Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up

Alcohol and drug use in adults younger than 60 years with hip fracture - A comparison of validated instruments and the clinical eye: A prospective multicenter cohort study of 218 patients

BACKGROUND

It is a common preconception that young individuals sustaining hip fractures have alcohol and/or drug use disorder. It is important to evaluate the actual use to avoid complications and plan the rehabilitation.

AIM

The primary objective was to assess alcohol and drug consumption in hip fracture patients <60 years using the validated Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT) scores. We secondarily investigated the agreement between the instruments and the physicians' clinical evaluation of usage.

MATERIAL AND METHODS

This is a sub-study of 91 women and 127 men from a multicenter cohort study of patients with an acute hip fracture treated at four hospitals in Denmark and Sweden. AUDIT and DUDIT forms were completed by the patients. In addition, the researchers made an evaluation of the patients' alcohol/drug use based on direct patient contact and information on previous alcohol/drug use from medical charts. AUDIT ranges 0-40 with 6 (women) and 8 (men) as the cut-off for hazardous use. DUDIT ranges 0-44 with cut-offs of 2 and 6 indicating drug-related problems.

RESULTS

According to the AUDIT, 29 % of the patients had a hazardous alcohol use (25 % women, 31 % men), whilst the clinical evaluation identified 26 % (24 % women, 28 % men). However, there was a low agreement between "the clinical eye" and AUDIT, as the clinical evaluation only correctly identified 35 of 56 individuals with AUDIT-scores indicating hazardous alcohol use. DUDIT equaled drug related problems in 8 % (5 % women, 10 % men), the clinical evaluation depicted 8 % with drug related problems (4 % women, 10 % men). The agreement was low between "the clinical eye" and DUDIT; only 7 of 15 with DUDIT-scores indicating drug related problems were correctly identified.

CONCLUSION

Hazardous alcohol consumption is more common in non-elderly hip fracture patients than in the general population. Considering both self-reported alcohol use and clinical evaluation, women have almost as high rate as men. DUDIT indicated drug related problems to be slightly more common than in the population. Still, a majority did not exhibit troublesome use of neither alcohol nor drugs. The two screening methods do not identify the same individuals, and further investigation in clinical practice is needed.

[Electric scooter-associated orthopedic injuries cause long absence from work, regret and are emerging as a major cause of hip fractures in young individuals: a comprehensive study from a regional trauma center in a densely populated urban setting]

PURPOSE

This study aimed to give a full spectrum of orthopedic injuries associated with electric scooter (e-scooter) use and analyze related factors, report on follow-up data from the patient's perspective and make a comparative etiological analysis of young adult hip fractures.

METHODS

A total of 851 consecutive patients were admitted to the Emergency Department following e‑scooter injuries between January 2021 and July 2022, of whom 188 had 214 orthopedic injuries. The demographics, injury, and incident characteristics of these patients were collected. All fractures were classified as per the AO/OTA classification. Two groups were created as operatively or conservatively treated patients and data were comparatively analyzed. Follow-up examination incorporated a survey using binary questions on patients' perspectives. An etiological comparative analysis of hip fractures in young adults admitted to the same center between 2016 and 2022 was conducted.

RESULTS

The median patient age was 25. Inexperienced drivers constituted 32% of the injured. The protective gear use rate was at 3%. Higher speed (p = 0.014) and age (p = 0.011) were significantly associated with operative treatment. A total of 39% of the operated patients could not return to preinjury physical function, while 74% regretted using an e‑scooter. The most common etiological factor for traumatic young hip fractures was fall from a height between 2016 and 2020, whereas it became e‑scooter accidents in 2021-2022.

CONCLUSION

The rate of e‑scooter-related operative treatment is high and leaves the patient in regret (84%) and a physically limited condition (39%). A speed limit of ≤ 15 km/h could decrease the rate of operative injuries. The e‑scooter was identified as the top etiological factor in the last 2 years for traumatic young hip fractures.

