip fracture surgery. Front Med (Lausanne) 2023; 10:1263930. [PMID: 38179269 PMCID: PMC10764586 DOI: 10.3389/fmed.2023.1263930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
Purpose Contralateral hip refracture following initial hip fracture surgery is life-threatening in the elderly with high incidence and mortality. This study investigated the associated independent risk factors and established a nomogram prediction model. Methods Totally 734 elderly patients with hip fractures who underwent surgical treatment (January 2016-December 2020) were enrolled. Following analyses on demographic variables, clinical characteristics, and laboratory examination, independent risk factors of contralateral hip fractures in the elderly were identified through the least absolute shrinkage and selection operator (LASSO) regression, and univariate and multivariate logistic regression. Patients were randomly allocated into training (n = 513) and validation sets (n = 221). A training set-based nomogram prediction model was established and assessed for predictability, discriminatory ability, and clinical applicability using the receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) in both sets. Results Contralateral hip refractures occurred in 7.08% (52/734) patients within 2 years after surgery. Age, hemoglobin (Hb), heart disease, neurovascular disease, Parkinson's disease (PD), Alzheimer's disease (AD), chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD) were independent risk factors. The nomogram prediction model had a favorable discriminatory ability, as indicated by the areas under the ROC curves (AUC): 0.906 (95% CI, 0.845-0.967) in the training set and 0.956 (95% CI, 0.927-0.985) in the validation set. The calibration curves demonstrated a good consistency between the actual subsequent contralateral hip fracture incidence and the predicted probability. The DCA of the nomogram demonstrated the model's excellent clinical efficacy. Conclusion The nomogram model enabled accurate individualized prediction for the occurrence of subsequent contralateral hip fracture in the elderly within 2 years after surgical treatment, which might help clinicians with precise references for appropriate perioperative management and rehabilitation education following initial hip surgery for their patients.
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Affiliation(s)
- Jiahui Liang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Graduate School of Dalian Medical University, Dalian Medical University, Dalian, China
| | - Jian Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Graduate School of Dalian Medical University, Dalian Medical University, Dalian, China
| | - Zhiyuan Lou
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Graduate School of Dalian Medical University, Dalian Medical University, Dalian, China
| | - Xin Tang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Graduate School of Dalian Medical University, Dalian Medical University, Dalian, China
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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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10
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Fu SH, Yu PY, Li CY, Hung CC, Lee CC, Chen HY, Tai TW, Hwang JS, Yang RS, Chiang H, Lin SY, Wu CH, Liao LC, Chuang CJ, Wu CY, Chang CY, Lee MT, Chen CH, Wang CY. Diagnostic accuracy of algorithms to define incident and second hip fractures: A Taiwan validation study. J Formos Med Assoc 2023; 122 Suppl 1:S82-S91. [PMID: 37353444 DOI: 10.1016/j.jfma.2023.05.037] [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: 12/29/2022] [Revised: 03/31/2023] [Accepted: 05/29/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Previous epidemiological researchers have used various algorithms to identify a second hip fracture; however, there has been no validation of these algorithms to date. This study aimed to verify existing algorithms for identifying second hip fracture under the International Classification of Diseases diagnostic coding systems. Furthermore, we examined the validity of two newly proposed algorithms that integrated the concept of periprosthetic fractures and laterality of the ICD-10 coding system. METHODS Claims data of patients hospitalized for hip fracture from National Taiwan University Hospitals between 2007 and 2020 were retrieved. Hip fracture was confirmed by 2 orthopaedic surgeons with medical records and imaging data as gold standards. The validity of 9 existing and 2 newly proposed algorithms for identifying second hip fracture was evaluated. RESULTS The positive predictive value (PPV) range between 84% and 90% in existing algorithms for identifying second hip fractures. Noteworthy, the longer time interval for discrimination resulted in slightly increased PPV (from 87% to 90%), while decreased sensitivity noticeably (from 87% to 72%). When considering the information about periprosthetic fracture, the PPV increased to 91% without diminished sensitivity. The PPV of the newly proposed ICD-10-specific algorithm was 100%. CONCLUSION Algorithms integrated clinical insights of periprosthetic fractures and laterality concept of ICD-10 coding system provided satisfactory validity and help precisely define second hip fracture in future database research.
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Affiliation(s)
- Shau-Huai Fu
- Department of Orthopedics, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Ying Yu
- Department of General Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Chih-Chien Hung
- Department of Orthopedics, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chia-Che Lee
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Hsuan-Yu Chen
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ta-Wei Tai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Biocompatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Rong-Sen Yang
- Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hongsen Chiang
- Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Yen Lin
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Hsing Wu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ling-Chiao Liao
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chin-Ju Chuang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chiu-Yi Wu
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Cheng-Ying Chang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Ming-Tsung Lee
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan; Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chung-Hwan Chen
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Orthopaedic Research Center and Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Chen-Yu Wang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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11
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Llopis-Cardona F, Armero C, Sanfélix-Gimeno G. Estimating disease incidence rates and transition probabilities in elderly patients using multi-state models: a case study in fragility fracture using a Bayesian approach. BMC Med Res Methodol 2023; 23:40. [PMID: 36788479 PMCID: PMC9930279 DOI: 10.1186/s12874-023-01859-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Multi-state models are complex stochastic models which focus on pathways defined by the temporal and sequential occurrence of numerous events of interest. In particular, the so-called illness-death models are especially useful for studying probabilities associated to diseases whose occurrence competes with other possible diseases, health conditions or death. They can be seen as a generalization of the competing risks models, which are widely used to estimate disease-incidences among populations with a high risk of death, such as elderly or cancer patients. The main advantage of the aforementioned illness-death models is that they allow the treatment of scenarios with non-terminal competing events that may occur sequentially, which competing risks models fail to do. METHODS We propose an illness-death model using Cox proportional hazards models with Weibull baseline hazard functions, and applied the model to a study of recurrent hip fracture. Data came from the PREV2FO cohort and included 34491 patients aged 65 years and older who were discharged alive after a hospitalization due to an osteoporotic hip fracture between 2008-2015. We used a Bayesian approach to approximate the posterior distribution of each parameter of the model, and thus cumulative incidences and transition probabilities. We also compared these results with a competing risks specification. RESULTS Posterior transition probabilities showed higher probabilities of death for men and increasing with age. Women were more likely to refracture as well as less likely to die after it. Free-event time was shown to reduce the probability of death. Estimations from the illness-death and the competing risks models were identical for those common transitions although the illness-death model provided additional information from the transition from refracture to death. CONCLUSIONS We illustrated how multi-state models, in particular illness-death models, may be especially useful when dealing with survival scenarios which include multiple events, with competing diseases or when death is an unavoidable event to consider. Illness-death models via transition probabilities provide additional information of transitions from non-terminal health conditions to absorbing states such as death, what implies a deeper understanding of the real-world problem involved compared to competing risks models.
