Burden of fractures in France: incidence and severity by age, gender, and site in 2016

Fracture analysis of working-age adults in Turkey: a 7-year national registry study

BACKGROUND

The primary objective of this study was to examine the incidence of fractures among individuals aged 20-64 years over a 7-year timeframe by utilising an electronic recording system that is integrated with a substantial portion of the Turkish population.

METHODS

De-identified health records were acquired from the nationwide personal health recording system. Four age groups were established: 20-34, 35-44, 45-54, and 55-64 years. Incidence rates were further analysed according to sex and age group.

RESULTS

A total of 3,286,991 fractures were recorded in the 7-year time period, with male patients accounting for 62.1% of those cases. The overall fracture incidence rate in the Turkish adult population was 1029/100,000. The incidence rate was 727.44/100,000 for women and 1158.86/100,000 for men (p < 0.001). The age group with the highest number of fractures was 20-34 years with 1337.012 (37.3%) fractures. Wrist fractures (17.46%), finger fractures (14.4%), and foot fractures (11.85%) accounted for 43.7% of all fractures. In women, the incidence of fractures, excluding those of the hand and wrist, increased significantly as the age groups increased (p < 0.05).

CONCLUSION

Wrist, finger, and foot fractures were found to be the most common fractures among individuals aged 20-64 years. Fracture incidence was highest in men and in the age group of 20-34 years, encompassing individuals who are more active in work and sports.

Hospitalisation from fractures in New Zealand octogenarians: LiLACS NZ

Longitudinal data quantifying fracture rates beyond 80 years are lacking. Over 5 years, hospitalised fracture incidences increased by 85% in Māori and 73% in non-Māori octogenarians. However, while fracture-related hospital nights increased by 107% in non-Māori, they remained stable for Māori. Hospitalised fracture risk increases markedly with 5 years of advanced ageing.

PURPOSE

Fractures become increasingly common in people beyond 80 years, the most serious resulting in hospitalisation. This study examines longitudinal changes in hospitalised fractures in octogenarians.

METHODS

Hospital discharge records from a cohort study of Māori aged 80-90 years and non-Māori turning 85 years (LiLACS NZ) were used to determine the incidence of hospitalised fractures for 5 years before and 5 years after enrolment.

RESULTS

Records were available for 378 Māori (aged 82.6 ± 2.8 years; mean ± SD) and 498 non-Māori (84.6 ± 0.5 years). In the 5 years prior to enrolment, 22 (5.8%) Māori and 43 (8.6%) non-Māori were hospitalised at least once for fracture, and 29 (7.7%) Māori and 62 (12.4%) non-Māori sustained hospitalised fractures in the 5 years following enrolment. Hospitalised fracture incidences were 1270/100,000 person-years in Māori and 2048/100,000 person-years in non-Māori before enrolment, increasing to 2345 (P = 0.02) and 3541 (P = 0.002) /100,000 person-years in the subsequent 5 years, respectively. Pelvis/femoral fractures accounted for almost half (47%) of fractures. Fracture-related hospital nights increased 107% in non-Māori (P < 0.0001), but remained stable for Māori, from before to after enrolment. Following enrolment, 21% of hospital nights spent by non-Māori women were fracture-related.

CONCLUSION

In octogenarians, hospitalised fracture risk increased markedly with 5 years of ageing, almost doubling fracture-related hospitalisation time in non-Māori but having little effect on time spent in hospital for Māori. Projections of fracture burden in advanced age need to consider rapidly changing risk with small increases in age and differences between demographic groups.

Preventing Falls in Older Adults After Upper Limb Fractures: A Scoping Review

OBJECTIVE

The objective was to identify and describe fall prevention strategies in upper limb fracture rehabilitation for older people using recent fall prevention guidelines as a standard.

METHODS

A systematic search was conducted in 9 electronic databases (PubMed/MEDLINE, EBSCOhost, Cochrane Library, Lilacs, SPORTDiscus, CINAHL, Web of Science, AgeLine, and SciELO), gray literature, and in bibliographic and citation searching of selected articles between May and December 2022 and updated between February and March 2024. Two independent reviewers screened citations for inclusion. Data extraction was performed by 1 reviewer and verified by a second reviewer. A frequency of strategies and content analysis syntheses were conducted.

RESULTS

A broad search strategy was used, initially identifying 25,945 articles and including 6 randomized clinical trials. The gray literature search identified 18 records. Five studies included forearm fractures, 1 upper limb fracture, and no study exclusively on rehabilitation after humerus fractures. None of the studies provided comprehensive multifactorial fall risk assessments to guide tailored interventions. Assessments mainly focused on gait and balance. Exercise was the most offered intervention alone or in combination with education. Exercise programs were aligned with recommendations to include progressive balance and functional exercises overall. However, the frequency of ≥3 times weekly was less frequently offered. The gray literature showed a lack of fall prevention-specific information after upper limb fractures and mostly called attention to fall prevention after hip fractures.

