Sequential fractures of both hips in elderly patients--a prospective study

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

BACKGROUND

The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery.

METHODS

Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression.

RESULTS

The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7-6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6-29).

CONCLUSION

An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

Incidence and risk factors for bilateral proximal femoral fractures

BACKGROUND

Proximal femoral fractures (PFFs) are a public health issue due to their high frequency. The frequency of a second PFF on the other side is estimated at 10%. This estimation is controversial, however, and the risk factors have not been evaluated in a large population of French patients. The objective of this retrospective case-control study was to determine: (1) the incidence of second PFFs and (2) their risk factors.

HYPOTHESIS

The incidence of second PFFs is >2% after 1 year and >5% after 3 years.

MATERIAL AND METHODS

We conducted a case-control study in a population of consecutive patients managed surgically for PPF at the Lyon Sud Hospital between 2013 and 2014. We analysed the following clinical factors: age, sex, body mass index (BMI), institutionalisation, the Parker score, the American Society of Anesthesiologists score (ASA), comorbidities, and the use of psychoactive drugs.

RESULTS

We included 474 PFFs (trochanter, n=240 and neck, n=234) of which 36 were bilateral. The contralateral fracture occurred within 1 year of the first fracture in 6/474 (1.3%) cases and within 3 years in all 36 cases (7.6%). The case-control study comprised 49 cases with bilateral PFF and 161 controls with no second hip fracture within 3 years. Risk factors for a second hip fracture were age older than 90 years (odds ratio [OR]=5.44; 95% confidence interval [95%CI], 112-2642 (p=0.002)) and a history of heart disease (OR, 2.18; 95%CI, 1.06-4.47 [p=0.03]). A Parker score≥6 was protective (OR, 0.84; 95%CI, 0.71-0.99 [p=0.03]). Mortality after 3 years was 42% (201/474), and 13% (63/474) of patients were lost to follow-up.

DISCUSSION

Age older than 90 years, a Parker score below 6, and a history of heart disease are risk factors for a second PFF within 3 years after the first PFF.

LEVEL OF EVIDENCE

III; case-control study.

Second hip fracture in Hong Kong - Incidence, demographics, and mortality

Objectives

The aim of this study is to investigate the incidence of second hip fractures after a previous hip fracture and subsequent mortality in Chinese men and women.

Methods

Data of patients aged 65 years or above with operatively treated hip fracture in the years 2000-2011 in Hong Kong were retrieved from Hospital Authority clinical database. During the follow-up period, second contralateral operatively treated hip fractures were identified. The incidence of a second fracture was determined using survival analysis.

Results

A total of 2399 second hip fractures were identified. The cumulative incidence of a second fracture was 1.24% at 1 year and 4.42% at 5 years with 60% of second fractures occurring within 4 years after the initial fracture. In cox regression model, a higher incidence was observed as age increased (hazard ratio [HR], 1.08; P < 0.001). The cumulative mortality at 1 and 5 years after a second fracture was 16.9% and 54.8%, respectively. The median survival after single fracture was 4.9 years, while after a second fracture it was 3.8 years (P < 0.05). Lower survival was observed after the second fracture (HR, 5.44; P < 0.05), in men (HR, 1.91; P < 0.05) and older patients (HR, 1.061; P < 0.05).

Conclusions

Patients with history of hip fracture are at high risk to develop a second fracture. Initiation of treatment and fragility fracture prevention program after primary hip fracture should be started in order to reduce second fracture incidence and related mortality.

Second Hip Fracture: Incidence, Trends, and Predictors

Older persons who have suffered a hip fracture (HFx) are at increased risk of subsequent hip fractures. The cumulative incidence of a second hip fracture (SHFx) has been estimated in 8.4%; however, no studies have been carried out in our country, and the information on risk markers of SHFx is limited. The aim of this study was to estimate the incidence, explore trends, and examine predictors of SHFx in a suburban population of Spain. An observational longitudinal retrospective study was performed in a universal health coverage setting (Alcorcón, 1999-2011). Data were obtained from the area hospital discharge database. Annual incidence of HFx was estimated over 100,000 population (general and persons with HFx), and median time to SHFx by Kaplan-Meier tables. Cox regression was used for the analysis of association between SHFx and baseline predictors, measured by hazard ratio (HR). Among the 3430 patients who suffered a first HFx in the study period, 255 (7.4%) experienced a SHFx (4.5% of men and 8.5% of women). Median time between the first and second HFx was 3.7 years (SD 3.2). Annual incidence of HFx in population over 45 was 290.5 per 100,000 inhabitants (131.03 in men and 433.11 in women). Annual incidence of SHFx among persons with a HFx was 956.7 per 100,000 (1052.1 in women and 595.5 in men). There was a decline trend along the study period with an annual reduction of 10.4% (95% CI 7.7-13.0%; p < 0.001) in both sexes. The following associations were found: female sex (HR 1.41, 95% CI 0.97-2.02), age (HR 1.03, 95% CI 1.01-1.04), living in a nursing house (HR 1.46, 95% CI 1.10-1.94), and moderate to severe liver disease (HR 4.96, 95% CI 1.23-20.06). In our environment the occurrence of a SHFx is 7.4%, three-fold risk compared to no previous HFx. Being woman, elderly, living in a nursing home, and having severe to moderate liver disease may be important predictors of a SHFx. There seems to be adequate time between the first and the SHFx for interventions that may reduce the risk.

Incidence of bone protection and associated fragility injuries in patients with proximal femur fractures

OBJECTIVES

Our aim was to investigate whether patients presenting with fragility fractures of the proximal femur are receiving osteoporosis treatment and to assess the number of other fragility fractures they have sustained prior to admission.

METHODS

All patients presenting to our institution with fragility fractures of the proximal femur within an 18-month period (January 2012-August 2013) were included. Patient demographics; fracture classification (AO/OTA); American Society of Anesthesiologists (ASA) grade; Abbreviated Mental Test Score (AMTS) on admission; type of operation; time to operation; peri-operative complications; length of hospital stay (LOS); walking status; osteoporotic medication; Dual-energy X-ray absorptiometry (DEXA) results; additional fragility fractures; and mortality were collected and analysed.

RESULTS

A total of 1004 patients (278 male) met the inclusion criteria and were included into the study. The mean age was 82.01 years and mean LOS was 19.54days. Fifty-four per cent of the patients were admitted from their own homes whereas 43% were capable to walk indoors without any aids before their injury. Mean time to surgery was 2.06days (Median: 1.31, range: 0-26days). Three hundred and six patients (30.5%) had at least another fragility fracture before the index episode (mean 1.40 fractures; SD: 0.71 fractures; range: 1-6 fractures). Only 16.4% were under complete osteoporosis treatment on admission, defined as receiving calcium with vitamin D and a bisphosphonate or an alternative agent. When we compared patients without a history of a previous fragility fracture (Group A) and patients with at least another previous fragility fracture (Group B), we found that patients in Group B had a significantly lower AMTS score, lower bone mineral density (BMD) as evident on the DEXA scan, an inferior mobility before admission and a higher incidence of extracapsular fractures (p<0.05). On discharge, patients in Group B had a higher chance of receiving complete bone protection compared to group A (27.9% versus 41.7%; p<0.01). Following discharge, 11.2% of the patients sustained an additional fragility fracture. The mean time from the index episode to the additional fracture was 0.65 years, whilst these injuries were more frequent in Group B (RR=1.638; p<0.05).