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Affiliation(s)
- Fran Llopis-Cardona
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.
| | - Carmen Armero
- grid.5338.d0000 0001 2173 938XDepartment of Statistics and Operations Research. Universitat de València, Valencia, Spain ,grid.428862.20000 0004 0506 9859Joint research unit FISABIO-UV for the analysis of biomedical data, Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- grid.428862.20000 0004 0506 9859Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain ,Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Valencia, Spain
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12
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Inoue H, Oyama R, Nakamura K, Inokuchi A, Hamada T, Izumi T, Imamura R, Ebihara T, Inoue T, Arizono T. Bisphosphonates Prescription for Patients With Hip Fractures Based on Evaluation by a Dentist. Cureus 2023; 15:e35407. [PMID: 36987487 PMCID: PMC10040204 DOI: 10.7759/cureus.35407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 03/30/2023] Open
Abstract
Background The purpose of this study is to clarify the current status of the prescription of postoperative bisphosphonates for patients with hip fractures and to explore the factors that prevent the postoperative prescription of bisphosphonates. Methods Of 180 patients with hip fractures treated surgically at our hospital between August 2019 and April 2020, 149 patients (46 men and 103 women; mean age: 83.9 ± 9.0 years), excluding 31 patients already prescribed bisphosphonates or denosumab, were included in the study. All patients were treated based on our clinical pathway, and their risk of jaw osteonecrosis was evaluated prior to the initiation of bisphosphonates by a dentist in our hospital. We collected data from the medical records on osteoporosis treatment interventions at admission and discharge, the reasons why postoperative bisphosphonates could not be prescribed at discharge, the proportion of patients who had follow-ups at our hospital, and patients' osteoporosis treatment status. Results Eighteen (12.8%) and 95 (63.8%) patients were prescribed anti-osteoporosis drugs at admission and discharge, respectively. One hundred and twenty-one patients (86.8%) could not be prescribed postoperative bisphosphonates at discharge - 71 (58.7%) because of oral hygiene problems, 34 (28.1%) because they did not have regular dental consultations, seven (5.8%) because of renal dysfunction, eight (6.6%) because of poor cognitive and swallowing function, and one (0.8%) because of medication side effects. Forty-nine patients (32.9%) went to our hospital for follow-up and 11 were introduced to bisphosphonates or denosumab at follow-up. Conclusions The number of patients with hip fractures who were prescribed postoperative bisphosphonates was low in our study. The oral hygiene problems identified by dentists accounted for responsible for the low prescription rate of postoperative bisphosphonates. Therefore, coordination with dentists may be important to increase the postoperative bisphosphonate prescription.
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Affiliation(s)
- Hayato Inoue
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Ryunosuke Oyama
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Kimitaka Nakamura
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Akihiko Inokuchi
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takahiro Hamada
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Teiyu Izumi
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Ryuta Imamura
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Toshihiro Ebihara
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takahiro Inoue
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takeshi Arizono
- Department of Orthopedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
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13
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Risk factors for a second nonsimultaneous hip fracture in a prospective cohort study. Arch Orthop Trauma Surg 2022; 142:2611-2617. [PMID: 34125250 DOI: 10.1007/s00402-021-03991-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/09/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The risk factors for a second nonsimultaneous hip fracture are unclear, and in general, it is empirically assumed that they are similar to those associated with the first hip fracture. We aimed to determine the incidence of a second hip fracture and define the characteristics of the patients sustaining the event in a prospective cohort study in a Spanish population. MATERIALS AND METHODS We conducted a multicentric, prospective cohort study in a representative sample of 45 hospitals from 15 autonomic regions in Spain. In total, the study included 994 patients. One hundred and one patients presented a nonsimultaneous contralateral hip fracture, constituting the intervention group. The remaining 893 patients presenting with a hip fracture formed the control group. The main outcome measures of this study were sociodemographic characteristics of the patient, comorbid conditions, and baseline and postfracture clinical outcomes (inpatient complications and acute mortality). RESULTS The key fracture risk factors were a history of fragility fractures, the need for assistance when walking outdoors and a history of falls. There were no associations between the groups in any of the common fragility risk factors, including rheumatoid arthritis, secondary osteoporosis, or steroid consumption. The results showed that patients suffering a nonsimultaneous hip fracture had an increased risk of mortality after discharge compared with the control group. CONCLUSION A nonsimultaneous second hip fracture leads to a near-significant increase in four-month mortality. In our study, this fracture was associated with a history of falls, prior fragility fractures, and the need for a walking aid.
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14
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Yu S, Li C, Zhong Y, Zang J, Zhou Z, Wang S, Zhang Y. Risk factors for contralateral hip refractures in patients aged over 80 years with intertrochanteric femoral fractures. Front Surg 2022; 9:924585. [PMID: 36176341 PMCID: PMC9513157 DOI: 10.3389/fsurg.2022.924585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The purpose of this study was to identify which of the risk factors would contribute to the contralateral fracture in very elderly patients after intramedullary nail fixation. Methods Clinical data of 227 intertrochanteric fracture patients aged 80 years or older were retrospectively reviewed. Intramedullary nails (IMNs) were used on all of the patients. Potential risk factors for contralateral hip refractures were determined using univariate and logistic regression analyses. Results Contralateral hip refractures occurred in 11 patients (4.84%). Univariate analysis revealed that age, gender, body mass index, fracture classification, hematocrit, D-dimer, and CRP level were not associated with contralateral fractures (P > 0.05). However, neurological diseases, cardiovascular disease, and visual impairments were significantly associated with contralateral fractures (P < 0.05). Multivariate analysis further revealed that neurological diseases (OR 4.25, P = 0.044) and visual impairments (OR 5.42, P = 0.015) were independent risk factors associated with contralateral refractures. Conclusion To prevent contralateral refractures, more attention should be paid to elderly intertrochanteric fracture patients with underlying neurological disease and visual impairments.
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Affiliation(s)
- Shujun Yu
- The First Department of Hip Traumatology, Tianjin Hospital, Tianjin, China
| | - Chen Li
- The First Department of Hip Traumatology, Tianjin Hospital, Tianjin, China
| | - Yuqiao Zhong
- Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Jiacheng Zang
- The First Department of Hip Traumatology, Tianjin Hospital, Tianjin, China
| | - Zhanzhe Zhou
- Department of Orthopedics, Tianjin Xiqing Hospital, Tianjin, China
| | - Song Wang
- The First Department of Hip Traumatology, Tianjin Hospital, Tianjin, China
- Correspondence: Song Wang Yinguang Zhang
| | - Yinguang Zhang
- The First Department of Hip Traumatology, Tianjin Hospital, Tianjin, China
- Correspondence: Song Wang Yinguang Zhang
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15
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Llopis-Cardona F, Armero C, Hurtado I, García-Sempere A, Peiró S, Rodríguez-Bernal CL, Sanfélix-Gimeno G. Incidence of Subsequent Hip Fracture and Mortality in Elderly Patients: A Multistate Population-Based Cohort Study in Eastern Spain. J Bone Miner Res 2022; 37:1200-1208. [PMID: 35441744 PMCID: PMC9322522 DOI: 10.1002/jbmr.4562] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/17/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Osteoporotic hip fractures in older people may confer an increased risk of subsequent hip fractures and death. The aim of this study was to estimate the cumulative incidence of both recurrent hip fracture and death in the Valencia region. We followed a cohort of 34,491 patients aged ≥65 years who were discharged alive from Valencia Health System hospitals after an osteoporotic hip fracture between 2008 and 2015, until death or end of study (December 31, 2016). Two Bayesian illness-death models were applied to estimate the cumulative incidences of recurrent hip fracture and death by sex, age, and year of discharge. We estimated 1-year cumulative incidences of recurrent hip fracture at 2.5% in women and 2.3% in men, and 8.3% and 6.6%, respectively, at 5 years. Cumulative incidences of total death were 18.3% in women and 28.6% in men at 1 year, and 51.2% and 69.8% at 5 years. One-year probabilities of death after recurrent hip fracture were estimated at 26.8% and 43.8%, respectively, and at 57.3% and 79.2% at 5 years. Our analysis showed an increasing trend in the 1-year cumulative incidence of recurrent hip fracture from 2008 to 2015, but a decreasing trend in 1-year mortality. Male sex and age at discharge were associated with increased risk of death. Women showed higher incidence of subsequent hip fracture than men although they were at the same risk of recurrent hip fracture. Probabilities of death after recurrent hip fracture were higher than those observed in the general population. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Fran Llopis-Cardona
