Mortality after distal radial fractures in the Medicare population

Selection for treatment of patients at high risk of fracture by the short versus long term prediction models - data from the Belgian FRISBEE cohort

Our imminent model was less sensitive but more selective than FRAX® in the choice of treatment to prevent imminent fractures. This new model decreased NNT by 30%, which could reduce the treatment costs. In the Belgian FRISBEE cohort, the effect of recency further decreased the selectivity of FRAX®.

PURPOSE

We analyzed the selection for treatment of patients at high risk of fracture by the Belgian FRISBEE imminent model and the FRAX® tool.

METHODS

We identified in the FRISBEE cohort subjects who sustained an incident MOF (mean age 76.5 ± 6.8 years). We calculated their estimated 10-year risk of fracture using FRAX® before and after adjustment for recency and the 2-year probability of fracture using the FRISBEE model.

RESULTS

After 6.8 years of follow-up, we validated 480 incident and 54 imminent MOFs. Of the subjects who had an imminent fracture, 94.0% had a fracture risk estimated above 20% by the FRAX® before correction for recency and 98.1% after adjustment, with a specificity of 20.2% and 5.9%, respectively. The sensitivity and specificity of the FRISBEE model at 2 years were 72.2% and 55.4%, respectively, for a threshold of 10%. For these thresholds, 47.3% of the patients were identified at high risk in both models before the correction, and 17.2% of them had an imminent MOF. The adjustment for recency did not change this selection. Before the correction, 34.2% of patients were selected for treatment by FRAX® only, and 18.8% would have had an imminent MOF. This percentage increased to 47% after the adjustment for recency, but only 6% of those would suffer a MOF within 2 years.

CONCLUSION

In our Belgian FRISBEE cohort, the imminent model was less sensitive but more selective in the selection of subjects in whom an imminent fracture should be prevented, resulting in a lower NNT. The correction for recency in this elderly population further decreased the selectivity of FRAX®. These data should be validated in additional cohorts before using them in everyday practice.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications.

INTRODUCTION

The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression.

RESULTS

A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40).

CONCLUSION

Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.

Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study

CONTEXT

Individualized fracture risk may help to select patients requiring a pharmacological treatment for osteoporosis. FRAX and the Garvan fracture risk calculators are the most used tools, although their external validation has shown significant differences in their risk prediction ability.

OBJECTIVE AND METHODS

Using data from the Fracture Risk Brussels Epidemiological Enquiry study, a cohort of 3560 postmenopausal women aged 60 to 85 years, we aimed to construct original 5-year fracture risk prediction models using validated clinical risk factors (CRFs). Three models of competing risk analysis were developed to predict major osteoporotic fractures (MOFs), all fractures, and central fractures (femoral neck, shoulder, clinical spine, pelvis, ribs, scapula, clavicle, sternum).

RESULTS

Age, a history of fracture, and hip or spine BMD were predictors common to the 3 models. Excessive alcohol intake and the presence of comorbidities were specific additional CRFs for MOFs, a history of fall for all fractures, and rheumatoid arthritis for central fractures. Our models predicted the fracture probability at 5 years with an acceptable accuracy (Brier scores ≤ 0.1) and had a good discrimination power (area under the receiver operating curve of 0.73 for MOFs and 0.72 for central fractures) when internally validated by bootstrap. Three simple nomograms, integrating significant CRFs and the mortality risk, were constructed for different fracture sites. In conclusion, we derived 3 models predicting fractures with an acceptable accuracy, particularly for MOFs and central fractures. The models are based on a limited number of CRFs, and we constructed nomograms for use in clinical practice.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning.

PURPOSE

To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over.

METHODS

Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes.

RESULTS

78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes.

CONCLUSION

Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further.

PROSPERO

CRD42018116478.

Wrist Hemiarthroplasty for Complex Intraarticular Distal Radius Fracture in a Patient with Manifest Osteoporosis

Distal radius fracture (DRF) is one of the most common fractures of the elderly. The higher the degree of joint surface destruction, and the more adverse factors are involved, the more challenging proper treatment becomes. In this regard, osteoporosis as underlying systemic disease, chondropathy or degeneration of adjacent wrist bones as well as incompliance significantly impair the success of the chosen primary therapy. Wrist hemiarthroplasty has already been reported as primary or secondary procedure for DRFs. In this case report, we present a patient with a severely comminuted DRF including posttraumatic degeneration of the lunate as well as manifest osteoporosis. Wrist hemiarthroplasty using the ReMotion radius component in combination with proximal row carpectomy was performed as secondary surgery. This procedure proved to be a viable treatment option in terms of achieving low pain levels, high range of motion values and stable osteointegration over a course of 6.5 follow-up years.