CONCLUSION

Patients presenting with a hip fracture are generally under-treated for osteoporosis. Post-operative assessment by a designated geriatrician and use of a standardised protocol is of paramount importance for reducing the risk of additional fragility fractures. Additionally, screening of the elderly population for identifying the patients who suffer from osteoporosis can potentially reduce the risk of sustaining a further fragility fracture.

Rate of contralateral hip fracture after dynamic hip screw vs intramedullary nail for treatment of pertrochanteric hip fractures

A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.

Secular trends in incidence and recurrence rates of hip fracture: a nationwide population-based study

We assessed the incidence of hip fracture and second hip fractures in Taiwan from 2001 to 2012. Age-standardized incidence rates decreased after 2005. However, mortality rate after first hip fracture was substantial compared to second hip fracture rate in a competing risk model.

INTRODUCTION

The aim of the study is to assess the incidence rates (IRs) of hip fractures, including changes in trends and medical costs, and second hip fractures in the Taiwanese population.

METHODS

The number of hip fractures and the associated medical costs were obtained from the annual report of the Ministry of Health and Welfare, Taiwan, for individuals ≥50 years of age. The data of population at risk were retrieved from annual population reports from the Ministry of the Interior, Taiwan. The incidence of second hip fractures was evaluated from the National Health Insurance Research Database of Taiwan for insured individuals aged ≥50 years from 2001 to 2011 with follow-up until 2013 using a competing risk model.

RESULTS

The IR for the entire population increased from 332.7 to 336.5 per 100,000 person-years during 2001-2005 and decreased thereafter. This secular change was driven by a decrease in hip fractures for both men and women. The 10-year cumulative incidence rate of second hip fracture was 11.2% (95% CI 11.0-11.5%) in women and 7.9% (95% CI 7.6-8.1%) in men. Adjusted by consumer price index (CPI), the costs of hospitalization due to hip fracture increased from NTD 1.17 billion in 2001 to NTD 1.43 billion in 2012. However, the CPI-adjusted costs of each admission decreased from NTD 74944 in 2001 to NTD 65791 in 2012.

CONCLUSIONS

Since 2006, the IR of hip fractures has been declining in Taiwan. The 10-year cumulative IR of mortality is substantial for individuals who with first hip fracture.

Incidence of second hip fractures and associated mortality in Taiwan: A nationwide population-based study of 95,484 patients during 2006-2010

OBJECTIVES

The aim of the study is was to determine the incidence and mortality of second hip fracture using a nationwide database.

PATIENTS AND METHODS

A nationwide epidemiological study was conducted using the Taiwan National Health Insurance Research Database from 2001 to 2011. Patients older than 50 years with hip fractures from 2006 to 2011 were included in the study. A total of 95,484 hip fractures were identified, with subsequent second hip fracture occurred in 4102 of them.

RESULTS

The incidence rate ratio of second hip fracture showed a 7.13 fold of risk of further hip fracture in 3 months, 5.21 fold in one year, and remained more than 2 fold in the end of 6th year when compared with the general population. The 6-year cumulative incidence of a second hip fracture was higher in female (8.0%) than in male (6.2%). A significantly higher 1-year mortality rate was seen after a second hip fracture (18.8%) compared to the first hip fracture (14.1%) (p < 0.05). Men had higher 1- and 5-year mortality rates after second hip fractures (12.1% and 41.2%, respectively) than women (17.4% and 47.3%, respectively).

CONCLUSIONS

Patients with hip fractures would have a 2-7 fold of risk of a second fracture within 6 years. Women were more prone to a second hip fracture than men but men had a higher mortality rate.

Prophylactic augmentation of the proximal femur: an investigation of two techniques

INTRODUCTION

Osteoporotic hip fractures are an increasing problem in an ageing population. They result in high morbidity, mortality and high socioeconomic costs. For patients with poor bone quality, prophylactic augmentation of the proximal femur might be an option for fracture prevention.

METHODS

In two groups of paired human femora the potential of limited polymethyl-methacrylate (PMMA) augmentation (11-15 ml) in a V-shape pattern and the insertion of a proximal femur nail antirotation (PFNA) blade were investigated. The testing was carried out pair wise simulating the single leg stand. The untreated femur in each pair served as control. An axial load was applied until failure. Load displacement parameters and temperature increase during the augmentation process were recorded.

RESULTS

In the PMMA group no significant difference was found between the augmented and non-augmented specimen concerning load to failure (p = 0.35) and energy to failure (p = 0.9). A median temperature increase of 9.5 °C was observed in the augmented specimen. A significant correlation was found between the amount of applied PMMA and the temperature increase (Cor. Coef. = 0.82, p = 0.042). In the PFNA group, a significant decrease of load to failure and a non-significant decrease of energy to failure were observed (p = 0.037 and p = 0.075).

CONCLUSION

Limited V-shaped PMMA augmentation and PFNA blade insertion did not show any improvement in failure load or energy to failure. Volumes of up to 15 ml PMMA did not cause a critical surface temperature increase.

Parameters Pointing at an Increased Risk for Contralateral Hip Fractures: Systematic Review

BACKGROUND

Early identification of hip fracture (HF) patients bearing an increased risk for a contralateral occurrence would allow providing preventive measures timely.

OBJECTIVES

To summarize the available evidence describing risk scores, prognostic instruments, or (groups of) parameters predicting contralateral HFs at the time point of the first fracture. Methods/Systematic Review: Articles were identified through searches in MEDLINE and Scopus from inception to April 2014, checking of reference lists of the included studies and reviews. One reviewer assessed all articles for inclusion and abstracted the data. Uncertain cases were discussed and decided with a second reviewer. Salient study and population characteristics were abstracted for each article. Studies reporting the association of a set of risk factors for second HFs were further examined and compared. The number of studies reporting on a risk parameter was assessed.

RESULTS

Searches identified 3560 records, and 47 studies were included in this review. There was a large spectrum of study designs, patient populations, and follow-up periods. Among 11 studies reporting on a set of parameters, female gender was assessed most commonly (7 times), followed by age (5) and parameters of general health, vision, and stroke (each 4 times). We were unable to depict stringent patterns of risk parameters to be used for decision making in clinical practice.

CONCLUSIONS

The findings of this article call for a conjoint effort to achieve an expert consensus regarding a critical set of parameters for a risk instrument identifying patients bearing an increased risk for contralateral HFs early.

Risk factors for the second contralateral hip fracture in elderly patients: a systematic review and meta-analysis

OBJECTIVES

To achieve a quantitative and comprehensive conclusion concerning the risk factors for the second contralateral hip fracture in elderly patients with initial hip fractures.

DATA SOURCES

This search was applied to Medline, Embase, Cochrane central database (all up to April 2014).

METHODS

All the studies on bilateral hip fractures in elderly patients published in English were reviewed and qualities of included studies were assessed using the Newcastle-Ottawa Scale. All the data were carefully and independently abstracted by two reviewers, any disagreement was settled by discussion. Data was pooled and a meta-analysis completed.