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
| | - Carmen Armero
- Department of Statistics and Operations Research, Universitat de València, Valencia, Spain
| | - Isabel Hurtado
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Aníbal García-Sempere
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Salvador Peiró
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Clara L Rodríguez-Bernal
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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16
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Wang L, Yin L, Yang M, Ge Y, Liu Y, Su Y, Guo Z, Yan D, Xu Z, Huang P, Geng J, Liu X, Wang G, Blake GM, Cao W, He B, Lyu L, Cheng X, Wu X, Jiang L, Vlug A, Engelke K. Muscle density is an independent risk factor of second hip fracture: a prospective cohort study. J Cachexia Sarcopenia Muscle 2022; 13:1927-1937. [PMID: 35429146 PMCID: PMC9178374 DOI: 10.1002/jcsm.12996] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Patients with a first hip fracture are at high risk of fracturing their other hip. Despite this, preventive therapy is often not given. Because little is known about specific risk factors of a second hip fracture, we investigated the association with areal bone mineral density (aBMD), muscle size, and density. We also investigated whether muscle parameters predict the risk of a contralateral fracture independently of aBMD. METHODS Three groups were included, one without hip fracture (a subcohort of the China Action on Spine and Hip Status study), one with a first, and one with a second hip fracture. Subjects with fractures were recruited from the longitudinal Chinese Second Hip Fracture Evaluation (CSHFE). Computed tomography scans of CSHFE patients, which were obtained immediately following their first fracture, were used to measure cross-sectional area and density of the gluteus maximus (G.MaxM) and gluteus medius and minimus (G.Med/MinM) muscles. Computed tomography X-ray absorptiometry was used to measure aBMD of the contralateral femur. Median follow-up time to second fracture was 4.5 years. Cox proportional hazards models were used to compute hazard ratios (HR) of second hip fracture risk in subjects with a first hip fracture. Multivariate logistic regressions were used to compare odds ratios (OR) for the risk of a first and second hip fracture. RESULTS Three hundred and one participants (68.4 ± 6.1 years, 64% female) without and 302 participants (74.6 ± 9.9 years, 71% female) with a first hip fracture were included in the analysis. Among the latter, 45 (79.2 ± 7.1 years) sustained a second hip fracture. ORs for first hip fracture were significant for aBMD and muscle size and density. ORs for a second fracture were smaller by a factor of 3 to 4 and no longer significant for femoral neck (FN) aBMD. HRs for predicting second hip fracture confirmed the results. G.Med/MinM density (HR, 1.68; CI, 1.20-2.35) and intertrochanter aBMD (HR, 1.62; CI, 1.13-2.31) were the most significant. FN aBMD was not significant. G.Med/MinM density remained significant for predicting second hip fracture after adjustment for FN (HR, 1.66; Cl, 1.18-2.30) or total hip aBMD (HR, 1.50; 95% Cl, 1.04-2.15). CONCLUSIONS Density of the G.Med/MinM muscle is an aBMD independent predictor of the risk of second hip fracture. Intertrochanteric aBMD is a better predictor of second hip fracture than FN and total hip aBMD. These results may trigger a paradigm shift in the assessment of second hip fracture risk and prevention strategies.
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Affiliation(s)
- Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China.,Department of Radiology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Lu Yin
- Medical Research & Biometrics Center, National Center for Cardiovascular Disease, Beijing, China
| | - Minghui Yang
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Yufeng Ge
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Yandong Liu
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yongbin Su
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Zhe Guo
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Dong Yan
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Zhengyang Xu
- Department of Radiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Pengju Huang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Jian Geng
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Xingli Liu
- Department of Radiology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Gang Wang
- Department of Radiology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Glen M Blake
- School of Biomedical Engineering & Imaging Sciences, King's College London, St Thomas' Hospital, London, UK
| | - Weiming Cao
- Health Commission of Yunnan Province, Kunming, China
| | - Bo He
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Liang Lyu
- Department of Radiology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Xinbao Wu
- Departments of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Lihong Jiang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Annegreet Vlug
- Center for Bone Quality, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Klaus Engelke
- Department of Medicine 3, FAU University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Institute of Medical Physics, University of Erlangen, Erlangen, Germany
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17
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Prommik P, Tootsi K, Veske K, Strauss E, Saluse T, Kolk H, Märtson A. Isolated greater trochanter fracture may impose a comparable risk on older patients' survival as a conventional hip fracture: a population-wide cohort study. BMC Musculoskelet Disord 2022; 23:394. [PMID: 35477499 PMCID: PMC9044808 DOI: 10.1186/s12891-022-05336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Isolated greater trochanter fracture (IGT) and conventional hip fracture (HF) affect the same anatomical area but are usually researched separately. HF is associated with high mortality, and its management is well established. In contrast, IGT’s effect on mortality is unknown, and its best management strategies are unclear. This study aims to compare these patient populations, their acute- and post-acute care, physical and occupational therapy use, and up to three-year mortality. Methods This retrospective cohort study is based on population-wide data of Estonia, where routine IGT management is non-operative and includes immediate weight-bearing as tolerated. The study included patients aged ≥ 50 years with a validated index HF or IGT diagnosis between 2009–2017. The fracture populations’ acute- and post-acute care, one-year physical and occupational therapy use and three-year mortality were compared. Results A total of 0.4% (50/11,541) of included patients had an IGT. The baseline characteristics of the fracture cohorts showed a close resemblance, but the IGT patients received substantially less care. Adjusted analyses showed that the IGT patients’ acute care was 4.5 days [3.4; 5.3] shorter they had 39.2 percentage points [25.5; 52.8] lower probability for receiving post-acute care, and they had 50 percentage points [5.5: 36]] lower probability for receiving physical and occupational therapy. The IGT and HF patients’ mortality rates were comparable, being 4% and 9% for one month, 28% and 31% for one year, and 46% and 49% for three years, respectively. Crude and adjusted analyses could not find significant differences in their three-year mortality, showing a p-value of 0.6 and a hazard ratio of 0.9 [0.6; 1.3] for the IGT patients, retrospectively. Conclusions Despite IGT being a relatively minor injury, the evidence from this study suggests that it may impose a comparable risk on older patients’ survival, as does HF due to the close resemblance of the two fracture populations. Therefore, IGT in older patients may signify an underlying need for broad-based medical attention, ensuring need-based, ongoing, coordinated care. Trial registration Retrospectively registered.
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Affiliation(s)
- Pärt Prommik
- Department of Traumatology and Orthopaedics, University of Tartu, L. Puusepa 8, 50406, Tartu, Estonia. .,Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia.
| | - Kaspar Tootsi
- Department of Traumatology and Orthopaedics, University of Tartu, L. Puusepa 8, 50406, Tartu, Estonia.,Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
| | - Karin Veske
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
| | - Eiki Strauss
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
| | - Toomas Saluse
- Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
| | - Helgi Kolk
- Department of Traumatology and Orthopaedics, University of Tartu, L. Puusepa 8, 50406, Tartu, Estonia.,Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
| | - Aare Märtson
- Department of Traumatology and Orthopaedics, University of Tartu, L. Puusepa 8, 50406, Tartu, Estonia.,Traumatology and Orthopaedics Clinic, Tartu University Hospital, L. Puusepa 8, 50406, Tartu, Estonia
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18
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Schemitsch E, Adachi JD, Brown JP, Tarride JE, Burke N, Oliveira T, Slatkovska L. Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients. Osteoporos Int 2022; 33:113-122. [PMID: 34379148 PMCID: PMC8354846 DOI: 10.1007/s00198-021-06080-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs. PURPOSE This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients. METHODS A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017. RESULTS Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture. CONCLUSION A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.