LEVEL OF EVIDENCE

II, Diagnostic cohort study.

Hand Grip Strength, Osteoporosis, and Quality of Life in Middle-Aged and Older Adults

Background and Objectives: Hand grip strength (HGS) and osteoporosis are known to be closely related to the health condition of the elderly, respectively. Comprehensive studies including adults over middle age were insufficient. This study aimed to investigate the relationship between HGS with osteoporosis and health-related quality of life (HRQoL) in adults aged >40 years. Materials and Methods: This cross-sectional analysis included data from 13,966 people aged >40 years between 2015 to 2018 provided by the Korea National Health and Nutrition Examination Survey. The HGS was divided into strong and weak quartiles, defined as the highest and lowest quartiles, respectively. We used the European Quality of Life Scale-Five dimensions (EQ-5D) for HRQoL. We performed multiple logistic regression and post hoc analysis to confirm the relationship between the four groups and HRQoL. Results: Osteoporotic patients with weak HGS showed the lowest EQ-5D index (0.87 ± 0.01) among all groups and had a significantly impaired HRQoL in all EQ-5D dimensions, at least 1.75 times more than healthy individuals with strong HGS (0.95 ± 0.00). Osteoporotic patients with weak HGS showed, notably, 2.68 times more impaired mobility compared to healthy individuals with strong HGS among all five dimensions of the EQ-5D. In self-care, significant sex differences in impaired HRQoL were observed (males 6.03, 2.23-16.35; females 2.51, 1.70-3.71). Conclusions: Weak HGS and the presence of osteoporosis were associated with low HRQoL, respectively. Middle-aged and older adults with both weak HGS and osteoporosis showed poorer HRQoL compared to healthy middle-aged and older adults. This suggests that HGS is a possible factor for predicting poor HRQoL in adults aged >40 years with or without osteoporosis. It is necessary to assess the risk of low HRQoL by measuring HGS and confirming whether osteoporosis is accompanied in adults over middle age.

Electric scooter-associated orthopedic injuries cause long absence from work, regret and are emerging as a major cause of hip fractures in young individuals: a comprehensive study from a regional trauma center in a densely populated urban setting

PURPOSE

This study aimed to give a full spectrum of orthopedic injuries associated with electric scooter (e-scooter) use and analyze related factors, report on follow-up data from the patient's perspective and make a comparative etiological analysis of young adult hip fractures.

METHODS

A total of 851 consecutive patients were admitted to the Emergency Department following e-scooter injuries between January 2021 and July 2022, of whom 188 had 214 orthopedic injuries. The demographics, injury, and incident characteristics of these patients were collected. All fractures were classified as per the AO/OTA classification. Two groups were created as operatively or conservatively treated patients and data were comparatively analyzed. Follow-up examination incorporated a survey using binary questions on patients' perspectives. An etiological comparative analysis of hip fractures in young adults admitted to the same center between 2016 and 2022 was conducted.

RESULTS

The median patient age was 25. Inexperienced drivers constituted 32% of the injured. The protective gear use rate was at 3%. Higher speed (p = 0.014) and age (p = 0.011) were significantly associated with operative treatment. A total of 39% of the operated patients could not return to preinjury physical function, while 74% regretted using an e-scooter. The most common etiological factor for traumatic young hip fractures was fall from a height between 2016 and 2020, whereas it became e-scooter accidents in 2021-2022.

CONCLUSION

The rate of e-scooter-related operative treatment is high and leaves the patient in regret (84%) and a physically limited condition (39%). A speed limit of ≤ 15 km/h could decrease the rate of operative injuries. The e-scooter was identified as the top etiological factor in the last 2 years for traumatic young hip fractures.

LEVEL OF EVIDENCE

II, Diagnostic cohort study.