RESULTS

A total of 13 case-control studies were identified for the meta-analysis. The significant risk factors were female (odds ratio (OR), 1.30; 95% confidence interval (CI), 1.02-1.64), living in institutions (OR, 2.53; 95% CI, 1.33-4.85), osteoporosis (OR, 10.02; 95% CI, 5.41-18.57), low vision (OR, 2.09; 95% CI, 1.06-4.12), dementia (OR, 2.02; 95% CI, 1.54-2.65), dizziness (OR, 2.87; 95% CI, 1.42-5.87) cardiac diseases (OR, 1.33; 95% CI, 1.00-1.78) and respiration diseases (OR, 2.58; 95% CI, 1.22-5.47). No significant difference was found in admission age between patients with the unilateral hip fracture and the first hip fracture of bilateral hip groups (standardized mean difference, 0.02, 95% CI, -0.30 to 0.35].

CONCLUSIONS

Patients involved with female, living in institutions, osteoporosis, low vision, dizziness, dementia, respiration diseases and cardiac diseases were at risk for a second contralateral hip fracture after the initial hip fracture.

Incidence and risk factors of subsequent hip fractures in Korea: multicenter study

This study analyzes the incidence of subsequent hip fractures and its risk factors in the northwestern region of Korea. We analyzed hip fracture patients who visited any of the 5 teaching hospitals in the Bucheon and Incheon area from January 2000 to December 2010. Medical records were reviewed and presence of subsequent hip fractures, alcohol history, marital status, live in solitude, dementia, dizziness, American society of anesthesiologists score, osteoporosis treatment after fracture, body mass index (BMI) and initial bone mineral density were analyzed. The average follow-up period was 12 months (range 1-130 months). A total of 2,546 patients (women 1,770, men 776) who had experienced hip fractures were included. Of these, subsequent hip fractures were found in 233 patients (9.2%) (women 187, men 46). Mean age at the time of the first fracture was 79.2 yr old (range 50-100 yr). The average interval between the first fracture and the subsequent hip fractures was 30.2 months (range 4 days-154 months). In this large-scale, retrospective, multicenter study, overall incidence of subsequent hip fractures is 9.2%. Independent risk factors of subsequent fracture are women, BMI<22 kg/m(2), and being unmarried.

Meta-analysis of risk factors for the second hip fracture (SHF) in elderly patients

This study aims to quantitatively summarize the risk factors for the incidence of SHF. A meta-analysis was performed with the data obtained from 22 relevant papers published in Pubmed, Embase and Cochrane central database (all through January 2014) following strict selection. The pooled odds ratios (ORs) or standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated for potential risk factors associated with SHF. Our meta-analysis indicated the significant risk factors for SHF were female (OR, 1.46; 95%CI, 1.29-1.66), living in institutions (OR, 2.23; 95%CI, 1.29-3.83), osteoporosis (Singh index (SI) 1-3) (OR, 10.02; 95%CI, 5.41-18.57), low vision (OR, 2.09; 95%CI, 1.06-4.12), dementia (OR, 1.89; 95%CI, 1.47-2.43), Parkinson (OR, 2.90; 95%CI, 1.41-5.95), cardiac diseases (OR, 1.32; 95%CI, 1.02-1.70) and respiratory disease (OR, 1.97; 95%CI, 1.16-3.32). Related strategies must be implemented on those involved with above-mentioned medical conditions to effectively prevent a SHF.

Vitamin D reduces falls and hip fractures in vascular Parkinsonism but not in Parkinson's disease

Purpose

Vitamin D supplementation is suggested to reduce the risk of falls in older institutionalized or ambulatory individuals by 20%. The present study was undertaken to address the reduced risk, by vitamin D supplementation, of falls and hip fractures in patients with vascular Parkinsonism (VP) and Parkinson’s disease (PD).

Patients and methods

In the open-label-study, 94 elderly patients with VP and 92 age-matched patients with PD were followed for 2 years. All patients received 1200 IU ergocalciferol daily. The number of falls per person and incidence of hip fractures were compared between the two groups.

Results

At baseline, serum 25-hydroxyvitamin D (25-OHD) levels were in the deficient range (<25 nmol/L) in all patients, and vitamin D treatment enhanced serum 25-OHD and 1,25-dihydroxyvitamin D levels in both groups. Improved muscle strength of lower extremities was observed in both groups. There was significant difference between the two groups in the number of falls per subject during the 2 years (1.9 ± 0.5 in the PD group and 0.8 ± 0.4 in the VP group, P < 0.001). Hip fractures occurred in seven of 88 in the PD group and one in 90 of the VP group during the 2-year study period (P = 0.035).

Conclusion

It is suggested that vitamin D decreases falls and hip fractures in VP by increasing muscle strength but not in PD.

Strategy for prevention of hip fractures in patients with Parkinson's disease

Hypovitaminosis D and K due to malnutrition or sunlight deprivation, increased bone resorption due to immobilization, low bone mineral density (BMD) and an increased risk of falls may contribute to an increased risk of hip fractures in patients with Parkinson's disease. The purpose of the present study was to clarify the efficacy of interventions intended to prevent hip fractures in elderly patients with Parkinson's disease. PubMed was used to search the literature for randomized controlled trials (RCTs) regarding Parkinson's disease and hip fractures. The inclusion criteria were 50 or more subjects per group and a study period of 1 year or longer. Five RCTs were identified and the relative risk and 95% confidence interval were calculated for individual RCTs. Sunlight exposure increased serum hydroxyvitamin D [25(OH)D] concentration, improved motor function, decreased bone resorption and increased BMD. Alendronate or risedronate with vitamin D supplementation increased serum 25(OH)D concentration, strongly decreased bone resorption and increased BMD. Menatetrenone (vitamin K(2)) decreased serum undercarboxylated osteocalcin concentration, decreased bone resorption and increased BMD. Sunlight exposure (men and women), menatetrenone (women), alendronate and risedronate with vitamin D supplementation (women) significantly reduced the incidence of hip fractures. The respective RRs (95% confidence intervals) according to the intention-to-treat analysis were 0.27 (0.08, 0.96), 0.13 (0.02, 0.97), 0.29 (0.10, 0.85) and 0.20 (0.06, 0.68). Interventions, including sunlight exposure, menatetrenone and oral bisphosphonates with vitamin D supplementation, have a protective effect against hip fractures elderly patients with Parkinson's disease.

Outcome after sequential hip fracture in the elderly

BACKGROUND

Hip fracture is a common cause of morbidity and mortality in the elderly. As the risk factors for hip fracture often persist after the original injury, patients remain at risk for sequential fractures. Our aim was to report the incidence, epidemiology, and outcome of sequential hip fracture in the elderly.

METHODS

Data were collected during the acute hospital stay and at 120 days after admission from twenty-two acute orthopaedic units across Scotland between January 1998 and December 2005. These data were analyzed according to two separate time periods: by six-month intervals up to eight years after the primary fracture and by twenty-day intervals for the first two years after the primary fracture.

RESULTS

The risk of sequential fracture was highest in the first twelve months, affecting 3% of surviving patients and decreasing to 2% per survival year thereafter. Survival to twelve months after sequential fracture was 63% compared with 68% for those with a single fracture (p = 0.03). Sequential hip fracture was also associated with greater loss of independent mobility and changes in residential status compared with single fractures.

CONCLUSIONS

Sequential hip fracture is a relatively rare injury. Individuals who sustain this injury combination have poorer outcomes both in terms of survival and functional status.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The rate of contralateral proximal femoral fracture following closed reduction and percutaneous pinning compared with arthroplasty for the treatment of femoral neck fractures

BACKGROUND

As the population ages, the number of proximal femoral fractures seen each year is expected to increase. Subsequent contralateral hip fractures have been reported to occur in as many as 11.8% of patients after surgical fixation of the initial fracture, but it is unknown if this rate is similar among patients managed with different surgical procedures.