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Affiliation(s)
- Emil Schemitsch
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | | | - Jacques P Brown
- CHU de Québec Research Centre and Laval University, Québec, QC, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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19
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Fu TS, Huang TS, Sun CC, Shyu YC, Chen FP. Impact of bisphosphonates and comorbidities on initial hip fracture prognosis. Bone 2022; 154:116239. [PMID: 34688941 DOI: 10.1016/j.bone.2021.116239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
The aim of this study is to investigate the impact of bisphosphonate treatment on the prognosis of patients with initial hip fracture. Patients aged fifty years and older with initial hip fracture were identified from the Taiwan National Health Insurance Research Database between 2002 and 2011. A multi-state model was established to evaluate the transition between "first to second hip fracture", "first hip fracture to death", and "second hip fracture to death". Transition probability and cumulative hazards were used to compare the prognosis of initial hip fracture in a bisphosphonate treated cohort versus non-treated cohort. In addition, Deyo-Charlson comorbidities, both vertebral and non-vertebral fractures, and cataracts were also included for analysis. After 10-year follow-up, there is decreased cumulative transition probability for both second hip fracture and mortality after both first and second hip fracture in the bisphosphonate treated cohort. Multivariable, transition-specific time-dependent Cox model revealed that bisphosphonate treatment significantly reduced risk for second hip fracture in the first 5 years of the treatment (HR 0.88; 95% CI 0.79-0.99; P: 0.034), first hip fracture mortality (HR 0.88; 95% CI 0.83-0.93; P < 0.001), and second hip fracture mortality in the first 2 years of the treatment (HR 0.78; 95% CI 0.65-0.95; P = 0.011). Female sex, both vertebral and non-vertebral fractures, cataracts, dementia in the first 2 years, and DM with complication were all significantly associated with risk of a second hip fracture. Cerebrovascular disease and hemiplegia comorbidities had less risk of a second hip fracture. The risk of mortality after both first and second hip fracture was significantly associated with congestive heart failure, renal disease, myocardial infarction, and moderate to severe liver disease. Our study demonstrated that bisphosphonate treatment and strict management of comorbidities after the initial hip fracture significantly decrease the risk for a second hip fracture and mortality.
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Affiliation(s)
- Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Ting-Shuo Huang
- Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of General Surgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Chi-Chin Sun
- Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Institute of Molecular Biology, Academia Sinica, Nankang, 115 Taipei, Taiwan
| | - Fang-Ping Chen
- Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan.
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20
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Hadji P, Schweikert B, Kloppmann E, Gille P, Joeres L, Toth E, Möckel L, Glüer CC. Osteoporotic fractures and subsequent fractures: imminent fracture risk from an analysis of German real-world claims data. Arch Gynecol Obstet 2021; 304:703-712. [PMID: 34247254 PMCID: PMC8325652 DOI: 10.1007/s00404-021-06123-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Abstract
Purpose In osteoporosis, prior fracture is a strong predictor of subsequent fracture. This study aimed to assess the imminent risk of subsequent fracture following an initial fracture in osteoporosis patients in Germany, and to identify clinical and demographic characteristics that are independently associated with subsequent fracture risk. Methods In this retrospective, observational cohort study using German real-world claims data, male and female patients aged ≥ 50 years with osteoporosis who experienced an initial (“index”) hip/femur, vertebral, forearm/wrist/hand or shoulder/upper arm fracture between 2010 and 2014 were included. The incidence and timing of subsequent fractures during a 1-year follow-up period were analyzed. Independent risk factors for subsequent fracture were identified by multivariate regression analysis. Results A total of 18,354 patients (mean age: 77 years; standard deviation: 9.8) were included. Of these, 2918 (15.9%) suffered a subsequent fracture during the 1-year follow-up period. The incidence of subsequent fracture was higher following an index vertebral fracture (18.0%) than after an index forearm/wrist/hand fracture (14.1%) or index hip/femur fracture (12.1%). Subsequent 1-year fracture incidence was generally higher in older patients. Index fracture type, age, epilepsy/use of antiepileptics, and heart failure were all independently associated with subsequent fracture risk. Conclusion Osteoporosis patients in Germany are at imminent risk of subsequent fracture during the first year following an initial fracture. They should be targeted for immediate post-fracture treatment to reduce the risk of further fractures, especially in the presence of specific risk factors such as old age or index vertebral fracture. Supplementary Information The online version contains supplementary material available at 10.1007/s00404-021-06123-6.
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Affiliation(s)
- Peyman Hadji
- Frankfurt Center of Bone Health, Philipps-University of Marburg, Frankfurt, Germany
| | | | | | | | | | | | - Luis Möckel
- UCB Pharma, Monheim, Germany
- HSD Hochschule Döpfer GmbH, University of Applied Sciences, Cologne, Germany
| | - Claus-C Glüer
- Biomedical Imaging Section, Department of Radiology and Neuroradiology, Universitätskrankenhaus Schleswig-Holstein, Christian-Albrechts-Universität zu Kiel, Kiel, Germany.
- Department of Radiology and Neuroradiology, Molecular Imaging North Competence Center, Am Botanischen Garten 14, 24118, Kiel, Germany.
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21
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Saunders H, Sujic R, Bogoch ER, Jain R, Jinah A, Elliot-Gibson V, Mendlowitz AB, Linton D, Inrig T, Isaranuwatchai W, Sale JEM. Cost-Utility Analysis of the Ontario Fracture Screening and Prevention Program. J Bone Joint Surg Am 2021; 103:1175-1183. [PMID: 33764937 DOI: 10.2106/jbjs.20.00795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications). METHODS We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported. RESULTS The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP. CONCLUSIONS The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist. LEVEL OF EVIDENCE Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hailey Saunders
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rebeka Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Earl R Bogoch
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Mobility Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ravi Jain
- Osteoporosis Strategy, Osteoporosis Canada, Toronto, Ontario, Canada
| | - Ashna Jinah
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Victoria Elliot-Gibson
- Mobility Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Andrew B Mendlowitz
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada
| | - Denise Linton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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22
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Nolan P, Tiedt L, Ellanti P, McCarthy T, Hogan N. Incidence of Non-Simultaneous Contralateral Second Hip Fractures: A Single-Center Irish Study. Cureus 2020; 12:e11154. [PMID: 33133797 PMCID: PMC7586354 DOI: 10.7759/cureus.11154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction Hip fractures are a significant cause of morbidity and mortality in the elderly and are also associated with increased healthcare costs. A second contralateral hip fracture can lead to even more complications and healthcare costs. A significant proportion of the Irish hip fracture population does not receive a bone health assessment or falls specialist assessment to reduce the risk of future falls and fractures. This study aimed to analyze the incidence of a non-simultaneous contralateral hip fracture in an Irish population. Methods We retrospectively analyzed 1,344 patients presenting to our institution with a hip fracture from January 2007 to June 2019. Patients aged ≥ 60 years old presenting with a neck of femur or pertrochanteric fracture were included in our study. We excluded patients who had sub-trochanteric and femoral shaft fractures, high energy fractures, and pathological fractures. We also excluded patients less than 60 years old, as fractures in these younger patients may not be purely related to osteoporosis. Results A total of 1,099 hip fractures meeting the inclusion criteria were treated at our unit during the designated time period. A total of 102 (9.3%) patients experienced a second hip fracture. The mean age at first presentation in our institution was 78.5 years old, with a mean time between first and second hip fractures of 37.2 months. Conclusions Patients presenting with a second hip fracture may represent 9.3% of the Irish hip fracture population. We hope that this study will help inform on the rate of second hip fractures in an Irish population and help advocate for improved resources and implementation of secondary prevention strategies.