CONCLUSION

Upper limb fracture rehabilitation in older adults, considered at high risk of falling, did not include comprehensive and tailored multifactorial fall assessment and intervention. Unequivocally, exercise programs were overall aligned with recent recommendations and were the most frequent intervention. There is a crucial gap for humerus fractures. This study can help align the treatment of upper limb fractures with updated fall prevention recommendations and impact future research, guiding and influencing implementation in clinical practice.

IMPACT

There is an urgent need to implement comprehensive and tailored multifactorial fall assessments and interventions in rehabilitation programs for older adults recovering from upper limb fractures. Guidelines should direct this work to enhance clinical practice.

The Role of Temporal Bone Pneumatization on Fracture Line and Involved Cranial Structures

OBJECTIVE

Temporal bone pneumatization (TBP) is speculated to serve as a shock absorber in temporal bone fractures (TBF), directing the fracture line away from vital structures. This study correlates TBP extent with TBF patterns and preservations of vital TB structures.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral medical center.

METHODS

All TBF patients referred to a single tertiary center 2017 to 2023 were evaluated. A pneumatization index score for each of their TBs was derived by counting automated-voxel density in a 0 to 100 scale. Results were correlated to the TBF type and the violated structure(s). The ossification index was compared to previously detailed qualitative classification systems of TBP.

RESULTS

One hundred and forty-five patients were enrolled (mean age 43 ± 17 years). Kinematics were motor vehicle accidents (46%), scooter (15%), bicycle (14%), falls (13%), and assaults (8%). The mastoid ossification index we used showed a strong correlation to all qualitative classification systems (sigmoid = 0.829; labyrinthine = 0.849; carotis = 0.863, infralabyrinthine = 0.869, all P < .001). The pneumatization index strongly correlated with capsule-violating TBFs, with a mean of 44 ± 23 for otic capsule-sparing TBF and 61 ± 20 for otic capsule-violating (OCV) TBF (P < .001). The facial nerve was violated in 30 patients. Facial canal (FC) involvement was not correlated to the ossification index: it was 49 ± 23 for FC-sparing and 44 ± 23 for FC-violating (P = .620).

CONCLUSION

TBP serves as a protective mechanism against OCV TBF. The more pneumatized the TB, the less likely the otic capsule will be violated in the event of a TBF with the exception of the carotid and FCs. TBP index is in strong agreement with qualitative TBP classification systems.

Epidemiological characteristics of traumatic spinal fractures among the elderly in China

The exploration of traumatic spinal fractures (TSFs) within the senior demographic has not been thoroughly scrutinized, particularly with respect to variations across genders, age groups, seasonal periods, and causative factors. This retrospective analysis aimed to dissect differences in the prevalence and characteristics of TSFs among the elderly, factoring in gender, age, seasonal timing, and causation. A retrospective analysis was conducted on the medical and imaging records of 1,415 patients, all aged 60 years or older, who were diagnosed with TSFs from 2013 to 2019. This study categorized the data by gender, age groups (60-70, 70-80, and 80 years or older), seasons, and the cause of injuries, including road traffic crashes (RTCs), falls from low heights (LHF), falls from high heights (HHF), and injuries incurred during everyday activities and agricultural labor (DFI). Male patients exhibited notably higher incidences of RTCs, high-height falls (HHFs), outdoor incidents, comas post-injury, fractures of the lower limbs (LLFs), pelvic fractures (PFs), rib fractures (RFs), intra-thoracic injuries (ITIs), intra-abdominal injuries (IAIs), cervical fractures, and spinal cord injuries (SCIs). With advancing age, there was a marked decline in occurrences of RTCs, HHFs, outdoor incidents, RFs, craniocerebral injuries (CCIs), ITIs, cervical fractures, and SCIs, while the incidences of DFIs, indoor incidents, and thoracic and lumbar (T + L) fractures notably increased. During autumn, LLF occurrences were significantly reduced, whereas the winter season saw an increase in thoracic fractures. Spring time was associated with a higher frequency of lumbar fractures and noncontiguous spinal fractures (NSFs). Significant distinctions were observed in the age distribution, injury circumstances, associated injuries, and SCIs between high-energy impacts (RTCs and HHFs) and low-energy traumas (LHFs and DFIs). In the elderly demographic, TSFs exhibited discernible distinctions based on gender, age, seasonal variations, and etiological factors, impacting the nature and circumstances of injuries, associated traumas, complications, fracture sites, and the occurrence of SCIs.

Epidemiology of limb trauma interventions in France: Current state and future projections

CONTEXT

The distributions and projections of trauma, treated according to the anatomical region, have not been studied in France. The objectives of this study were to obtain French epidemiological data specific to trauma procedures in orthopedic surgery, as well as to establish a statistical trend on the evolution of medical and surgical procedures resulting from this, since 2013 and over the years to come. Our hypothesis was that an increasing trend in trauma procedures since 2013 exists, with an epidemiological forecast of a continuing increase over 50 years, mainly in the context of the management of osteoporotic fractures related to the ageing French population.

MATERIAL AND METHODS

We conducted a retrospective study using national data to obtain completion of procedures between the start of 2013 and the end of 2021.