Lingering challenges in everyday life for adults under age 60 with hip fractures - a qualitative study of the lived experience during the first three years

PURPOSE

We aimed to illuminate the lived experiences and the path of recovery for adults sustaining a hip fracture before the age of 60.

METHODS

Participants were purposively sampled from a prospective multicenter cohort study in Sweden and Denmark, and narrative interviews were conducted with 19 individuals 0.7-3.5 years after the fracture. We used a phenomenological hermeneutic method to describe the participants' expressed essential meaning.

RESULTS

The experience of sustaining a hip fracture was expressed as a painful and protracted process of regaining self-confidence, function, and independence. It also implied a sense of growing old from one day to the next. Participants were afraid of new falls and fractures, resulting in an increased wariness. When expressing fears and persisting symptoms, participants described being neglected and marginalized by the healthcare system, which was perceived as non-receptive and routinely driven by a notion that hip fractures affect only the elderly. Rehabilitation targeted towards needs different from those of elderly individuals was requested.

CONCLUSION

The lived experience of sustaining a hip fracture in individuals under 60 includes substantial challenges in everyday life, even up to 3.5 years after the injury. Rehabilitation pathways tailored to the needs of younger patients are requested.

Development and validation of risk prediction nomograms for acute respiratory failure in elderly patients with hip fracture

BACKGROUND

Hip fractures in the elderly often lead to acute respiratory failure, but there is currently no tool to assess the prognosis of such patients. This study aims to develop a risk prediction model for respiratory failure in these patients.

METHODS

A retrospective cross-sectional study was conducted using the Medical Information Mart for Intensive Care (MIMIC)-IV database, incorporating data from 3,266 patients with hip fractures aged over 55 years from 2008 to 2019. Data included demographic information, laboratory indicators, comorbidities, and treatment methods. Patients were divided into a training group (70%) and a validation group (30%). Least Absolute Shrinkage and Selection Operator (LASSO) regression was applied to select prognostic predictors, and a visualized nomogram model was constructed using multivariate logistic regression analysis. Model performance and clinical applicability were assessed. Statistical analyses were done using R4.2.2, with P < 0.05 deemed significant.

RESULTS

Seven key factors, including age, height, albumin, chloride, pneumonia, acute kidney injury (AKI), and heparin use, were associated with respiratory failure risk. The model demonstrated good performance with area under the curve (AUC) values of 0.77 and 0.73 in the training and validation sets, respectively. The calibration curve showed good agreement, and decision curve analysis (DCA) indicated the model's clinical benefit.

CONCLUSIONS

This risk prediction model can effectively predict respiratory failure in hip fracture patients, assisting clinicians in identifying high-risk individuals and providing evidence-based references for treatment strategies.

Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: a nationwide study

This study evaluated the incidence rates and societal burden of hip fractures in The Netherlands. Although incidence in the elderly population is decreasing and hospital stay is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

PURPOSE

The aim of this nationwide study was to provide an overview of the incidence rate and economic burden of acute femoral neck and trochanteric fractures in The Netherlands.

METHODS

Data of patients who sustained acute proximal femoral fractures in the period January 1, 2000, to December 31, 2019, were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), health care and lost productivity costs, and years lived with disability (YLD) were calculated for age- and sex-specific groups.

RESULTS

A total of 357,073 patients were included. The overall incidence rate increased by 22% over the 20-year study period from 16.4 to 27.1/100,000 person-years (py). The age-specific incidence rate in elderly > 65 years decreased by 16% (from 649.1 to 547.6/100,000 py). The incidence rate in men aged > 90 has surpassed the incidence rate in women. HLOS decreased in all age groups, hip fracture subtypes, and sexes from a mean of 18.5 to 7.2 days. The mean health care costs, over the 2015-2019 period, were lower for men (€17,723) than for women (€23,351) and increased with age to €26,639 in women aged > 80. Annual cumulative costs reached €425M, of which 73% was spent on women.