METHODS

A retrospective comparative study was performed at a single institution at which electronic medical records and digital radiographs were reviewed for 1177 patients who underwent closed reduction and percutaneous pinning or arthroplasty for the treatment of a proximal femoral fracture. For the primary outcome of subsequent fracture, logistic regression analysis was applied.

RESULTS

Four hundred and ninety-five patients were managed with closed reduction and percutaneous pinning, and 682 were managed with arthroplasty. Patients who underwent closed reduction and percutaneous pinning were two times more likely to have a subsequent contralateral femoral fracture in comparison with those who underwent arthroplasty, with contralateral fracture rates of 10.10% for the closed reduction and percutaneous pinning group and 5.57% for the arthroplasty group (p = 0.0035).

CONCLUSIONS

Patients undergoing closed reduction and percutaneous pinning as the initial treatment for a hip fracture had an increased risk of a subsequent contralateral hip fracture in comparison with those undergoing arthroplasty, after controlling for patient characteristics.

Contralateral hip fractures and other osteoporosis-related fractures in hip fracture patients: incidence and risk factors. An observational cohort study of 1,229 patients

PURPOSE

To report risk factors, 1-year and overall risk for a contralateral hip and other osteoporosis-related fractures in a hip fracture population.

METHODS

An observational study on 1,229 consecutive patients of 50 years and older, who sustained a hip fracture between January 2005 and June 2009. Fractures were scored retrospectively for 2005-2008 and prospectively for 2008-2009. Rates of a contralateral hip and other osteoporosis-related fractures were compared between patients with and without a history of a fracture. Previous fractures, gender, age and ASA classification were analysed as possible risk factors.

RESULTS

The absolute risk for a contralateral hip fracture was 13.8 %, for one or more osteoporosis-related fracture(s) 28.6 %. First-, second- and third-year risk for a second hip fracture was 2, 1 and 0 %. Median (IQR) interval between both hip fractures was 18.5 (26.6) months. One-year incidence of other fractures was 6 %. Only age was a risk factor for a contralateral hip fracture, hazard ratio (HR) 1.02 (1.006-1.042, p = 0.008). Patients with a history of a fracture (33.1 %) did not have a higher incidence of fractures during follow-up (16.7 %) than patients without fractures in their history (14 %). HR for a contralateral hip fracture for the fracture versus the non-fracture group was 1.29 (0.75-2.23, p = 0.360).

CONCLUSION

The absolute risk of a contralateral hip fracture after a hip fracture is 13.8 %, the 1-year risk was 2 %, with a short interval between the 2 hip fractures. Age was a risk factor for sustaining a contralateral hip fracture; a fracture in history was not.

The effects of vitamin D on brain development and adult brain function

A role for vitamin D in brain development and function has been gaining support over the last decade. Multiple lines of evidence suggest that this vitamin is actually a neuroactive steroid that acts on brain development, leading to alterations in brain neurochemistry and adult brain function. Early deficiencies have been linked with neuropsychiatric disorders, such as schizophrenia, and adult deficiencies have been associated with a host of adverse brain outcomes, including Parkinson's disease, Alzheimer's disease, depression and cognitive decline. This review summarises the current state of research on the actions of vitamin D in the brain and the consequences of deficiencies in this vitamin. Furthermore, we discuss specific implications of vitamin D status on the neurotransmitter, dopamine.

Non-simultaneous bilateral hip fracture: epidemiologic study of 241 hip fractures

INTRODUCTION

Hip fractures are an important public health problem given their growing incidence as well as their functional and vital repercussions. With longer survival, patients with a contralateral fracture are increasingly numerous. The objective of this study was to investigate the bilateralization of hip fractures in terms of anatomic location and time to the second fracture.

HYPOTHESIS

Contralateral fractures are of the same anatomical type as the primary fractures.

PATIENTS AND METHODS

This was a retrospective epidemiological study on all patients managed for hip fractures between January 2007 and May 2008. Each case of bilateralization was studied.

RESULTS

We included 241 patients in the study. The mean age at occurrence of the primary fracture was 83.3 years (range, 60-99 years). The distribution showed 45.6% true femoral neck fractures and 54.4% trochanteric fractures. Twenty-six of the 241 patients had already suffered from a hip fracture (10.8%). This fracture was the same type as the recent fracture in 80.8% of the cases. The mean time between the two fractures was 5.6 years (range, 1-277 months).

DISCUSSION

The contralateral fractures were the same anatomical type as the primary fracture in eight out of ten patients and the symmetry remains intact in 64-83% depending on the series. The fracture occurred on average within 5 years of the first hip fracture. In cases of asymmetry, the second fracture was more often a trochanteric fracture. The causes explaining this symmetry are several and are poorly known. The risk factors are numerous and their prevention is essential (acting on the patient's environment to prevent falls, rehabilitation to reestablish autonomy after the first fracture, and preventive treatment of osteoporosis), although these notions are often ignored by surgeons.

LEVEL OF EVIDENCE

IV, retrospective study.

Age-specific incidence of first and second fractures of the hip

We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data. The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men. Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care.

Evaluation of a care pathway in the initiation of calcium and vitamin D treatment of patients after hip fracture

Hip fractures, fragility fractures, indicate an increased risk for further fragility fractures. Although the way to define osteoporosis, requiring antiresorptive therapy, is not clear, all patients who have had hip fractures should be prescribed calcium and vitamin D at a minimum. In a retrospective chart review, we have explored the effectiveness of incorporating a standing recommendation (but not a standing order) for calcium and vitamin D treatment in a hip fracture care pathway, comparing units where the pathway had been implemented with those where it had not yet been started. The pathway resulted in significantly more initiation of calcium and vitamin D compared to patients not on the pathway (72% vs. 13.5%, p < 0.01). However, a follow-up study after four years showed a marked decline in the frequency of the initiation of calcium and vitamin D, suggesting the need for ongoing encouragement for the intervention to continue to be successful.

Secular trends in hip fracture incidence and recurrence

The decline in hip fracture incidence is now accompanied by a further reduction in the likelihood of a recurrent hip fracture among survivors of the first fracture.

INTRODUCTION

Hip fracture incidence is declining in North America, but trends in hip fracture recurrence have not been described.

METHODS

All hip fracture events among Olmsted County, Minnesota residents in 1980-2006 were identified. Secular trends were assessed using Poisson regression, and predictors of recurrence were evaluated with Andersen-Gill time-to-fracture regression models.

RESULTS

Altogether, 2,752 hip fractures (median age, 83 years; 76% female) were observed, including 311 recurrences. Between 1980 and 2006, the incidence of a first-ever hip fracture declined by 1.37%/year for women (p < 0.001) and 0.06%/year for men (p = 0.917). Among 2,434 residents with a first-ever hip fracture, the cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men with death treated as a competing risk. Age and calendar year of fracture were independently associated with hip fracture recurrence. Accounting for the reduction in first-ever hip fracture rates over time, hip fracture recurrence appeared to decline after 1997.

CONCLUSION

A recent reduction in hip fracture recurrence is somewhat greater than expected from the declining incidence of hip fractures generally. Additional research is needed to determine the extent to which this can be attributed to improved patient management.