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Affiliation(s)
- Patrick Nolan
- Trauma and Orthopaedics, St. James' Hospital, Dublin, IRL
| | - Lauren Tiedt
- Trauma and Orthopaedics, St. James' Hospital, Dublin, IRL
| | - Prasad Ellanti
- Trauma and Orthopaedics, St. James' Hospital, Dublin, IRL
| | - Tom McCarthy
- Trauma and Orthopaedics, St. James' Hospital, Dublin, IRL
| | - Niall Hogan
- Trauma and Orthopaedics, St. James' Hospital, Dublin, IRL
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23
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Dubljanin Raspopovic E, Marković Denić L, Tomanović Vujadinović S, Kadija M, Nedeljković U, Ilić N, Milovanović D. Instrumental Activities of Daily Living-A Good Tool to Prospectively Assess Disability after a Second Contralateral Hip Fracture? Geriatrics (Basel) 2020; 5:geriatrics5040067. [PMID: 33003454 PMCID: PMC7709669 DOI: 10.3390/geriatrics5040067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. Methods: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/− 7.53 years) and second (25 patients, 78.96 +/− 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). Results: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. Conclusions: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales.
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Affiliation(s)
- Emilija Dubljanin Raspopovic
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
- Correspondence: ; Tel.: +381-(11)3615605
| | - Ljiljana Marković Denić
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Sanja Tomanović Vujadinović
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
| | - Marko Kadija
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
| | - Una Nedeljković
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
| | - Nela Ilić
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
| | - Darko Milovanović
- Clinic for Physical Medicine and Rehabilitation, Clinical Center Serbia Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (S.T.V.); (M.K.); (U.N.); (N.I.); (D.M.)
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24
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Jorissen RN, Lang C, Visvanathan R, Crotty M, Inacio MC. The effect of frailty on outcomes of surgically treated hip fractures in older people. Bone 2020; 136:115327. [PMID: 32209422 DOI: 10.1016/j.bone.2020.115327] [Citation(s) in RCA: 15] [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: 12/05/2019] [Revised: 03/06/2020] [Accepted: 03/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hip fractures are associated with mortality, disability, and loss of independence in older adults. While several risk factors associated with poor outcomes following a hip fracture have been identified, the effect of frailty status prior to hip fracture is not well established. AIM To examine the associations of frailty with mortality, change in activities of daily living (ADL) limitations, and transition to permanent residential aged care in older people following a hip fracture. METHODS A retrospective cohort study was conducted on people aged 65 years and older with a surgically treated hip fracture between 2003 and 2015. Frailty was estimated using a cumulative deficit-based frailty index and categorized into quartiles. Cox multivariable regression, logistic regression, and Fine-Gray multivariable regression models estimated associations of frailty with mortality, ADL limitations, and entry into permanent residential aged care, respectively. Hazard ratios (HR), odds ratios (OR), subdistribution hazard ratios (SHR), and 95% confidence intervals (95%CI) are reported. RESULTS Out of 4771 individuals with hip fractures, 75.6% were female and the median age was 86 (interquartile range 82-90) years old. The two-year survival of patients following hip fracture was 43.7% (95%CI 40.9-46.7%) in those in the highest quartile of frailty, compared to 54.4% (95%CI 51.8-57.2%) for those in the lowest quartile (HR = 1.25, 95%CI 1.11-1.41, p < 0.001). No associations between pre-fracture frailty and post-fracture ADL limitations were observed. Additionally, no association of frailty with transition to permanent residential aged care for patients living in the community (n = 1361) was observed (SHR = 0.98, 95%CI 0.81-1.18, p = 1.000). CONCLUSIONS Older patients with the highest level of frailty had an increased risk of mortality after hip fracture. Consideration for appropriate clinical interventions, including fall and frailty prevention measures, may be appropriate for this identified group of vulnerable individuals.
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Affiliation(s)
- Robert N Jorissen
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia; Department of Rehabilitation, Aged and Extended Care, Flinders University, Rehabilitation Building, Flinders Medical Centre, Australia.
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Renuka Visvanathan
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing and Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Faculty of Health and Medical Science, University of Adelaide, Adelaide, Australia
| | - Maria Crotty
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Rehabilitation Building, Flinders Medical Centre, Australia
| | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia; Division of Health Sciences, University of South Australia, Adelaide, Australia
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25
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Kristensen MT. Factors influencing performances and indicating risk of falls using the true Timed Up and Go test time of patients with hip fracture upon acute hospital discharge. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 25:e1841. [PMID: 32363803 DOI: 10.1002/pri.1841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the influence and risk of falls of individual factors on timed up and go test (TUG) times using standardized instructions in patients with hip fracture upon discharge from an acute orthopaedic hip fracture unit. METHODS Following instructions, the TUG was performed three times with a rollator (standardized aid), as fast as safely possible. Up to a 1-min rest was given after the first and second TUG trial. Multivariable linear regression analysis was used to investigate the factors influencing TUG-times and corresponding logistic analysis was used to investigate factors indicating risk of falls, using a cut-off of 24 s for TUG. RESULTS A total of 181 patients (122 women), 60 years or older, with a mean (SD) age of 78.1 (9.1) years were studied. The fastest of three TUG trials performed within a mean of 10.0 (5.2) post-surgery days and used in analyses reached a mean of 25.6 (11.0) s. Multivariable regression analysis showed that greater age (B = 0.24; 2.4s more per decade older), a low pre-fracture function level (New Mobility Score <7 points, B = 6.4s more than high level), having a trochanteric fracture (B = 6.2 s, vs. cervical), and the post-surgery day of testing (B = 0.42, 4.2s per 10 days later) were independently associated with using more time for performing the TUG. Correspondingly, the same four factors indicated an increased risk of falls in the logistic analysis. The linear model explained 28% of the variance on TUG, while the accuracy of the logistic model to predict patients having TUG≥24 s was 69%. CONCLUSION The age, pre-fracture function, fracture type and post-surgery day of TUG testing were identified as strong factors influencing TUG performances and TUG-times indicating risk of falls in patients with hip fracture. We suggest that these factors be considered when interpreting TUG test results and in further rehabilitation and fall prevention efforts.
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Affiliation(s)
- Morten T Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic Surgery, Amager-Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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Gallardo P, Clavel O. FRACTURA DE CADERA Y GERIATRÍA, UNA UNIÓN NECESARIA. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Evaluation of the need for a fracture liaison service in a patient-centered medical home. J Am Pharm Assoc (2003) 2019; 59:565-569. [PMID: 30948237 DOI: 10.1016/j.japh.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the need for a fracture liaison service (FLS) based on postfracture care in a patient-centered medical home (PCMH). METHODS Patients in a PCMH who presented to a local 763-bed community teaching hospital with fragility fracture of the hip, spine, or forearm between January 1, 2013, and December 31, 2014, were identified using ICD-9 codes. A retrospective chart review of inpatient and outpatient medical records 2 years before the fracture and 1 year afterward was conducted. The primary outcome was dual X-ray absorptiometry (DXA) scan utilization or pharmacotherapy for osteoporosis 6 months after fracture. RESULTS One hundred eighty-two patients were identified, and 75 patients were included in the analysis. The median age of the cohort was 84 years, and 70.7% of patients were white women. Fragility fractures included hip fracture (42.7%), vertebral fracture (40.0%), and forearm fracture (17.3%). Six months after fracture, 30.7% of patients were prescribed prescription therapy for osteoporosis, and 6.7% had received a DXA scan. Although nearly all patients had a follow-up visit in the PCMH during the year after fracture, only 8.3% were seen in an established osteoporosis clinic. Twenty-three percent of patients were deceased at 1 year. CONCLUSIONS More patients in this PCMH received a DXA scan or pharmacotherapy, or both, for osteoporosis 6 months after fragility fracture than observed nationally. However, approximately 70% of patients were undertreated. Incorporating principles of an FLS into an existing osteoporosis clinic is warranted.