CONCLUSION

The total incidence of hip fractures in The Netherlands has increased by 22%. Although incidence in the elderly population is decreasing and HLOS is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

Physical activity in young hip fracture patients is associated with health-related quality of life and strength; results from a multicenter study

BACKGROUND

The World Health Organization recommends a minimum of 150 min of moderate intensity exercise per week or 75 min of strenuous activity weekly for adults. Younger hip fracture patients are often assumed less active than the general population, however, knowledge on physical activity (PA) and health-related quality of life (HRQoL) in younger hip fracture patients is limited.

OBJECTIVES

We aimed to 1) investigate the variation in pre-fracture PA for adult patients with hip fractures under the age of 60; and 2) to quantify the association with patient characteristics, including outcomes of HRQOL and handgrip strength.

DESIGN AND METHODS

A prospective multicenter cohort study of 207 adult hip fracture patients under 60 years admitted to four study hospitals from July 2015 to December 2018. Data was collected through medical records, questionnaires, physical tests and interviews. PA level was assessed using a validated questionnaire from the Swedish National Board of Health and Welfare, providing a total score from 3 to 19. A score ≥11 corresponds to fulfillment of the WHO recommendation for weekly PA. Handgrip strength was measured in kilograms using a handheld dynamometer following a standardized protocol. Recall pre-fracture HRQoL was assessed using the EQ-5D-3L questionnaire.

RESULTS

Fifty-nine percent had a PA score ≤10 out of these 46% had an ASA grade of 3 or 4, 38% had a BMI over 25 and 81% had a low energy fracture. A PA score ≤10 was associated with a lower HRQoL compared to those who had a PA score ≥11. PA score ≤10 points was associated with weaker hand grip strength and a worse health status (higher ASA-grade) p<0.001.

CONCLUSION

We found that close to two-thirds of the patients had a pre-fracture PA level below WHO recommendations. Being more active was associated with better handgrip strength, HRQoL, and ASA score. Our findings indicate that individuals under 60 years who sustain a hip fracture form a heterogeneous group, some severely comorbid and others highly active and seemingly healthy. This suggests a more nuanced approach to rehabilitation, as the more active patient might need a more individualized plan than the standard program can offer.

Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures

PURPOSE

This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device.

METHODS

Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively.

RESULTS

Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram.

CONCLUSION

A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.

Longitudinal Associations of High-Volume and Vigorous-Intensity Exercise With Hip Fracture Risk in Men

Maintenance of vigorous exercise habits from young to old age is considered protective against hip fractures, but data on fracture risk in lifelong vigorous exercisers are lacking. This longitudinal cohort study examined the hazard of hip fractures in 1844 male former athletes and 1216 population controls and in relation to exercise volume and intensity in later years. Incident hip fractures after age 50 years were identified from hospital discharge register from 1972 to 2015. Exercise and covariate information was obtained from questionnaires administered in 1985, 1995, 2001, and 2008. Analyses were conducted using extended proportional hazards regression model for time-dependent exposures and effects. During the mean ± SD follow-up of 21.6 ± 10.3 years, 62 (3.4%) athletes and 38 (3.1%) controls sustained a hip fracture. Adjusted hazard ratio (HR) indicated no statistically significant difference between athletes and controls (0.84; 95% confidence interval [CI], 0.55-1.29). In subgroup analyses, adjusted HRs for athletes with recent high (≥15 metabolic equivalent hours [MET-h]/week) and low (<15 MET-h/week) exercise volume were 0.83 (95% CI, 0.46-1.48) and 1.04 (95% CI, 0.57-1.87), respectively, compared with controls. The adjusted HR was not statistically significant between athletes with low-intensity exercise (<6 METs) and controls (1.08; 95% CI, 0.62-1.85). Athletes engaging in vigorous-intensity exercise (≥6 METs at least 75 minutes/week) had initially 77% lower hazard rate (adjusted HR 0.23; 95% CI, 0.06-0.86) than controls. However, the HR was time-dependent (adjusted HR 1.04; 95% CI, 1.01-1.07); by age 75 years the HRs for the athletes with vigorous-intensity exercise reached the level of the controls, but after 85 years the HRs for these athletes increased approximately 1.3-fold annually relative to the controls. In conclusion, these data suggest that continuation of vigorous-intensity exercise is associated with lower HR of hip fracture up to old age. © 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).