Bone resorption in stroke and institutionalized subjects

Stroke increases the risk of hip fracture on the affected side. Although bone is lost by 1 year, rapidity of onset and relationship with immobility are uncertain. Using the bone resorption marker urinary cross-linked N telopeptide of type I collagen (uNTx), we examined bone resorption in the first 4 weeks after stroke, relating uNTx with bone density and mobility in subjects over 60 years. Two separate control groups acted as comparators, healthy (HC) and institutionalized (IC) controls, the latter to control for the effects of institutionalization. uNTx, urinary calcium (both related to creatinine and log-transformed), heel bone mineral density (BMD), Tinetti scores, and Barthel scores for prestroke function were measured. Log uNTx/Cr was lower in males compared with females, but this difference was not evident in stroke or IC subjects. Log uNTx/Cr was inversely related with BMD in females from both control groups and in male stroke subjects. Tinetti scores were divided into tertiles and were lower in stroke than IC subjects (P < 0.01). Log uNTx/Cr was similar in stroke and IC subjects in the lowest Tinetti tertile. Log uNTx/Cr was higher in stroke subjects of both sexes in the lowest tertile compared with the higher two tertiles combined (P < 0.05) and higher in all tertiles compared with HC subjects (P < 0.05). Subjects with a prestroke Barthel index of < or = 17 had higher log uNTx/Cr compared with HCs. Log uCa/Cr was higher only in male stroke patients. Bone resorption in stroke starts early, and measures to reduce this are merited.

Factors associated with a second hip fracture: a systematic review

OBJECTIVE

To provide a systematic review of factors associated with subsequent hip fracture among individuals who have fractured a hip.

DATA SOURCES

We searched Ageline, CINAHL, EMBASE and MEDLINE, from database inceptions to the week of 5 June 2006.

REVIEW METHODS

Studies were selected if they provided information regarding risk of subsequent hip fracture among individuals who had fractured a hip. Study quality was assessed using the Jadad criteria for randomized controlled trials (RCTs) and a simple scale based on the MOOSE criteria for cohort studies.

RESULTS

Four RCTs and seven cohort studies were identified. Older age, cognitive impairment and lower bone mass appear to increase the risk of subsequent fracture, as did impaired depth perception, impaired mobility, previous falls, dizziness and poor or fair self-perceived health. Pharmacologic treatment for osteoporosis decreased the risk of subsequent fracture. Use of hip protectors by community-dwelling seniors did not appear to protect against a second fracture.

CONCLUSION

A number of easily observed risk factors may help identify those individuals at higher risk for subsequent fracture.

Incidence of second hip fractures. A population-based study

We studied the incidence of second hip fractures and medication use among the patients with sequential hip fractures. This study shows that the incidence rate of second hip fractures is higher than that of the first hip fractures. Improvement in osteoporosis care and a more critical policy for prescription of psychotropic drugs are needed.

INTRODUCTION

This study had two goals: (1) to determine incidence of second hip fractures; (2) to describe changes in pharmacotherapy between first and second hip fractures, especially the use of those psychotropics which increase the risk of falling and also pharmacotherapy for osteoporosis.

METHODS

The residents of Central Finland Health Care District who had sustained a hip fracture in 2002-2003 were followed up for subsequent hip fractures until 2006. Hip fracture patients were identified and clinical data were obtained by using hospital registers and medical records.

RESULTS

Five hundred and one persons aged >or= 60 years suffered their first hip fracture in 2002-2003. During the follow-up of 936 person-years, 34 second hip fractures occurred. The cumulative incidence of second hip fractures was 5.08% (95% CI: 3.30 to 7.78) at one year, and 8.11% (95% CI: 5.73 to 11.43) at two years after the first fracture. The second part of this study investigated 75 patients with two non-contemporaneous hip fractures. Between the first and second fractures, the number of psychotropic drug users rose from 27 (36%) to 44 (59%). At the time of second hip fracture, osteoporosis had been diagnosed in 17 (23%) patients only. Twelve (16%) patients used bisphosphonates or calcitonin, 15 (20%) used calcium and 9 (12%) vitamin D supplements.

CONCLUSIONS

There is a high incidence of second hip fractures. Secondary prevention of hip fractures needs to be improved. In addition to adequate treatment for osteoporosis, more attention should be directed toward appropriate use of psychotropic drugs.

Vitamin D and Parkinson's disease—A hypothesis

Parkinson's disease (PD), a common disease of the elderly, is a movement disorder characterized by tremor, akinesia, and loss of postural reflexes, leading to immobility and frequent falls. It results from selective loss (death) of dopaminergic neurons in the substantia nigra region of the brain, largely developed prior to clinical diagnosis, and continuous after diagnosis, despite use of current therapeutic modalities. In PD in the United States the cause and mechanism of continued neuron cell death in the substantia nigra is currently unknown. We hypothesize, based upon several lines of evidence, that documented chronically inadequate vitamin D intake in the United States, particularly in the northern states and particularly in the elderly, is a significant factor in the pathogenesis of PD. This hypothesis implies that dietary aid for prevention and therapy for PD is possible.

Alendronate and vitamin D2 for prevention of hip fracture in Parkinson's disease: a randomized controlled trial

Incidence of a fracture, particularly in the hip joint, is high in elderly women with Parkinson's disease (PD), and this is due to the immobilization-induced bone resorption and vitamin D deficiency with reduced bone mineral density (BMD). The objective of this study was to address the possibility that treatment with alendronate and vitamin D2 may reduce the incidence of hip fractures in elderly women with PD. PD patients were randomly assigned to daily treatment with 5 mg alendronate (n = 144) or a placebo combined with 1,000 IU of vitamin D2 (n = 144) and followed for 2 years. Incidence of hip fractures in the two patient groups during the 2-year follow-up period was studied. At baseline, both groups of patients had low BMD with high levels of serum-ionized calcium and urinary deoxypyridinoline (D-Pyr). Hip fractures occurred in 14 patients in the placebo group and 4 in the alendronate group. The relative risk for hip fractures in the alendronate group as compared with the placebo group was 0.29 (95% CI, 0.10-0.85). The number of hip fracture per 1,000 patient-years was 14 and 49 for the alendronate and placebo groups, respectively. In the alendronate group, serum calcium and urinary D-Pyr levels decreased significantly during the follow-up period, while the levels in the placebo group were increased. BMD increased by 3.1% in the alendronate group and decreased by 2.8% in the placebo group (P < 0.01). Treatment with alendronate and vitamin D2 increases BMD in elderly women with PD and leads to the prevention of hip fractures.

Longitudinal study of bone and calcium metabolism and fracture incidence in spinocerebellar degeneration

Little is known about bone and calcium metabolism and fracture incidence in spinocerebellar degeneration (SCD) despite frequent falls and immobilization. To address bone and calcium metabolism and fracture incidence in SCD, we conducted a 10-year prospective study in a cohort of adult patients with SCD. Bone mineral density (BMD) and serum levels of ionized calcium, parathyroid hormone, 25-hydroxyvitamin D, and pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP) were followed in 110 patients with SCD for 10 years. Age-matched healthy volunteers (n = 110) served as controls. At baseline, the SCD patients had a low BMD with high levels of serum ionized calcium and ICTP which correlated with the degree of immobilization (Barthel index). Over 10 years, serum 25-hydroxyvitamin D decreased to the osteomalacic level (<5 ng/ml), and calcium and ICTP further increased in accordance with a decreased Barthel index score. The BMD decreased by 15.2% in men and by 24.6% in women. The incidence of fractures in the patients was significantly higher as compared with the control group (men 8/49 vs. 1/42, p = 0.0428; women 16/49 vs. 2/48, p = 0.0026). Over 10 years, the BMD was significantly reduced in the SCD patients, particularly in women, which increased the risk of a fracture. Vitamin D deficiency due to sunlight deprivation, increased bone resorption due to immobilization, and frequent falls are probable causes of osteoporosis and fractures in these patients. Hypovitaminosis D and increased bone resorption may be corrected readily by the routine use of vitamin D supplements together with bisphosphonate.