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Prommik P, Kolk H, Sarap P, Puuorg E, Harak E, Kukner A, Pääsuke M, Märtson A. Estonian hip fracture data from 2009 to 2017: high rates of non-operative management and high 1-year mortality. Acta Orthop 2019; 90:159-164. [PMID: 30669948 PMCID: PMC6461069 DOI: 10.1080/17453674.2018.1562816] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - There are no national guidelines for treatment of hip fractures in Estonia and no studies on management. We assessed treatment methods and mortality rates for hip fracture patients in Estonia. Patients and methods - We studied a population-based retrospective cohort using validated data from the Estonian Health Insurance Fund's database. The cohort included patients aged 50 and over with an index hip fracture diagnosis between January 1, 2009 and September 30, 2017. The study generated descriptive statistics of hip fracture management methods and calculated in-hospital, 1-, 3, 6-, and 12-month unadjusted all-cause mortality rates. [CrossRef] Results - 91% (number of hips: 11,628/12,731) of the original data were included after data validation. Median patient age was 81 years, 83 years for women and 74 years for men. 28% were men. Treatment methods were: total hip arthroplasty 7%; hemiarthroplasty 25%; screws 6%; sliding hip screw 25%; intramedullary nail 27%; and nonoperative management 10%. Unadjusted all-cause mortality rates for in-hospital, 1, 3, 6, and 12 months were: 3%, 9%, 18%, 24%, and 31% respectively. The 12-month mortality rate for nonoperative management was 58%. [CrossRef] Interpretation - High rates of nonoperative management and overall high 1-year mortality rates after an index hip fracture indicate the need to review exclusion criteria for surgery and subacute care in Estonia.
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Affiliation(s)
- Pärt Prommik
- University of Tartu; ,Tartu University Hospital, Estonia,Correspondence:
| | - Helgi Kolk
- University of Tartu; ,Tartu University Hospital, Estonia
| | - Pirja Sarap
- University of Tartu; ,Tartu University Hospital, Estonia
| | | | - Eva Harak
- University of Tartu; ,Tartu University Hospital, Estonia
| | | | | | - Aare Märtson
- University of Tartu; ,Tartu University Hospital, Estonia
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Sheehan KJ, Levy AR, Sobolev B, Guy P, Tang M, Kuramoto L, Sutherland JM, Beaupre L, Morin SN, Harvey E, Bradley N. Operationalising a conceptual framework for a contiguous hospitalisation episode to study associations between surgical timing and death after first hip fracture: a Canadian observational study. BMJ Open 2018; 8:e020372. [PMID: 30530471 PMCID: PMC6287122 DOI: 10.1136/bmjopen-2017-020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers. DESIGN Retrospective observational study. SETTING All acute care hospitals in nine Canadian provinces. PARTICIPANTS We retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES The percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care. RESULTS Using contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively. CONCLUSION We demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn.
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Affiliation(s)
- Katie Jane Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Kings College London, London, UK
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Tang
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren Beaupre
- Department of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Alberta, Edmonton, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Edward Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Québec, Canada
| | - Nick Bradley
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
A high proportion of patients with fragility fracture, mainly hip fracture, have a variable degree of comorbidity and show some degree of dependence in basic or more complex activities of daily living. Evaluating these patents following the geriatric concept of frailty, about one third of hip fracture patients may be categorised as frail with high risk of poor outcomes and prolonged length of stay, one third as not frail, and about one third with an intermediate condition. Due to the high vulnerability, combined with the hip fracture event and surgical repair procedures, a multidisciplinary approach that includes geriatric competencies becomes essential to improve short and long-term outcomes after hip fracture. A key element of an effective process of care is a true co-managed approach that applies quality standards and provides a fast-track pathway of care, minimises the time the patient spends in bed, and reduces postoperative complications by means of standardised procedures. The occurrence of a fragility fracture is the strongest risk factor for a subsequent fracture. Moreover, frail subjects have a further risk of fracture due to high risk of falls - related to loss of muscle mass, multiple illnesses, impaired balance and weakness. Thus, effective secondary prevention strategies are essential to reduce morbidity and mortality after hip fracture, and they are currently a standard task of orthogeriatric care. Fracture liaison services (FLS) are probably the most efficient way of addressing secondary prevention including the assessment of both bone health and falls risk. Therefore, the optimal management of frail patients with fragility fracture includes both orthogeriatric care and FLS, which are complementary to each other. Orthogeriatric collaboration is also powerful in influencing healthcare policy. British experience as well as that in Ireland, Australia and New Zealand, have shown that when two widely disparate specialisms say the same thing, they may achieve a fundamental shift in attitudes and behaviour of both managers and clinicians. Furthermore, a continuous real-time audit, at national level, is a powerful driver for change and better standards of care.
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Martinez-Laguna D, Nogues X, Abrahamsen B, Reyes C, Carbonell-Abella C, Diez-Perez A, Prieto-Alhambra D. Excess of all-cause mortality after a fracture in type 2 diabetic patients: a population-based cohort study. Osteoporos Int 2017; 28:2573-2581. [PMID: 28744600 DOI: 10.1007/s00198-017-4096-y] [Citation(s) in RCA: 24] [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: 02/24/2017] [Accepted: 05/15/2017] [Indexed: 01/09/2023]
Abstract
UNLABELLED Post-fracture mortality in type 2 diabetes mellitus (T2DM) patients has been poorly studied. We report an absolute and relative excess all-cause mortality following a fracture in these patients compared to non-diabetic patients. INTRODUCTION T2DM and osteoporotic fractures are independently associated with a reduced lifespan, but it is unknown if T2DM confers an excess post-fracture mortality compared to non-diabetic fracture patients. We report post-fracture all-cause mortality according to T2DM status. METHODS This is a population-based cohort study using data from the SIDIAP database. All ≥50 years old T2DM patients registered in SIDIAP in 2006-2013 and two diabetes-free controls matched on age, gender, and primary care center were selected. Study outcome was all-cause mortality following incident fractures. Participants were followed from date of any fracture (AF), hip fracture (HF), and clinical vertebral fracture (VF) until the earliest of death or censoring. Cox regression was used to calculate mortality according to T2DM status after adjustment for age, gender, body mass index, smoking, alcohol intake, and previous ischemic heart and cerebrovascular disease. RESULTS We identified 166,106 T2DM patients and 332,212 non-diabetic, of which 11,066 and 21,564, respectively, sustained a fracture and were then included. Post-fracture mortality rates (1000 person-years) were (in T2DM vs non-diabetics) 62.7 vs 49.5 after AF, 130.7 vs 112.7 after HF, and 54.9 vs 46.2 after VF. Adjusted HR (95% CI) for post-AF, post-HF, and post-VF mortality was 1.30 (1.23-1.37), 1.28 (1.20-1.38), and 1.20 (1.06-1.35), respectively, for T2DM compared to non-diabetics. CONCLUSIONS T2DM patients have a 30% increased post-fracture mortality compared to non-diabetics and a remarkable excess in absolute mortality risk. More research is needed on the causes underlying such excess risk, and on the effectiveness of measures to reduce post-fracture morbi-mortality in T2DM subjects.