Conversion of failed internal fixation in proximal femur fractures using calcar-guided short-stem total hip arthroplasty

PURPOSE

Reoperations for secondary osteoarthritis, osteonecrosis, or hardware failure following failed internal fixation after intertrochanteric fracture (ITF) or femoral neck fracture (FNF) are common. An effective salvage treatment often involves complete removal of the hardware followed by total hip arthroplasty (THA). Almost no data are available regarding conversion to short-stem THA. This study aimed to evaluate clinical and radiological outcomes, potential complications, and the survival rate of short-stem THA following revision surgery.

METHODS

We investigated 27 patients who underwent conversion THA using a calcar-guided short stem. Patient-reported outcome measurements were obtained, including the Harris hip score, the Western Ontario and McMaster Universities Osteoarthritis Index, as well as pain and satisfaction on the visual analogue scale. Radiological follow-up was also performed.

RESULTS

We identified 18 (66.7%) patients diagnosed with FNF and 9 (33.3%) patients with ITF. Clinical and radiological outcomes were satisfactory at the last follow-up (30.56 ± 11.62 months). One patient required early revision surgery due to dislocation and greater trochanter fracture. At the last follow-up, none of the short stems required revision. No other major complications occurred.

CONCLUSION

Given the low rate of complications and 100% survival, our findings indicate that short stems for conversion THA due to failed internal fixation may be considered an option in a properly selected patient population. However, it should not be considered a standard procedure and should only be performed by experienced surgeons.

Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population.

INTRODUCTION

Knowledge on younger patients with hip fractures is limited. Common preconceptions are that they suffer fractures due to high-energy trauma, alcohol or substance use disorder but not associated to osteoporosis. We aimed to descriptively analyze the characteristics of young and middle-aged patients with hip fractures and examine bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) at the time of the fracture.

METHODS

A prospective multicenter cohort study on adult patients with hip fractures below age 60 collected detailed information on patient characteristics regarding demographics, trauma mechanism, previous fractures, comorbidity and medication, and lifestyle factors. DXA results were compared to population-based reference data.

RESULTS

The cohort contains 91 women and 127 men, median age 53 (IQR 47-57). Most fractures, 83%, occurred in patients aged 45-59. Two-thirds of all fractures resulted from low-energy trauma. Half of the patients had prior fractures after age 20. Thirty-four percent were healthy, 31% had one previous disease, and 35% had multiple comorbidities. Use of medication associated with increased fracture risk was 32%. Smoking was prevalent in 42%, harmful alcohol use reported by 29%, and signs of drug-related problems by 8%. Osteoporosis according to WHO criteria was found in 31%, osteopenia in 57%, and normal BMD in 12%.

CONCLUSION

In patients with hip fractures below age 60, risk factors for osteoporosis and fractures were numerous. Moreover, the prevalence of osteoporosis was markedly higher than in the general population. We suggest that young and middle-aged patients with hip fractures undergo a thorough health investigation including DXA, regardless of trauma mechanism.

Dilemmas in the Management of Osteoporosis in Younger Adults

Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Neck of Femur Fracture in Young Patients With End-Stage Renal Disease and Hyperparathyroidism: A Report of Three Cases and Proposed Treatment Algorithm

Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.