Outcome of bilateral hip hemiarthroplasty for displaced fracture of the hip

Our aim was to evaluate the outcome in patients with bilateral non-simultaneous hip fracture treated with hemiarthroplasty at our institution between 1997 and 2003. We looked for any important modification factor that could change the devastating functional and social results. Twenty-two patients with a mean age of 79 at the initial fracture and 82 at the subsequent fracture were evaluated; all were Garden grade III-IV. The second fracture happened a mean of 28 months after the first one. The outcome measurement was the incidence of hip pain, recovery of pre-injury level of ambulation and activities of daily living at a minimum follow-up of one year. Following the first hemiarthroplasty patients deteriorated in their walking capacity and other activities of daily life, and this happened to an even greater extent after the second operation. With respect to walking ability (measured in metres) we concluded that it improved if a modular hemiarthroplasty was used after both fractures (p<0.05) and that worse functional outcomes were observed when different kinds of hemiarthroplasties were used in the same patient.;

Bilateral hip fractures

BACKGROUND

In the past, patients admitted for hip fractures had often sustained a contralateral hip fracture. The incidence of bilateral hip fractures has been reported to be 5%-10%, and in the future the number of bilateral hip fractures is expected to increase with the increase of unilateral hip fractures. We believe that bilateral hip fractures can be efficiently prevented if a fracture on the other side could be predicted after unilateral hip fracture. Therefore, this retrospective study of 835 patients with hip fractures investigated the incidence, prognosis, and risk factors of bilateral hip fractures.

METHODS

We examined 835 hip fractures retrospectively in Japan. Among them, we found 94 patients with bilateral noncontemporary hip fractures. We investigated age, sex, interval between the two fractures, type of fractures, cause, physical functioning, and complications. Differences between the unilateral fracture and bilateral fractures groups were analyzed statistically for age, sex, and complications using Student's t test and the chi-square test.

RESULTS

In this study, the mean interval between two fractures was 4.28 years, and the second hip fracture occurred within 5 years in more than 70% of patients. The type of hip fracture was the same in 72.2% of bilateral hip fractures. No difference in age and sex was found between the unilateral and the bilateral groups. However, concerning complications, 22.1% of patients in the unilateral group and 34.8% in the bilateral group had dementia, the difference being significant.

CONCLUSIONS

These results revealed that the second hip fracture occurred within 5 years of the first in more than 70% of bilateral hip fracture patients and that dementia is a risk factor of bilateral hip fractures.

Short time-frame from first to second hip fracture in the Funen County Hip Fracture Study

INTRODUCTION

Hip fracture patients represent a frail group of elderly with increased morbidity and mortality. The aim of this study was to evaluate the occurrence and distribution of a second hip fracture in the time interval between the first and the second hip fracture.

METHODS

All incident hip fractures in residents of Funen County, Denmark, from 1994 through 2004 were recorded. Verified fractures were sequenced within each patient using the unique Danish identification numbers.

RESULTS

In total, 9990 incident hip fractures occurred: 9122 first hip fractures and 868 (8.7%) second fractures. Within the first year after the first hip fracture, the incidence rate of the second fracture in men decreased from 73 per 1000 person-years (py) during the first 3 months to 8 per 1000 py at 12 months; in women, it decreased from 116 per 1000 py during the first 3 months to 15 per 1000 py at 12 months. Of all the second fractures, 50% occurred within 12 months in men and within 19 months in women.

CONCLUSIONS

Few hip fracture patients experience a second hip fracture and when they do, it is within a short time-frame from the first. The risk of sustaining a second hip fracture is high during the first 12 months following the first hip fracture, decreasing to a level equal to or below the incidence of the first hip fracture after this 12-month period. Preventive strategies at the time of the first hip fracture should therefore aim at immediate effects, as interventions with effects after 12 months (men) and 19 months (women) bypass at least 50% of the fractures.

RETRACTED: Homocysteine as a predictive factor for hip fracture in elderly women with Parkinson's disease

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article is being retracted at the request of the Editor in Chief because of the stated concerns listed below. The article was accepted for publication by a previous editor and editorial board nearly 15 years ago, at a time when submissions and documentation were in paper form, prior to the transition of The American Journal of Medicine to a digital submission and review process. The records, including the original manuscript and peer reviewers' comments, are no longer extant and consequently we are unable to review the comments of the peer reviewers and the editors involved at that time. Nevertheless, the allegations of Grey et al. (as detailed in their Letter of Concern, published in the March 2018 issue of AJM, Volume 131, Issue 3, pages e107–e108; DOI: 10.1016/j.amjmed.2017.10.009) seem valid. A response by the Editor-in-Chief was also published in that issue. Therefore, given the documentation of Grey et al, the journal has concluded that this article should be considered as likely fraudulent and should not be quoted in the scientific literature in support of its conclusions. The article is severely compromised by wide-ranging and serious concerns about governance, ethics, authorship, implausible study conduct, implausible workload, discrepant participant numbers and treatment groups, impossible data, implausible data, implausible outcome data and discrepant methodology. The concerns are detailed in the afore-referenced letter of concern and can be summarized as follows: • It is stated that the study was approved by the Human Investigation Committee of the Futase Social Insurance Hospital, yet Futase Hospital did not have an ethics committee until 2010. • Given the size of the hospital and volume of clinics undertaken, it is highly unlikely that the stated number of participants could have been recruited within 3 months, or followed up as reported. • There are inconsistencies in the reported data. In Table 1 the mean ages of participants by quartiles of plasma homocysteine are 69.0, 70.6, 71.9, and 72.6 years. The corresponding mean years since menopause are 13.7, 14.6, 15.2, and 16.2 years, meaning that the average age of menopause is 55–57 years, implausibly older than the expected value of 50 years. The plasma homocysteine data in quartile 1 are incorrect. Among 50 women with a range of 6.1-9.0 μmol/L, the reported mean (standard deviation), 7.1 (2.5) μmol/L, is not possible. • In Table 3 the rate of hip fractures in the cohort (72 per 1000 patient-years) is implausibly high, being at least 3 to 4 times that reported in large observational studies of PD. The 51 incident hip fractures in 50 women in quartile 4 represents an astonishing hip fracture incidence of 227 per 1000 patient-years, yet only 6 women (3%) in this quartile were lost to follow-up (Table 1), and none was apparently treated with medications known to reduce fracture risk. The reported incident rates for hip fracture are incorrect. We have attempted to contact the authors regarding these concerns and have received no response. We are therefore retracting this article since the evidence presented indicates that there has been scientific misconduct. Joseph S. Alpert, MD Professor of Medicine, University of Arizona College of Medicine, Tucson, Arizona; Editor in Chief, The American Journal of Medicine