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Affiliation(s)
- D Martinez-Laguna
- GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute, CIBERFES ISCIII, Universitat Autonoma de Barcelona, Barcelona, Spain
- Ambit Barcelona, Primary Care Department, Institut Catala de la Salut, Barcelona, Spain
| | - X Nogues
- Internal Medicine Department IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - B Abrahamsen
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- OPEN Odense Patient Data Explorative Network, Institute of Clinical Research, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - C Reyes
- GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute, CIBERFES ISCIII, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - C Carbonell-Abella
- GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute, CIBERFES ISCIII, Universitat Autonoma de Barcelona, Barcelona, Spain
- Ambit Barcelona, Primary Care Department, Institut Catala de la Salut, Barcelona, Spain
| | - A Diez-Perez
- Internal Medicine Department IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Autonomous University of Barcelona and CIBERFES, ISCIII, Barcelona, Catalonia, Spain
| | - D Prieto-Alhambra
- GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute, CIBERFES ISCIII, Universitat Autonoma de Barcelona, Barcelona, Spain.
- Internal Medicine Department IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
- Autonomous University of Barcelona and CIBERFES, ISCIII, Barcelona, Catalonia, Spain.
- MRC Lifecourse Epidemiology Unit, Southampton University, Southampton, UK.
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Centre, University of Oxford, Oxford, UK.
- Musculoskeletal Pharmaco and Device Epidemiology, Botnar Research Centre, Nuffield Orthopaedics Centre, Windmill Road, Oxford, OX3 7LD, UK.
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Guy P, Sobolev B, Sheehan KJ, Kuramoto L, Lefaivre KA. The burden of second hip fractures: provincial surgical hospitalizations over 15 years. Can J Surg 2017; 60:101-107. [PMID: 28234218 DOI: 10.1503/cjs.008616] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Second hip fractures account for up to 15% of all hip fractures. We sought to determine if the proportion of hip fracture surgeries for second hip fracture changed over time in terms of patient and fracture characteristics. METHODS We reviewed the records of patients older than 60 years hospitalized for hip fracture surgery between 1990 and 2005 in British Columbia. We studied the proportion of surgeries for second hip fracture among all hip fracture surgeries. Linear regression tested for trends across fiscal years for women and men. RESULTS We obtained 46 341 patient records. Second hip fracture accounted for 8.3% of hip fracture surgeries. For women the proportion of second hip fracture surgeries increased linearly from 4% to 13% with each age decade (p = 0.001) and across fiscal years (p = 0.002). In men the proportion of second hip fracture surgeries was 5% for each age decade between the ages of 60 and 90 years across fiscal years, increasing to 8% for men older than 90 years across fiscal years (p = 0.20). These sex-specific trends were similar for both pertrochanteric and transcervical fracture types. CONCLUSION Second hip fracture surgeries account for an increasing proportion of hip fracture surgeries and may require more health care resources to minimize poorer reported outcomes. Future research should determine whether more health care resources are required to manage these patients and optimize their outcomes.
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Affiliation(s)
- Pierre Guy
- From the Department of Orthopedics, University of British Columbia, Vancouver, BC (Guy, Lefaivre); the School of Population and Public Health, University of British Columbia, Vancouver, BC (Sobolev, Sheehan); and the Vancouver Coastal Health Research Institute, Vancouver, BC (Kuramoto)
| | - Boris Sobolev
- From the Department of Orthopedics, University of British Columbia, Vancouver, BC (Guy, Lefaivre); the School of Population and Public Health, University of British Columbia, Vancouver, BC (Sobolev, Sheehan); and the Vancouver Coastal Health Research Institute, Vancouver, BC (Kuramoto)
| | - Katie Jane Sheehan
- From the Department of Orthopedics, University of British Columbia, Vancouver, BC (Guy, Lefaivre); the School of Population and Public Health, University of British Columbia, Vancouver, BC (Sobolev, Sheehan); and the Vancouver Coastal Health Research Institute, Vancouver, BC (Kuramoto)
| | - Lisa Kuramoto
- From the Department of Orthopedics, University of British Columbia, Vancouver, BC (Guy, Lefaivre); the School of Population and Public Health, University of British Columbia, Vancouver, BC (Sobolev, Sheehan); and the Vancouver Coastal Health Research Institute, Vancouver, BC (Kuramoto)
| | - Kelly Ann Lefaivre
- From the Department of Orthopedics, University of British Columbia, Vancouver, BC (Guy, Lefaivre); the School of Population and Public Health, University of British Columbia, Vancouver, BC (Sobolev, Sheehan); and the Vancouver Coastal Health Research Institute, Vancouver, BC (Kuramoto)
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Patient Perspectives on Engagement in Recovery after Hip Fracture: A Qualitative Study. J Aging Res 2017; 2017:2171865. [PMID: 28409031 PMCID: PMC5376933 DOI: 10.1155/2017/2171865] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/17/2016] [Accepted: 02/26/2017] [Indexed: 11/23/2022] Open
Abstract
Purpose. To understand older adults' engagement in their recovery experience and rehabilitation after a fall-related hip fracture. Method. 50 community-dwelling older adults recovering from a recent (3–12 months) hip fracture (32 women, 18 men) participated in telephone interviews using a semistructured format at 6 and 12 months after recruitment into the study. Interviews were conducted as part of a mixed-methods study designed to test the effect of a postoperative hip fracture management program (B4 Clinic). Results. Three substantive themes were identified in the qualitative data: (1) managing expectations; (2) engaging in physical activity; and (3) there is life after fracture. Participants shared valuable insight into how their expectations for their recovery period compared to their lived experience and the role of physical activity in their ability to return to their prefracture activities. Conclusions. Our findings reflect older adults' expectations for recovery from hip fracture. Encouraging engagement in rehabilitative exercises and addressing expectations prior to hospital discharge may improve patients' adherence to rehabilitation programs, functional outcomes, and postoperative quality of life. Implications for rehabilitation include the necessity for early and ongoing engagement of rehabilitation professionals.
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Wu TY, Hu HY, Lin SY, Chie WC, Yang RS, Liaw CK. Trends in hip fracture rates in Taiwan: a nationwide study from 1996 to 2010. Osteoporos Int 2017; 28:653-665. [PMID: 27858121 DOI: 10.1007/s00198-016-3783-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/22/2016] [Indexed: 02/08/2023]
Abstract
UNLABELLED There was an initial increase and a later decrease in hip fracture rates in Taiwan between 1996 and 2010 (457.9 to 390.0 fractures per 100,000 people per year). Mortality rates decreased but re-emerged later (2.26 to 1.91 deaths per 100 hip fracture admissions). The turning point for change in trends was 2003. INTRODUCTION Fractures of the proximal femur remain a major cause of mortality and morbidity. We aimed to examine recent trends in hip fracture rates, in-hospital mortality rates, and length of hospital stay (LOS) due to hip fractures in people aged 55 and over in Taiwan. METHODS This is a time-trend study. We used data from the National Health Insurance Research Database between 1996 and 2010 in Taiwan. Insurants aged 55 and over were included. The outcome measures were age-adjusted hip fracture rates, age-adjusted in-hospital mortality rates, and LOS due to hip fractures. We classified hip fractures into femoral neck, trochanteric, and subtrochanteric fractures. RESULTS We identified 250,919 hospitalizations for hip fractures. The total number of hip fractures increased steadily from 12,479 to 19,841 cases. There was a trend towards initial increase and then later decrease in hip fracture rates (from 457.9 to 390.0 fractures per 100,000 people per year). LOS decreased by 46.5 % (17.53 to 9.38 days). By contrast, mortality rates for hip fractures decreased initially, but re-emerged later with a total decrement of 15.5 % (2.26 to 1.91 deaths per 100 hip fracture admissions). Women outnumbered men in all types of hip fractures, but men had higher in hospital mortality rates. LOS was similar between genders and among age groups. The turning point for change in trends was year 2003. CONCLUSIONS While LOS shortened gradually since 1996, the absolute number of hip fractures in Taiwan continues to rise. There is still room for improvement in reducing mortality due to hip fractures.