RESULTS

From 2013 to 2021, we noted a total of 5,216,567 procedures related to orthopedic traumatology for an average of 579,618 procedures per year. We noted an overall increase in all procedures, continuing from 2013 to 2019, with an average annual increase of 1.125%. The most commonly performed procedure was osteosynthesis, with an average of 276,989 procedures per year. This was followed by wound sutures with an average of 185,023 procedures, orthopedic reductions of fractures and/or dislocations at an average of 62,960, then arthroplasties with 25,425 procedures per year, musculotendinous ruptures were 19,755 procedures per year, surgical reductions of fractures and/or dislocations represented 6920 procedures per year, and fasciotomies with 2848 procedures. From 2013 to 2021, there was an annual average of 276,989 osteosynthesis procedures. Open osteosynthesis, with an average of 146,547 procedures per year, represented 55% of osteosynthesis procedures. Fractures of the proximal end of the femur represented 79,549 procedures on average per year, including 46,621 (58%) involving the trochanter, while 32,852 (41%) were of the femoral neck. Wrist fractures accounted for an annual average of 55,300. Hand fractures represented an annual average of 38,444, of which 52.2% were closed (17,778). On average, 1000 fractures per year involved the carpus without scaphoid involvement, and 2177 scaphoid fractures. Ankle fractures represented 37,951 procedures on average per year, including 74% of the malleolar complex (28,199). Leg fractures represented 17,613 procedures per year, 58% tibial diaphysis (10,091), 41% tibial plateau (6,857). The strengths of this study are the exhaustiveness of the data, presenting all the Common Classification of Medical Procedures (CCAM) chosen during the defined period.

CONCLUSION

This study allowed us to establish, to our knowledge, the first epidemiological database of French orthopedic traumatology.

LEVEL OF EVIDENCE

IV; epidemiological descriptive study.

Targeted prophylactic anticoagulation based on the TRiP(cast) score in patients with lower limb immobilisation: a multicentre, stepped wedge, randomised implementation trial

BACKGROUND

Prophylactic anticoagulation in emergency department patients with lower limb trauma requiring immobilisation is controversial. The Thrombosis Risk Prediction for Patients with Cast Immobilisation-TRiP(cast)-score could identify a large subgroup of patients at low risk of venous thromboembolism for whom prophylactic anticoagulation can be safely withheld. We aimed to prospectively assess the safety of withholding anticoagulation for patients with lower limb trauma at low risk of venous thromboembolism, defined by a TRiP(cast) score of less than 7.

METHODS

CASTING was a stepped-wedge, multicentre, cluster-randomised trial with blinded outcome assessment. 15 emergency departments in France and Belgium were selected and randomly assigned staggered start dates for switching from the control phase (ie, anticoagulation prescription according to the physician's usual practice) to the intervention phase (ie, targeted anticoagulation according to TRiP(cast) score: no prescription if score <7 and anticoagulation if score was ≥7). Patients were included if they presented to a participating emergency department with lower limb trauma requiring immobilisation for at least 7 days and were aged 18 years or older. The primary outcome was the 3-month cumulative rate of symptomatic venous thromboembolism during the intervention phase in patients with a TRiP(cast) score of less than 7. The targeted strategy was considered safe if this rate was less than 1% with an upper 95% CI of less than 2%. The primary analysis was performed in the intention-to-treat population. This study is registered at ClinicalTrials.gov (NCT04064489).

FINDINGS

Between June 16, 2020, and Sept 15, 2021, 15 clusters and 2120 patients were included. Of the 1505 patients analysed in the intervention phase, 1159 (77·0%) had a TRiP(cast) score of less than 7 and did not receive anticoagulant treatment. The symptomatic venous thromboembolism rate was 0·7% (95% CI 0·3-1·4, n=8/1159). There was no difference between the control and the intervention phases in the cumulative rate of symptomatic venous thromboembolism or in bleeding rates.

INTERPRETATION

Patients with a TRiP(cast) score of less than 7 who are not receiving anticoagulation have a very low risk of venous thromboembolism. A large proportion of patients with lower limb trauma and immobilisation could safely avoid thromboprophylaxis.

FUNDING

French Ministry of Health.

Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture

Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.

Validity of distal radius fracture diagnoses in the Swedish National Patient Register

Distal radius fractures are one of the most common fractures in adults. More research is needed to establish evidence-based clinical practice guidelines to generate cost-effective and fair fracture treatment. The Swedish National Patient Register is a principal source for population-based epidemiologic studies in Sweden. The validity of some-but not all-diagnoses in the register is high. Little is known regarding the validity of registration of distal radius fractures.A dataset of cases registered with diagnosis of distal radius fracture (S52.5) or distal radius and ulna fracture (S52.6) were collected from the Swedish National Inpatient and Outpatient Registers. Six cohorts, each containing 240 simple random samples, were constructed. Radiographic reports and medical records were reviewed to confirm or reject the diagnosis as well as, in relevant cases, the surgical intervention. Positive predictive values (PPV) were calculated.The PPV for distal radius fracture in the register ranges between 92 and 100%, lower if coded as S52.6 and higher if there was an adherent code of surgical intervention. Codes for surgical intervention reached a PPV of 95-100%.In conclusion, the validity of the codes for diagnosis and the surgical treatment of distal radius fracture is high in the Swedish National Patient Register. According to our results, the register may be used as a reliable data source for population-based research of distal radius fractures.