Good clinical outcome for the majority of younger patients with hip fractures: a Swedish nationwide study on 905 patients younger than 50 years of age

Background and purpose - Studies regarding hip fractures in young patients are rare since the patient population is small. We assessed clinical outcomes 4 months after hip fracture in patients < 50 years of age and whether there were differences between sexes and different age groups.Patients and methods - We included adult patients < 50 years with a hip fracture between January 1, 2014 and December 31, 2018. Baseline data were extracted from the Swedish Registry for Hip Fracture Patients and Treatment (RIKSHÖFT) and mortality data was obtained from Statistics Sweden. The outcome variables were change of walking ability, pain in fractured hip, use of analgesics, living conditions, and mortality rate at 4 months.Results - Of the 905 patients included, 72% were men and femoral neck fractures were most common (58%). 4 months after surgery, 23% used a walking aid and 7% reported severe pain. Women reported slightly more pain and higher usage of analgesics. Patients aged 40-49 reported higher usage of analgesics than patients aged 15-39, although the latter group reported more pain. Nearly all of those who lived independently before fracture did so at 4 months. The mortality rate was < 1%.Interpretation - Most patients did not use any walking aid and few had severe pain at 4 months. Furthermore, a hip fracture is not a life-threatening event in a patient < 50 years. The living conditions did not change for those who lived independently before the fracture.

Assessing outcomes in hip fracture patients under the age of 60

BACKGROUND

Hip fractures are a common and serious orthopaedic injury. The principle of treatment for hip fractures in the "non-elderly" patient is to preserve the native hip. There is limited published literature in this area.

AIM

The aim of this research is to review all of the "non-elderly" hip fracture patients to report on the demographics, fracture patterns, fixation types, and revisions.

METHODS

This was a retrospective single-site review of all of the "non-elderly" patients who underwent operative management for hip fractures between 1999 and 2019. A manual review was done of all of the x-rays for the identified patients to confirm the fracture type and identify further surgeries.

RESULTS

Three hundred and eighty-one patients were identified. The average age was 48.4 years old. Two hundred and thirty nine of them were intra-capsular, and 142 of them were extra-capsular fractures. Dynamic hip screw (DHS) was the most popular fixation method. In the recent decade of data, the number of hemi-arthroplasties remained consistent, but the number of total hip arthroplasties (THAs) performed increased sevenfold. Mean follow-up was 35 months. Forty-three (11%) patients required follow-up surgery. Non-union accounted for 56% of all revisions and avascular necrosis for 19%. THA was performed in 70% of all revisions.

CONCLUSION

DHS remains the most widely used fixation technique in an effort to preserve the native hip. The use of THA has increased and surpassed the usage of hemi-arthroplasty in recent times. A high proportion of these patients will go on to develop complications requiring secondary surgery; therefore, they all need long-term follow-up.

Osteoporosis in Premenopausal Women: A Clinical Narrative Review by the ECTS and the IOF

CONTEXT

Consensus regarding diagnosis and management of osteoporosis in premenopausal women (PW) is still lacking due to few studies carried out in this population.

DESIGN

The European Calcified Tissue Society and the International Osteoporosis Foundation convened a working group to produce an updated review of literature published after 2017 on this topic.

RESULTS

Fragility fractures in PW are rare and mostly due to secondary osteoporosis (ie, in presence of an underlying disease such as hormonal, inflammatory, or digestive disorders). In absence of another disorder, low bone mineral density (BMD) together with fragility fractures qualifies as idiopathic osteoporosis. In contrast, low BMD alone does not necessarily represent osteoporosis in absence of bone microarchitectural abnormalities. BMD increases in PW with osteoporosis when the underlying disease is treated. For example, in celiac disease, an increase of 9% in radius trabecular volumetric density was achieved after 1 year of gluten-free diet, while anti-tumor necrosis factor alpha improved BMD in PW with inflammatory bowel diseases. In amenorrhea, including anorexia nervosa, appropriately delivered estrogen replacement therapy can also improve BMD. Alternatively, antiresorptive or anabolic therapy has been shown to improve BMD in a variety of conditions, the range of improvement (3%-16%) depending on skeletal site and the nature of the secondary cause. No studies were powered to demonstrate fracture reduction. The effects of bisphosphonates in childbearing women have been scantly studied and caution is needed.