Prediction of an Imminent Fracture After an Index Fracture - Models Derived From the Frisbee Cohort

Patients who sustain a fracture are at greatest risk of recurrent fracture during the next 2 years. We propose three models to identify subjects most at risk of an imminent fracture, according to fracture site (any fracture, major osteoporotic fracture [MOF] or central). They were constructed using data of the prospective Frisbee cohort, which includes 3560 postmenopausal women aged 60 to 85 years who were followed for at least 5 years. A total of 881 subjects had a first incident validated fragility fracture before December 2018. Among these, we validated 130 imminent fractures occurring within the next 2 years; 79 were MOFs, and 88 were central fractures. Clinical risk factors were re-evaluated at the time of the index fracture. Fine and Gray proportional hazard models were derived separately for each group of fractures. The following risk factors were significantly associated with the risk of any imminent fracture: total hip bone mineral density (BMD) (p < 0.001), a fall history (p < 0.001), and comorbidities (p = 0.03). Age (p = 0.05 and p = 0.03, respectively) and a central fracture as the index fracture (p = 0.04 and p = 0.005, respectively) were additional predictors of MOFs and central fractures. The three prediction models are presented as nomograms. The calibration curves and the Brier scores based on bootstrap resampling showed calibration scores of 0.089 for MOF, 0.094 for central fractures, and 0.132 for any fractures. The predictive accuracy of the models expressed as area under the receiver operating characteristic (AUROC) curve (AUC) were 0.74 for central fractures, 0.72 for MOFs, and 0.66 for all fractures, respectively. These AUCs compare well with those of FRAX and Garvan to predict the 5- or 10-year fracture probability. In summary, five predictors (BMD, age, comorbidities, falls, and central fracture as the incident fracture) allow the calculation with a reasonable accuracy of the imminent risk of fracture at different sites (MOF, central fracture, and any fracture) after a recent sentinel fracture. © 2021 American Society for Bone and Mineral Research (ASBMR).

Risk factors for imminent fractures: a substudy of the FRISBEE cohort

Multiple factors increase the risk of an imminent fracture, including a recent fracture, older age, osteoporosis, comorbidities, and the fracture site. These findings could be a first step in the development of a model to predict an imminent fracture and select patients most at need of immediate treatment.

INTRODUCTION

The risk of a recurrent fragility fracture is maximal during the first 2 years following an incident fracture. In this prospective cohort study, we looked at the incidence of recurrent fractures within 2 years after a first incident fracture and we assessed independent clinical risk factors (CRFs) increasing this imminent fracture risk.

METHODS

A total of 3560 postmenopausal women recruited from 2007 to 2013 were surveyed yearly for the occurrence of fragility fractures. We identified patients who sustained a fracture during the first 2 years following a first incident fragility fracture. We quantified the risk of a new fracture and assessed independent CRFs, associated with an imminent fracture at various sites.

RESULTS

A recent fracture was a significant CRF for an imminent fracture (OR (95% CI): 3.7 (2.4-5.7) [p < 0.0001]). The incidence of an imminent fracture was higher in subjects above 80 years (p < 0.001). Other CRFs highly predictive in a multivariate analysis were osteoporosis diagnosis (p < 0.01), a central fracture as the index fracture (p < 0.01), and the presence of comorbidities (p < 0.05), with likelihood ratios of 1.9, 1.9, and 2.2, respectively. An imminent fracture was better predicted by a central fracture (p < 0.01) than by a major osteoporotic fracture. The hazard ratio was the highest for a central fracture.

CONCLUSION

In patients with a recent fracture, older age, osteoporosis, comorbidities, and fracture site were associated with an imminent fracture risk. These findings could be a first step in the development of a model to predict an imminent fracture and select patients most at need of immediate and most appropriate treatment.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures

Introduction:

Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups.

Materials and Methods:

Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated.

Results:

Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts.

Discussion/Conclusions:

The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care.

Level of evidence:

Prognostic Level III

Incidence of subsequent osteoporotic fractures after distal radius fractures and mortality of the subsequent distal radius fractures: a retrospective analysis of claims data of the Korea National Health Insurance Service

A better understanding of the features of subsequent fractures after distal radius fracture (DRF) is important for the prevention of further osteoporotic fractures. This study found that the cumulative incidence of subsequent osteoporotic fractures in South Korea increased over time and that the mortality rates of subsequent DRFs were lower than those of first-time DRFs.