Risk Factors of the 2-Year Mortality after Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture

Purpose

This study investigates the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), albumin, and 2-year mortality in elderly patients having hemiarthroplasty for displaced femoral neck fracture (FNF).

Materials and Methods

We retrospectively reviewed 284 elderly patients who underwent hemiarthroplasty for Garden type IV FNF from September 2014 to September 2020. Using the receiver operating characteristic curve, optimal cutoff values for LCR, NLR, and albumin were established, and patients were categorized as low or high. Associations with 2-year mortality were evaluated through univariate and multivariate Cox regression analyses.

Results

Of the 284 patients, 124 patients (45.9%) died within 2 years post-surgery. The optimal cutoff values were: LCR at 7.758 (specificity 58.5%, sensitivity 25.0%), NLR at 3.854 (specificity 39.2%, sensitivity 40.0%), and albumin at 3.750 (specificity 65.9%, sensitivity 21.9%). Patients with low LCR (<7.758), high NLR (≥3.854), and low albumin (<3.750) had a statistically significant reduced survival time compared to their counterparts.

Conclusion

Lower preoperative LCR and albumin levels, along with higher NLR, effectively predict 2-year mortality and 30-day post-surgery complications in elderly patients with Garden type IV FNF undergoing hemiarthroplasty.

Soft drinks, tea and coffee consumption in relation to risk of fracture: evidence from china health and nutrition survey

INTRODUCTION

To investigate the association between soft drinks, tea and coffee consumption, and risk of fracture in the China Health and Nutrition Survey.

MATERIALS AND METHODS

A cross-sectional study with multi-stage random cluster sampling was conducted in nine Chinese provinces in 2004, 2006, 2009 and 2011. A total of 36,740 participants were included the data analyses. Self-administered questionnaires and physical examinations provided data on beverages consumption, fracture history, and other potential risk factors. Binary logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for potentially confounding variables.

RESULTS

The prevalence of fracture increased over the 7-year period of the surveys, with 1833 (5.3%) participants reporting a fracture history. Soft drink consumption increased over this time period, and tea consumption was relatively stable, whereas coffee consumption tended to increase sharply. Consumers of soft drinks ≥ 3 times/week (versus never) had a higher risk of fracture (OR = 1.86, 95% CI = 1.43-2.32, p < 0.001, p for trend = 0.039). Consumers of tea ≥ 5 cups/day (versus never) also had a higher risk of fracture (OR = 1.21, 95% CI = 1.09-1.45, p = 0.028, p for trend < 0.001). Similarly, consumers of coffee ≥ 2 cups/day (versus never) had a higher risk of fracture (OR = 1.84, 95% CI = 1.01-3.34, p = 0.045, p for trend = 0.002). Subgroup analyses by gender suggested that coffee consumption increased risk of fracture in females (OR = 1.84, 95% CI = 1.32-2.63, p = 0.001).

CONCLUSION

Our findings suggest that high consumption of soft drinks, tea and coffee is associated with an increased risk of fracture in the Chinese population. Which has important public health implications given the widespread consumption of these beverages.

A nomogram model based on the combination of the systemic immune-inflammation index, body mass index, and neutrophil/lymphocyte ratio to predict the risk of preoperative deep venous thrombosis in elderly patients with intertrochanteric femoral fracture: a retrospective cohort study

OBJECTIVES

Deep vein thrombosis (DVT) has been considered as a frequent and serious consequence of intertrochanteric femoral fractures in the elderly. Several negative repercussions of DVT can be considerably mitigated by its timely recognition and treatment. The current work was aimed at exploring the factors independently predicting DVT among cases suffering from intertrochanteric femoral fractures and validate their predictive usefulness in diagnosing DVT.

METHODS

Between April 2017 and July 2022, clinical information from 209 cases showing preoperative DVT for femoral intertrochanteric fractures were retrospectively evaluated. In patients with femoral intertrochanteric fractures, logistic regression analysis with a backward stepwise method was adopted for detecting independent predictors for the diagnosis of preoperative DVT. Using multivariate logistic regression, a nomogram prediction model was developed and verified with the testing group.

RESULTS

According to multivariate logistic regression model, body mass index (BMI) (OR 0.79, 95% CI 0.63-0.99, P = 0.042), neutrophil/lymphocyte ratio (NLR) (OR 7.29, 95% CI 1.53, 34.64, P = 0.0012), and systemic immune-inflammation index (SII) (OR 6.61, 95% CI 2.35, 18.59, P = 0.001) were independent predictors for DVT before surgery among cases developing intertrochanteric femoral fracture. AUC values were 0.862 and 0.767 for training and testing groups, separately, while their mean errors in the calibration curve were 0.027 and 0.038 separately. Decision curve analysis (DCA) curve revealed a high value of clinical application for both groups.

CONCLUSION

Upon admission, BMI, NLR, and SII are independent predictors of DVT before surgery among cases developing intertrochanteric femoral fractures. Additionally, the nomogram based on the BMI, NLR, and SII can assist clinicians in determining if preventive and symptomatic therapies are required to improve DVT prognosis and reduce its associated mortality.