CONCLUSION

The majority of PW with osteoporosis have an underlying disease. Specific therapy of these diseases, as well as antiresorptive and anabolic drugs, improve BMD, but without evidence of fracture reduction.

Comorbidity and mortality after hip fracture in nineteen thousand six hundred and eighty two patients aged eighteen to sixty five years in Denmark from 1996 to 2012

PURPOSE

This nationwide study assessed associations between comorbidity and mortality after hip fracture in young and middle-aged patients.

METHODS

Data on 19,682 patients aged 18 to 65 years were extracted from Danish registries out of 154,047 patients who experienced a hip fracture between 1996 and 2012. Mortality and comorbidity were assessed using information on vital status, hospital admissions, and prescriptions.

RESULTS

Of the 19,682 patients 17,722 (90.0%) were middle-aged (40-65 years) and 1960 (10.0%) were young (18-39 years). The 30-day mortality rates were 3.2% (n = 570) and 1.6% (n = 32), respectively. Indicators of multi-trauma (hazard ratio (HR), 3.5 95% confidence interval (CI) [1.6-7.8], n = 2056) and having diabetes (HR, 4.4 [1.2-11.3], n = 59) and heart disease (HR, 4.4[1.3-14.8], n = 57) increased 30-day mortality in the young patients, while having cancer (HR, 5.0 [4.2-5.9], n = 1958) increased 30-day mortality in the middle-aged patients.

CONCLUSION

Heart disease and diabetes were associated with high mortality in the young patients while having cancer was associated with high mortality in the middle-aged patients.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

BACKGROUND

As morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant.

RESULTS

56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26-19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05-51.77, p < 0.001).

CONCLUSION AND RELEVANCE

The mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Hip fractures in the non-elderly-Who, why and whither?

Nonelderly hip fracture patients have gathered little scientific attention, and our understanding of the group may be biased by patient case-mix and lack of follow-up. Preconceptions may thwart adequate investigation of bone health and other comorbidities. This literature review focusses on who these patients between 20 and 60 years are, how to treat them and how to evaluate the outcome. 2-11% of the hip fractures occur in non-elderly, equally common in men and women. Every second to forth patient smoke, have chronic diseases, and abuse alcohol. Poor self-rated health, sleep disturbances, low cognitive function and education are associated with increased hip fracture risk in young adults. Bone health is poorly investigated, but literature suggest young patients to have lower bone mineral density regardless of trauma mechanism. Studies contradict on whether surgery within 8-12 h reduce the risk of avascular necrosis in femoral neck fractures (FNF). Based on rationality, surgery ought to be performed promptly, in order to reduce pain and permit rehabilitation. There is no convincing support from the existing literature to use open reduction. Good reduction is mandatory, preferably using a closed reduction technique. The failure rate following internal fixation of displaced FNF in younger patients can be as high as 59%. In some cases a displaced FNF is better treated with a primary arthroplasty; in case of rheumatoid arthritis or osteoarthritis for example. Complications after extracapsular fractures vary from 6 to 23%. The relatively few studies looking at functional outcome in non-elderly use a multitude of outcome measures, precluding comparisons. Many non-elderly patients seem not to fully recover. While some non-elderly hip fracture patients are healthy individuals sustaining high energy trauma, others have low-energy fractures and comorbidities including reduced bone strength (either as a primary or secondary condition). i.e. non-delaying medical optimization, proper surgical technique, bone health investigation and secondary fracture prevention is necessary. Younger hip fracture patients are at risk of permanent loss of function, and negative socioeconomic and psychological consequences. High-energy trauma does not exclude the presence of osteopenia. A hip fracture in adulthood and middle-age is very seldom caused by bad luck only!