Assessment of risk factors for second hip fractures in Japanese elderly

In an attempt to identify a cohort with a high risk of suffering a fracture of the contralateral hip (second hip fracture), we assessed patients who had suffered hip fracture. A total of 714 patients (130 men and 584 women) were prospectively followed to determine those who suffered a second hip fracture. Pathologic hip fractures and fractures that emerged from high-energy trauma were excluded from the analysis. Age, gender, Singh Index (SI), fracture type, cognitive impairment, and comorbid medical conditions were investigated as medical predictors. The 714 patients were observed for 1,579.5 person-years (mean: 2.4+/-1.4 years per patient). During the observation period, 45 second hip fractures were identified (bilateral group), giving an overall incidence of 0.029 per person-year. The annual incidence rate declined linearly from the occasion of the initial fracture. Furthermore, the second hip fracture tended to occur increasingly within 8 months after the initial hip fracture. The second hip fracture was of the same type (trochanteric or cervical) in 79% of the trochanteric and 71% of the cervical fractures. There was no significant difference in the incidence of second hip fracture by gender or age. In addition, there was no significant difference in the distribution of SI grades of the unfractured hip at the initial hip fracture between the 669 patients who had not suffered a second hip fracture (unilateral group) and the bilateral group. Cox proportional hazard regression analysis revealed that increased risk of a second hip fracture was associated with senile dementia and Parkinson's disease. We concluded that careful follow-up of hip fracture patients associated with senile dementia and Parkinson's disease might effectively prevent the incidence of a second hip fracture.

Facteurs de qualité de la prise en charge des sujets âgés opérés d’une fracture de l’extrémité supérieure du fémur

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

Beneficial Effect of Etidronate Therapy in Immobilized Hip Fracture Patients[Retracted]

OBJECTIVES

Hip fracture is among the most common causes of acute immobilization in elderly patients leading to increased bone resorption, and elderly patients with hip fracture are at high risk for a subsequent hip fracture.

DESIGN

In this double-blind, randomized, prospective study, 80 female patients who were immobilized because of a hip fracture were divided into two groups. The etidronate group received oral administration of 200 mg/day etidronate for 2 wks starting 1 day after the surgery. Then, after a 9-wk intermission, etidronate administration was resumed for 2 wks. The placebo group received placebo in a similar manner.

RESULTS

At baseline, both groups had high serum concentrations of ionized calcium, high urinary deoxypyridinoline (D-Pyr) concentrations, and decreased calcitriol concentrations, suggesting immobilization-induced hypercalcemia and inhibition of renal synthesis of calcitriol. After treatment, serum calcitriol concentrations increased in the etidronate and placebo groups. The etidronate group had significant decreases in serum ionized calcium and urinary D-Pyr, and the placebo group had higher serum calcium and urinary D-Pyr concentrations.

CONCLUSIONS

Etidronate therapy inhibits bone resorption and improves calcium balance, and such therapy may prevent bone loss and reduce the risk of subsequent hip fracture.

The second hip fracture--an analysis of 84 elderly patients

OBJECTIVES

Evaluation of patients with a second hip fracture, which means a fracture of the contralateral hip.

DESIGN

Retrospective database analysis.

SETTINGS

Academic teaching hospital.

PATIENTS

All patients who were admitted for their second hip fractures between November 1999 and September 2001 and had their first hip fracture treated in our institution.

INTERVENTION

In this study, we epidemiologically analyzed the fracture types, the interval between the two fractures, general status of the patients, type of operation performed, and the postfracture independence level.

RESULTS

This survey comprises 84 patients (65 females and 19 males). Their ages ranged from 57 to 91 years (mean: 79) and 58 to 93 years (mean: 82) for the first and the second operation, respectively. The interval between the operations ranged from 2 to 297 months (mean: 35 months, median: 30 months). Twenty-three patients had subcapital fractures in both hips. In 54 patients, bilateral intertrochanteric fractures were noted. Only 7 patients had a previous subcapital fracture and a second intertrochanteric fracture. The general status of the patients' health was defined by the number of pre-existing major medical conditions and was found to be between 0 and 4 (mean: 2.15). Thirty-two patients (38%) had additional fractures somewhere between 1 and 8 years prior to the hip fracture (vertebra, proximal humerus, or distal radius). Sixty-eight and 56 out of the 84 patients reached the same mobility status after the first and second operation, respectively.

CONCLUSIONS

A tendency was found for the second hip fracture to be of the same type as the previous one. Most patients showed a good potential for rehabilitation and for maintaining their prefall functional level.

Incidence and risk factors for a second hip fracture in elderly women. The Study of Osteoporotic Fractures

Women with hip fracture have an increased risk of second hip fracture but other risk factors for a second hip fracture have not been established. We sought to determine the incidence and risk factors for second hip fracture, in a prospective cohort study of community-dwelling postmenopausal women over 65 years: the Study of Osteoporotic Fractures. From a cohort of 9,704 women, 632 women with a documented first hip fracture during the study were followed up until a second hip fracture or the end of follow-up. Clinical risk factors and bone mineral density were assessed at the beginning of the study. Fifty-three second hip fractures were validated by radiographs. Women with hip fracture had a 2.3% per year risk of second hip fracture. Women who walked for exercise at baseline were less likely to sustain a second hip fracture with a relative risk (RR) of 0.5 [0.3-0.9], as were those who had normal depth perception (RR=0.5 [0.3-0.9]). Women who lost weight since age 25 years had an increased risk of second incident hip fracture (RR = 2.7 [1.6-4.6]), as did those who had a low calcaneal bone mineral density (RR=1.5 [1.1-2.0] per standard deviation decrease in bone mineral density). Current use of estrogen replacement therapy at baseline was protective (RR=0.5 [0.3-0.9]) up to 2 years of follow-up. We conclude that community-dwelling women with a first hip fracture have a high risk of second hip fracture, and risk factors for this second fracture are similar to those of first hip fracture.

The underuse of therapy in the secondary prevention of hip fractures

There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.

Amelioration of osteoporosis by menatetrenone in elderly female Parkinson's disease patients with vitamin D deficiency

Significant reduction in bone mineral density (BMD) occurs in patients with Parkinson's disease (PD), correlating with immobilization and with vitamin D deficiency, and increasing the risk of hip fracture, especially in elderly women. As a biological indicator of compromised vitamin K status, an increased serum concentration of undercarboxylated osteocalcin (Oc) has been associated with reduced BMD in the hip and an increased risk of fracture in otherwise healthy elderly women. We evaluated treatment with vitamin K(2) (menatetrenone; MK-4) in maintaining BMD and reducing the incidence of nonvertebral fractures in elderly female patients with PD. In a random and prospective study of PD patients, 60 received 45 mg of MK-4 daily for 12 months, and the remaining 60 (untreated group) did not. At baseline, patients of both groups showed vitamin D and K(1) deficiencies, high serum levels of ionized calcium, and glutaminic residue (Glu) Oc, and low levels of parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)(2)D], indicating that immobilization-induced hypercalcemia inhibits renal synthesis of 1,25-(OH)(2)D and compensatory PTH secretion. BMD in the second metacarpals increased by 0.9% in the treated group and decreased by 4.3% in the untreated group (p < 0.0001). Vitamin K(2) level increased by 259.8% in the treated group. Correspondingly, significant decreases in Glu Oc and calcium were observed in the treated group, in association with an increase in both PTH and 1,25-(OH)(2)D. Ten patients sustained fractures (eight at the hip and two at other sites) in the untreated group, and one hip fracture occurred among treated patients (p = 0.0082; odds ratio = 11.5). The treatment with MK-4 can increase the BMD of vitamin D- and K-deficient bone by increasing vitamin K concentration, and it can also decrease calcium levels through inhibition of bone resorption, resulting in an increase in 1,25-(OH)(2)D concentration.