Incidence and risk factors of admission deep venous thrombosis in nonagenarians and centenarians with intertrochanteric fracture: a retrospective study

PURPOSE

The objective of this study was to identify the risk factors for admission deep venous thrombosis (aDVT) and proximal aDVT in nonagenarians and centenarians with intertrochanteric fracture (IF).

METHODS

We collected statistics on nonagenarians and centenarians with IF admitting from January 2010 to October 2022. Patients with aDVT were considered as the aDVT group and those without aDVT as the non-aDVT group. Additionally, we also conducted a subgroup analysis based on the location of aDVT to investigate the predictors of proximal aDVT. The demographics, comorbidities and admission laboratory examinations of patients were computed by univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

RESULTS

In our study, the rate of aDVT (109 of 318) was 34.3%, and 5.7% (18 of 318) of patients had proximal aDVT. Logistic regression analysis showed that female patients and a high level of D-dimer were risk factors for aDVT. Similarly, hypoproteinemia and a high level of D-dimer were found to be risk factors for proximal aDVT. ROC curve analysis indicated the cut-off values of D-dimer to predict the aDVT and proximal aDVT were 1.28 mg/L and 1.485 mg/L, respectively.

CONCLUSIONS

Our findings investigated the risk factors of aDVT and proximal aDVT in nonagenarians and centenarians with IF and identified the cut-off values of D-dimer, helping us assess the risk of aDVT and proximal aDVT to manage early targeted interventions.

Bone Turnover Markers: Basic Biology to Clinical Applications

Bone turnover markers (BTMs) are used widely, in both research and clinical practice. In the last 20 years, much experience has been gained in measurement and interpretation of these markers, which include commonly used bone formation markers bone alkaline phosphatase, osteocalcin, and procollagen I N-propeptide; and commonly used resorption markers serum C-telopeptides of type I collagen, urinary N-telopeptides of type I collagen and tartrate resistant acid phosphatase type 5b. BTMs are usually measured by enzyme-linked immunosorbent assay or automated immunoassay. Sources contributing to BTM variability include uncontrollable components (e.g., age, gender, ethnicity) and controllable components, particularly relating to collection conditions (e.g., fasting/feeding state, and timing relative to circadian rhythms, menstrual cycling, and exercise). Pregnancy, season, drugs, and recent fracture(s) can also affect BTMs. BTMs correlate with other methods of assessing bone turnover, such as bone biopsies and radiotracer kinetics; and can usefully contribute to diagnosis and management of several diseases such as osteoporosis, osteomalacia, Paget's disease, fibrous dysplasia, hypophosphatasia, primary hyperparathyroidism, and chronic kidney disease-mineral bone disorder.

Low lymphocyte-to-C-reactive protein ratio relates to high 1-year mortality in elderly patients undergoing hemiarthroplasty for displaced femoral neck facture

OBJECTIVE

Lymphocyte-to-C-reactive protein (CRP) ratio (LCR) is a novel biomarker for predicting poor prognosis in many diseases. This study aims to analyze the association between preoperative LCR and 1-year mortality in elderly patients with displaced FNF undergoing hemiarthroplasty.

METHODS

Between May 2017 and May 2019, a retrospective study including 364 elderly patients undergoing hemiarthroplasty for displaced FNF was performed. LCR was defined as the ratio of preoperative lymphocyte count to CRP level. The optimal cutoff value of LCR was determined by receiver operating characteristic curve, and all patients were categorized into low-LCR group and high-LCR group accordingly. The relationship between LCR and 1-year mortality was evaluated by using univariate and multivariate Cox regression analysis. Furthermore, the complications within 30 days after surgery, length of hospital stay, and perioperative red blood cell transfusion were also analyzed stratified by LCR.

RESULTS

A total of 47 patients (12.9%) died within 1-year follow-up after surgery. The optimal cutoff value for LCR was 30,560 (specificity 76.6% and sensitivity 63.4%). Low-LCR (≤ 30,560) group had a higher mortality rate than high-LCR group (23.53% vs. 5.21%, P < 0.001). In multivariate analysis, low LCR, hypoalbuminemia, and Age-Adjusted Charlson Comorbidity Index ≥ 6 were identified as independent predictors for 1-year mortality. Moreover, low level of LCR was associated with high rate of total complications (19.6% vs. 11.4%, P = 0.029), perioperative transfusions (37.9% vs. 27.0%, P = 0.027), and longer hospital stay (7.84 ± 2.40 vs. 7.30 ± 2.32, P = 0.031).

CONCLUSIONS

The low level of preoperative LCR can effectively predict 1-year mortality and 30-day total complications after surgery in elderly patients with displaced FNF undergoing hemiarthroplasty.