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Affiliation(s)
- T Y Wu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, 5F, No. 17, Hsu-Chow Rd., Taipei, 100, Taiwan
- Department of Family Medicine, Renai Branch, Taipei City Hospital, 10F, No. 10, Sec. 4, Ren-Ai Rd., Taipei, 106, Taiwan
| | - H Y Hu
- Department of Education and Research, Taipei City Hospital, 10F, No. 10, Sec. 4, Ren-Ai Rd., Taipei, 106, Taiwan
- Institute of Public Health and Department of Public Health, National Yang-Ming University, No.155, Sec. 2, Li-nong St., Beitou District, Taipei, 112, Taiwan
| | - S Y Lin
- Department of Education and Research, Taipei City Hospital, 10F, No. 10, Sec. 4, Ren-Ai Rd., Taipei, 106, Taiwan
| | - W C Chie
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, 5F, No. 17, Hsu-Chow Rd., Taipei, 100, Taiwan
- Department of Public Health, College of Public Health, National Taiwan University, 5F, No. 17, Hsu-Chow Rd., Taipei, 100, Taiwan
| | - R S Yang
- Department of Orthopedics, College of Medicine, National Taiwan University Hospital, 11F, No.7, Chung-Shan S. Rd., Taipei, 100, Taiwan
| | - C K Liaw
- Department of Orthopedics, College of Medicine, National Taiwan University Hospital, 11F, No.7, Chung-Shan S. Rd., Taipei, 100, Taiwan.
- Department of Orthopedics, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen-Chang Rd., Taipei, 111, Taiwan.
- School of Medicine, Fu-Jen Catholic University, No. 510, Zhong-Zheng Rd., Xin-Zhuang Dist, New Taipei, 242, Taiwan.
- Department of Healthcare Information and Management, Ming Chuan University, No.5, De-Ming Rd., Gui-Shan Dist, Taoyuan County, 333, Taiwan.
- , 5F, No. 11, Aly. 25, Lan. 208, Rui-an St., Taipei, 10661, Taiwan.
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Bluhmki T, Peter RS, Rapp K, König HH, Becker C, Lindlbauer I, Rothenbacher D, Beyersmann J, Büchele G. Understanding Mortality of Femoral Fractures Following Low-Impact Trauma in Persons With and Without Care Need. J Am Med Dir Assoc 2016; 18:221-226. [PMID: 27776984 DOI: 10.1016/j.jamda.2016.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Persons with osteoporotic fracture history are subject to an increased risk for subsequent fractures and mortality. The aim of this retrospective study was to investigate the impact of a previous osteoporotic low-impact (fragility) index fracture (eg, forearm, lower leg) on mortality of a subsequent femoral fracture. DESIGN Retrospective cohort study. PARTICIPANTS/MEASUREMENTS Claims data of a German health insurance agency including >1.2 million insurants aged 65 years or older and observed between 2004 and 2009. METHODS A multistate model was developed handling index fractures and care need as time-dependent exposures, while age was chosen as the underlying time scale. Excess risks were expressed as differences in cause-specific hazards. Nelson-Aalen estimates were used for their nonparametric estimation. Time-simultaneous statistical inference was based on confidence bands provided by wild bootstrap resampling. RESULTS Excess femoral fracture risk increased with progressive age and was highest in persons with care need. It was observed starting from an age of 79 years in women and 85 years in men onward. A prior index fracture increased mortality after a femoral fracture by increasing femoral fracture risk, while leaving the hazard of death after a subsequent femoral fracture unchanged. CONCLUSIONS The results indicated that increased mortality of a subsequent femoral fracture is not triggered by an intrinsically increased mortality hazard but an increased femoral fracture incidence.
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Affiliation(s)
- Tobias Bluhmki
- Department of Mathematics and Economics, Institute of Statistics, Ulm University, Ulm, Germany
| | - Raphael Simon Peter
- Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Kilian Rapp
- Department for Geriatric Rehabilitation, Robert Bosch Krankenhaus, Stuttgart, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center, Hamburg, Germany
| | - Clemens Becker
- Department for Geriatric Rehabilitation, Robert Bosch Krankenhaus, Stuttgart, Germany
| | - Ivonne Lindlbauer
- Department of Health Economics and Health Services Research, University Medical Center, Hamburg, Germany
| | - Dietrich Rothenbacher
- Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Jan Beyersmann
- Department of Mathematics and Economics, Institute of Statistics, Ulm University, Ulm, Germany
| | - Gisela Büchele
- Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
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Bliemel C, Sielski R, Doering B, Dodel R, Balzer-Geldsetzer M, Ruchholtz S, Buecking B. Pre-fracture quality of life predicts 1-year survival in elderly patients with hip fracture-development of a new scoring system. Osteoporos Int 2016; 27:1979-87. [PMID: 26733375 DOI: 10.1007/s00198-015-3472-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Hip fractures are common in elderly people. Despite great progress in surgical care, the outcome of patients with hip fracture remains disappointing. This study determined four prognostic factors (lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender) to predict 1-year survival in patients with hip fracture. INTRODUCTION This study determined the prognostic factors for 1-year survival in patients with hip fracture. Based on these predictors, a scoring system was developed for use upon patients' admission to the hospital. METHODS Hip fracture patients, aged ≥60 years, were prospectively enrolled. Upon admission, patients' sociodemographic data, type of fracture, American Society of Anesthesiologists (ASA) score, health-related quality of life scores (EQ-5D index) and Mini-Mental State Examination (MMSE) scores were recorded, among other parameters. Correlational analysis was performed on all potential variables to identify relevant predictor variables of 1-year survival. Univariate regression analysis was performed on all selected variables, followed by a multivariate analysis for variables that were significant in the univariate analysis. The final score was developed by converting the β-coefficients of each variable from the multivariate analysis into a scoring system. RESULTS For 391 hip fracture patients, complete data were available at the time of the 1-year follow-up. In multivariate regression analysis, independent predictors of 1-year survival were lower ASA score, higher pre-fracture EQ-5D index, higher MMSE score, and female gender. The different variables were weighted according to their β-coefficient to build the prognostic score, which ranged from 0 to 10 points. The ROC curve for 1-year mortality after hip fracture showed an area under the curve of 0.74 (R (2) = 0.272; 95 % CI 0.68-0.79; p < 0.001). CONCLUSIONS With only four instruments, the new score represents a useful tool for estimating 1-year survival in elderly patients with hip fractures. At present, the score is limited due to a lack of validation. A validation study is currently underway to prove its reliability.
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Affiliation(s)
- C Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - R Sielski
- Department of Clinical Psychology and Psychotherapy, Philipps-University, Marburg, Germany
| | - B Doering
- Department of Clinical Psychology and Psychotherapy, Philipps-University, Marburg, Germany
| | - R Dodel
- Department of Neurology, University Hospital Giessen and Marburg, Marburg, Germany
| | - M Balzer-Geldsetzer
- Department of Neurology, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - B Buecking
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
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