Functional recovery and length of stay after recurrent hip fracture

OBJECTIVE

To evaluate the functional recovery and the rehabilitation length of stay after the sequential fracture of both hips in elderly patients.

DESIGN

A total of 372 in-patients with hip fractures consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 333 out of 372 were admitted for rehabilitation of their first hip fracture, and the other 39 patients had a second contralateral fracture. The functional recovery was evaluated by the Barthel index. The comparison between the two groups was performed by unpaired t test. Stepwise linear multiple regression analysis was performed, including nine prognostic factors together with the number of hip fractures (first or recurrent) as independent variables and the Barthel index score on discharge as the dependent variable. The statistical analysis was repeated, substituting hospital length of stay for Barthel index.

RESULTS

Both the functional recovery and the length of stay of the patients affected by recurrent fracture were similar to the ones of the patients suffering from a single fracture. Regression analysis showed that the previous hip fracture was associated neither with the Barthel index nor with the length of stay.

CONCLUSIONS

Our data suggest that the functional recovery in elderly patients with hip fractures is not significantly influenced by a previous fracture of the contralateral hip and that no significant prolonged rehabilitation length of stay is needed after the recurrent fracture.

Vitamin K deficiency and osteopenia in vitamin D-deficient elderly women with Parkinson's disease

OBJECTIVE

To assess the influence of vitamin K on bone mineral density (BMD) in vitamin-D-deficient women with Parkinson's disease (PD).

DESIGN

Cross-sectional study.

SETTING

Neurology department at a university medical center in Japan.

PARTICIPANTS

Sixty-two women with PD (mean age, 70.7yr) and 62 age-matched controls. Patients were divided into 2 groups according to their functional capabilities: group A (independent: stages I-II of Hoehn and Yahr stages of Parkinson's disease, n = 26); and group B (dependent: Hoehn and Yahr stages 3-5; n = 36).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sera were analyzed to relate vitamin K concentrations to bone-related biochemical indices. BMD was measured by computed radiograph densitometry.

RESULTS

Group B had significantly lower metacarpal BMD (P <.0001) lower serum concentrations of vitamin K1 (P <.01) and 25-hydroxyvitamin D (25-OHD; P <.0001) than group A. Serum undercarboxylated osteocalcin levels were higher in group B than in group A (P <.0001). The serum concentration of vitamin K1 correlated positively with that of 25-OHD (r =.735, P <.0001), and negatively with undercarboxylated osteocalcin (r = -.751, P <.0001) and Hoehn and Yahr stages (r =.787, P <.0001). Multiple regression analysis identified Hoehn and Yahr stages, vitamin K1, 25-OHD, and undercarboxylated osteocalcin as independent determinants of BMD (P <.0364.0003).

CONCLUSION

In functionally dependent women with PD, nutritional vitamin K1 deficiency is believed to reduce production of fully carboxylated osteocalcin, causing reduced BMD.

Incidence of bilateral proximal femoral fractures in a tertiary care center

Over a 7-year period, a total of 545 osteoporotic fractures involving the proximal femur were treated at our institution. Twenty-nine patients sustained fractures of both hips, representing an overall incidence of bilateral hip fractures of approximately 5.5%. Of the 29 patients with bilateral hip fractures, adequate records and radiographs were avaialable for 28. There was a significant similarity between fracture patterns in the majority of bilateral hip fracture patients: 18 (64%) patients demonstrated similar fracture patterns on both sides. In these 18 patients, the average interval between fractures was approximately 1.7 years; in the remaining 10 patients, in whom the fractures were of dissimilar nature, the average interval between fractures was approximately 3.5 years. These findings suggest that at least 1 in 20 patients who sustain a fracture about the hip can expect to suffer a fracture involving the contralateral side. Moreover, the difference in the average interval for fractures of similar nature compared to fractures of dissimilar nature suggests the effects of physiologic age and the accordant changes in bone architecture play a larger role in predicting subsequent fracture pattern.

Risk factors for hip fracture among elderly patients with Parkinson's disease

Incidence of hip fracture among patients with Parkinson's disease (PD) is high, especially in elderly women. To determine effects of various factors on hip fracture risk, we prospectively studied fractures in a cohort of 115 elderly patients of both genders with PD (46 men, 69 women; mean age, 71.9 years) for 1 year. At baseline, we recorded body mass index (BMI), Hoehn and Yahr stage, and postmenopausal interval, and also measured bone mineral density (BMD) and serum concentrations of ionized calcium, intact parathyroid hormone (PTH), pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP; a bone resorption marker), and 25-hydroxyvitamin (25-OHD). During the year hip fractures occurred in 18 patients (2 male and 16 female). We compared baseline variables between patients with and without hip fracture. PD patients with decreased BMI, lower BMD, and low concentrations of serum ionized calcium, and 25-OHD (mean 4.0 ng/ml) with compensatory hyperparathyroidsim had increased risk of hip fracture. Female PD patients with long postmenopausal intervals also had increased hip fracture risk. BMI, illness duration, postmenopausal intervals, Hoehn and Yahr stage, 25-OHD, PTH, calcium, and ICTP were determinants of BMD in patients with fracture. Elderly PD patients with low BMI, low BMD, and serum 25-OHD concentrations < or =5 ng/ml with secondary hyperparathyroidism have increased risk of hip fracture, as do female PD patients with long postmenopausal intervals.

Stroke, a major and increasing risk factor for femoral neck fracture

BACKGROUND AND PURPOSE

Patients with stroke have up to a 4-fold increased risk of hip fracture because of their high incidence of falls and loss of bone mass in the paretic side, ie, hemiosteoporosis. The purpose of this study was to investigate the prevalence of previous stroke among patients with femoral neck fracture.

METHODS

The study included all 568 patients, aged >/=65 years, who underwent surgery for femoral neck fracture in 1980, 1983, 1987, 1993, and 1997 at the orthopedic clinic of Umeå University Hospital, Umeå, Sweden.

RESULTS

The prevalence of previous strokes ranged from 16.4% to 38.5% (P<0.001); this finding is only partly explained by the increased incidence of stroke in the corresponding population, and there was no significant increase in the overall incidence of femoral neck fracture. Fractures occurred 5.4+/-6.4 years after stroke (median 2.9 years, range 0 to 33 years). In stroke patients with unilateral stroke and persisting paresis at the time of fracture, 62.5% had their fracture on the paretic side (P=0. 034). Survival was significantly reduced in patients with previous stroke (P<0.001). In patients previously independently mobile, 69.2% with no previous stroke and 38.1% with previous stroke were still mobile at discharge from the orthopedic unit (P<0.001).

CONCLUSIONS

Attention must be focused on stroke as a major and increasing risk factor for femoral neck fracture and also on the poor postfracture outcome and reduced survival of these patients. Prevention of poststroke fractures is necessary and is aimed at reducing the risk of poststroke fall and preventing the development of hemiosteoporosis.