Multiscale Femoral Neck Imaging and Multimodal Trabeculae Quality Characterization in an Osteoporotic Bone Sample

Although multiple structural, mechanical, and molecular factors are definitely involved in osteoporosis, the assessment of subregional bone mineral density remains the most commonly used diagnostic index. In this study, we characterized bone quality in the femoral neck of one osteoporotic patients as compared to an age-matched control subject, and so used a multiscale and multimodal approach including X-ray computed microtomography at different spatial resolutions (pixel size: 51.0, 4.95 and 0.9 µm), microindentation and Fourier transform infrared spectroscopy. Our results showed abnormalities in the osteocytes lacunae volume (358.08 ± 165.00 for the osteoporotic sample vs. 287.10 ± 160.00 for the control), whereas a statistical difference was found neither for shape nor for density. The osteoporotic femoral head and great trochanter reported reduced elastic modulus (Es) and hardness (H) compared to the control reference (−48% (p < 0.0001) and −34% (p < 0.0001), respectively for Es and H in the femoral head and −29% (p < 0.01) and −22% (p < 0.05), respectively for Es and H in the great trochanter), whereas the corresponding values in the femoral neck were in the same range. The spectral analysis could distinguish neither subregional differences in the osteoporotic sample nor between the osteoporotic and healthy samples. Although, infrared spectroscopic measurements were comparable among subregions, and so regardless of the bone osteoporotic status, the trabecular mechanical properties were comparable only in the femoral neck. These results illustrate that bone remodeling in osteoporosis is a non-uniform process with different rates in different bone anatomical regions, hence showing the interest of a clear analysis of the bone microarchitecture in the case of patients’ osteoporotic evaluation.

Effect of Age on the Patterns of Traumatic Femoral Fractures: Seven Years of Experience at a Regional Tertiary Hospital

Objective

Femoral fractures are a common cause of mortality and functional loss, mainly among older people, and there are few studies about the age in relation to traumatic femoral fractures. The aim of this study was to investigate the effect of age on the patterns of traumatic femoral fractures in patients presenting to our regional tertiary hospital.

Methods

The records of 2020 patients who presented with traumatic femoral fractures between 2013 and 2019 were retrospectively reviewed. The patients' clinical and radiographic records were reviewed. Univariate and multivariable logistic regression were used to identify independent risk factors for associated injuries and complications.

Results

The patients were divided into a child group (CH group, n = 342) aged under 18 years, a young adult group (YA group, n = 484) aged 18–60 years, and an older people group (OP group, n = 1194) aged 60 years and over. There were significant differences among the three groups in several indexes, such as sex ratio (χ² = 301.699, p < 0.001), osteoporosis (χ² = 375.463, p < 0.001), injury time of day (χ² = 114.913, p < 0.001), injury cause (χ² = 748.187, p < 0.001), injury location (χ² = 490.153, p < 0.001), fracture side (χ² = 57.000, p < 0.001), fracture site (χ² = 806.650, p < 0.001), associated injuries (χ² = 322.921, p < 0.001), coma after injury (χ² = 147.814, p < 0.001), non‐surgery‐related complications (χ² = 7.895, p = 0.019), and surgery‐related complications (χ² = 82.186, p < 0.001). The YA group had a significantly higher percentage of patients with surgery‐related complications than the OP group. The OP group had a higher frequency of non‐surgery‐related complications than the YA group and CH group. The most common non‐surgery‐related complications were pneumonia (7.1%) in the OP group and deep venous thrombosis (6.4%) in the YA group. Multivariable logistic regression showed that young adults, high‐energy injury, outdoors, coma after injury, and fracture sites except for the proximal region were independent risk factors for associated injuries. Older age, male, and fracture site except for the proximal region were independent risk factors for complications.

Conclusions

Traumatic femoral fractures are mostly the result of low‐energy trauma and predominantly affect the proximal site of the femur among older people. A higher rate of shaft fractures, fractures occurring outdoors, and associated injuries were observed among young adults and children than among older people.

Collecting data on fractures: a review of epidemiological studies on orthopaedic traumatology and the Chinese experience in large volume databases

PURPOSE

This study aimed to review the epidemiological studies on orthopedic traumatology and the Chinese experience in large volume databases of fractures.

METHODS

Review of international and Chinese literature.

RESULTS

Traumatic fractures are associated with high risks of death and disability worldwide, thus increasing financial burden on affected families and society. In the current study, epidemiological surveys on fractures around the world were reviewed to explore distribution and types of fractures in different populations. Different populations exhibit heterogeneity in the type, incidence of traumatic fractures, and the underlying causes and severity of fractures. Fracture epidemiology has strengthened clinical practice and increased understanding of the causes and patterns of fracture occurrence. Fracture and trauma epidemiological studies provide findings for use in public health education and data that can be used to develop targeted prevention intervention strategies by health departments.

CONCLUSION

The current study summarized the worldwide epidemiological studies on orthopedic traumatology. The findings of this study will provide a basis for designing effective methods for fracture prevention and management.

Comparison of the Effect of Rhombic and Inverted Triangle Configurations of Cannulated Screws on Internal Fixation of Nondisplaced Femoral Neck Fractures in Elderly Patients

Objective

To investigate whether four‐screw fixation in rhombic configuration could improve the clinical outcomes and decrease the complication rate compared with three‐screw fixation in inverted triangle configuration in elderly patients with nondisplaced femoral neck fractures.

Method

From January 2018 to January 2019, 91 elderly patients with nondisplaced femoral neck fractures who were treated with a cannulated screw system were reviewed retrospectively. The inverted triangle configuration was applied in 51 patients and rhombic configuration in 40 patients. The demographic and perioperative information of the patients were extracted from medical records and surgical records. Variables including incision size, surgical blood loss, surgical time, fluoroscopy time, hospital stays, fracture union time, postoperative visual analogue scale (VAS) scores, and complications were compared between the two groups. Also, Harris hip score at the final follow‐up was used to evaluate the functional outcomes.

Results

All patients were followed up from 24 to 36 months, with an average of 29.75 months. The average age of patients was 72.37 ± 7.16 years. No significant differences were found between the two groups with regard to patients' age, gender, affected side, Garden classification, Pauwels classification and comminution of posterior wall (P > 0.05). We found shorter incision size (P < 0.001), less blood loss (P = 0.020), less surgical time (P = 0.026), and shorter fluoroscopy time (P < 0.001) in inverted triangle configuration group. However, shorter hospital stays (P = 0.001) and fracture union time (P = 0.002) were found in the rhombic configuration group. The VAS scores were lower in the rhombic configuration group at the first (P < 0.001) and third months (P = 0.010), but no significant difference was found at the sixth month (P = 0.075). Meanwhile, the total complication rate was relatively lower in the rhombic configuration group compared to the inverted triangle configuration group (P = 0.041). Harris hip score presented no significant difference between the two groups at final follow‐up (P = 0.078). No wound infection or cortical perforation occurred in either group.

Conclusion

Four‐screw fixation in rhombic configuration was superior to three‐screw fixation in inverted triangle configuration in the treatment of nondisplaced femoral neck fractures in elderly patients in terms of less early postsurgical pain, shorter fracture union time, and lower complication rate.

Assessment of Bone Microarchitecture in Fresh Cadaveric Human Femurs: What Could Be the Clinical Relevance of Ultra-High Field MRI

MRI could be applied for bone microarchitecture assessment; however, this technique is still suffering from low resolution compared to the trabecular dimension. A clear comparative analysis between MRI and X-ray microcomputed tomography (μCT) regarding microarchitecture metrics is still lacking. In this study, we performed a comparative analysis between μCT and 7T MRI with the aim of assessing the image resolution effect on the accuracy of microarchitecture metrics. We also addressed the issue of air bubble artifacts in cadaveric bones. Three fresh cadaveric femur heads were scanned using 7T MRI and µCT at high resolution (0.051 mm). Samples were submitted to a vacuum procedure combined with vibration to reduce the volume of air bubbles. Trabecular interconnectivity, a new metric, and conventional histomorphometric parameters were quantified using MR images and compared to those derived from µCT at full resolution and downsized resolutions (0.102 and 0.153 mm). Correlations between bone morphology and mineral density (BMD) were evaluated. Air bubbles were reduced by 99.8% in 30 min, leaving partial volume effects as the only source of bias. Morphological parameters quantified with 7T MRI were not statistically different (p > 0.01) to those computed from μCT images, with error up to 8% for both bone volume fraction and trabecular spacing. No linear correlation was found between BMD and all morphological parameters except trabecular interconnectivity (R2 = 0.69 for 7T MRI-BMD). These results strongly suggest that 7T MRI could be of interest for in vivo bone microarchitecture assessment, providing additional information about bone health and quality.

Bioinspired design proposal for a new external bone fixator device

The article presents a new medical device through an authorial and interdisciplinary approach. It consists of a flexible external fixator, whose flexible property may bring advantages over rigid mechanisms. Its design was inspired by the DNA biological mechanism of condensation, while the modeling was based on the pseudo-rigid modeling technique. From the models obtained, this study conducted prototyping and computational tests to obtain a proof-of-concept of the bioinspired theory and dynamic functioning effectiveness. The prototyping relied on hot glue manufacturing and the computational simulations consisted of linear static analysis. The experimental analysis concluded that the prototype with fewer beams and thinner beams delivered better results in all three parameters: flexibility, height variation and rotation arc. In the computational analysis, among the design models with the variation of the number of beams, the model with 8 beams performed better. Concerning thickness variation, the one whose beams measured 8mm in thickness showed better results. Among the models with length variation, the design made with 100 mm long beams better equilibrated the parameters.

Bisphosphonate Use and Hospitalization for Hip Fractures in Women: An Observational Population-Based Study in France

Bisphosphonates are widely used in the treatment of women at risk of osteoporotic hip fracture; however, the overall effectiveness of bisphosphonates in the prevention of osteoporotic fractures has not been studied in real life. To investigate whether the use of bisphosphonates in women aged 50 years and over is associated with a decrease in hospitalization for osteoporotic hip fractures, a historical prospective cohort study was conducted between 2009 and 2016 from a permanent representative sample consisting of 1/97 of the French health insurance beneficiaries. Bisphosphonate use was defined according to medication persistence and adherence regarding bisphosphonate dispensations. The primary outcome was the hospitalization rate for osteoporotic hip fracture. Among the 81,268 women included, 2005 were exposed to bisphosphonates. The median time of bisphosphonate exposure was 12 (IQR, 3–29) and 17 (IQR, 5–42) months for the persistence and adherence definitions, respectively. Exposure to bisphosphonates was not associated with a decrease in hospitalization for hip fracture: weighted HRadherence = 0.66 (95% CI, 0.33 to 1.33); HRpersistance = 0.77 (95% CI, 0.38 to 1.57). In real life, bisphosphonate use does not appear to reduce hospitalization for hip fractures, as to date, it is probably prescribed as primary prevention and for a duration too short to be effective.

Preoperative deep venous thrombosis (DVT) after femoral neck fracture in the elderly, the incidence, timing, location and related risk factors

Objective

To investigate the epidemiologic characteristics of deep venous thrombosis (DVT) in elderly patients with femoral neck fracture.

Methods

Retrospective analysis was performed on elderly patients with femoral neck fractures admitted to two institutions from January 2016 to October 2019. Duplex ultrasonography (DUS) was used to detect DVT. Patients’ hospitalization medical records were retrieved to collect the data, which were related to demographics, comorbidities, injury and laboratory results on admission. Patients with preoperative DVT were defined as the case group and those without DVT as control group, and compared using the univariate analyses. Multivariate logistic regression analysis was used to identify the independent factors associated with DVT.

Results

Totally, 980 patients met the predefined criteria and were included. Sixty-seven patients were diagnosed to have preoperative DVT, with incidence of 6.8% for overall, 1.7% for proximal and 5.1% for distal DVT. The mean time from injury to diagnosis of DVT was 6.0 ± 4.7 days (median, 5.0). Most (76.1%) patients with DVT had thrombi solely in the injured extremity, in contrast with 14.9% (10/67) in the uninjured and 9.0% (6/67) in both injured and uninjured extremity. Multivariate analysis showed chronic renal insufficiency (OR, 3.37; 95%CI, 1.57 to 7.28), current smoking status (OR, 2.42; 95%CI, 1.23 to 5.63), time from injury to DUS (OR, 1.26; 95%CI, 1.07 to 1.61) and PLT > 220*10⁹/L (OR, 1.94; 95%CI, 1.31 to 3.77) were independent factors for DVT.

Conclusion

Preoperative DVT is not very prevalent following elderly femoral neck fractures, but with a certain proportion in the uninjured extremity, necessitating the more attention. These identified risk factors aid in patient counseling, individualized risk assessment and risk stratification, and should be kept in mind.

Admission deep venous thrombosis of lower extremity after intertrochanteric fracture in the elderly: a retrospective cohort study

Objective

The purpose of this study was to investigate the incidence, location, and related factors of deep venous thrombosis (DVT) of the bilateral lower extremities after intertrochanteric fractures in the elderly.

Methods

Retrospective analysis was performed on the elderly patients with intertrochanteric fracture who were admitted from January 2017 to December 2019. At admission, patients receive routine ultrasound Doppler scanning of bilateral lower extremities to detect DVT; those with DVT were assigned to the case group and those without DVT to the control group. Patient data on demographics, comorbidities, injury-related data, and laboratory test results at admission were extracted. Logistic regression analyses were conducted to identify the independent risk factors associated with DVT.

Results

Five hundred seventy-eight patients were included, among whom 116 (20.1%) had DVT. Among those with DV, 70.7% (82/116) had DVT of the distal type, 24 (29.6%) had DVT of the proximal type, and 10 (10.4%) had mixed DVT. In 76.7% (89/116) of patients, DVT occurred in the fractured extremity, 9.5% (11/116) in the bilateral and 13.8% (16/116) in the non-fractured extremity. Multivariate analyses identified obesity, delay to admission, increased D-dimer level (> 1.44 mg/L) and reduced albumin (< 31.7 g/L) as independent factors.

Conclusions

Admission incidence of DVT was high in elderly patients with intertrochanteric fractures, especially the proximal DVT. Identification of associated risk factors is useful for individualized assessment risk of DVT and early targeted interventions.

SCALPEL3: A scalable open-source library for healthcare claims databases

OBJECTIVE

This article introduces SCALPEL3 (Scalable Pipeline for Health Data), a scalable open-source framework for studies involving Large Observational Databases (LODs). It focuses on scalable medical concept extraction, easy interactive analysis, and helpers for data flow analysis to accelerate studies performed on LODs.

MATERIALS AND METHODS

Inspired from web analytics, SCALPEL3 relies on distributed computing, data denormalization and columnar storage. It was compared to the existing SAS-Oracle SNDS infrastructure by performing several queries on a dataset containing a three years-long history of healthcare claims of 13.7 million patients.

RESULTS AND DISCUSSION

SCALPEL3 horizontal scalability allows handling large tasks quicker than the existing infrastructure while it has comparable performance when using only a few executors. SCALPEL3 provides a sharp interactive control of data processing through legible code, which helps to build studies with full reproducibility, leading to improved maintainability and audit of studies performed on LODs.

CONCLUSION

SCALPEL3 makes studies based on SNDS much easier and more scalable than the existing framework [1]. It is now used at the agency collecting SNDS data, at the French Ministry of Health and soon at the National Health Data Hub in France [2].