INTRODUCTION

We examined the incidence of osteoporotic fractures following distal radius fractures (DRFs) and the mortality rate after subsequent DRFs using claims data from the Korea National Health Insurance (KNHI) Service.

METHODS

We identified records for 41,417 patients with first-time DRFs in 2012. The occurrence of osteoporotic fractures of the spine, hip, wrist, and humerus at least 6 months after the index DRF was tracked through 2016. All fractures were identified by specific diagnosis and procedure codes. One-year mortality rates and standardized mortality ratios (SMRs) for initial and subsequent DRFs were calculated for all patients.

RESULTS

The 4-year cumulative incidence of all subsequent osteoporotic fractures was 14.74% (6105/41,417; 9.47% in men, 15.9% in women). The number of associated subsequent fractures was 2850 for the spine (46.68%), 2271 for the wrist (37.2%), 708 for the hip (11.6%), and 276 for the humerus (4.52%). The cumulative mortality rate 1 year after the first-time and subsequent DRF was 1.47% and 0.71%, respectively, and the overall SMR was 1.48 (95% CI: 1.37-1.61) and 0.71 (95% CI: 0.42-1.21), respectively.

CONCLUSION

The cumulative incidence of osteoporotic fractures following DRFs increased over the study period and was higher among women. The cumulative mortality rates and SMRs of subsequent DRFs were lower than those of first-time DRFs at the 1-year follow-up. Given the increasing incidence rate of DRFs, the incidence of subsequent osteoporotic fractures may also increase.

Mortality and cause of death in distal radius fracture patients: A longitudinal follow-up study using a national sample cohort

The various harmful impacts of distal radius fractures (DRFs) may cause adverse effects. Although previous studies have reported the adverse effects of DRFs on mortality, most studies were performed in adults of advanced age and paid little attention to confounding factors of mortality. Furthermore, most of these studies investigated the overall impact of DRFs on mortality without differentiating the specified causes of death.The purpose of the present study was to estimate the risk of mortality in DRF patients according to the cause of death.Data from the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002 to 2013 were collected. A total of 27,295 DRF participants who were 50 years or older were 1:4 matched with control participants for age, sex, income, and region of residence. The causes of death were grouped into 12 classifications.DRFs were not associated with increased overall mortality. The adjusted hazard ratio (HR) of mortality was 1.04 (95% confidence interval [CI] = 0.98-1.11, P = .237). The adjusted HR for mortality was not significantly different according to age. The odds ratio of overall mortality was 1.03 (95% CI = 0.97-1.11, P = .329).DRFs were not associated with a significant increase in mortality.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.

Higher Mortality in Men Compared with Women following Distal Radius Fracture in Population Aged 50 Years or Above: Are Common Distal Radius Fracture Classifications Useful in Predicting Mortality?

Introduction

Distal radius fractures (DRF) are one of the most common fractures with growing incidence in developed countries and are a reliable predictor of another osteoporotic fracture. Data concerning DRF mortality are conflicting and vague. Usefulness of common DRF classification systems in predicting mortality is unexplored.

Methods

We identified all patients hospitalized between January 1^st 2008 and May 30^th 2015 with isolated distal radius fracture, aged 50 y/o or above, in a 1^st level trauma center in Poland. Fractures were evaluated according to AO, Frykman, and Fernandez classifications. Mortality ratios and long-term survival analysis with Kaplan-Meier estimator and log-rank tests with univariate and multivariate Cox proportional hazards model were used.

Results

We enrolled 1308 consecutive patients. The average age of the entire cohort was 72.5 ± 12 years. The study group consisted of 256 men (19.6%) with mean age 66 ± 12 y/o and 1052 women (80.4%) with mean age 74 ± 12 y/o. Men were statistically younger at the time of the fracture than women (p<0.0001). After 1-year follow-up the overall study group mortality ratio was 4.5%, being 2.2-fold higher in men compared to women. In long-term survival analysis, excess men mortality remained significant. Factors associated with higher mortality at any point of the study were age (HR: 1.08, 95%CI: 1.07-1.10, p<0.000001), male sex (HR: 1.92, 95%CI: 1.34-2.77; p<0.001), AO type A (HR: 1.64 95%CI 1.19-2.25, p<0.01), and Frykman type I (HR: 2.12 95%CI: 1.36-3.29, p<0.001).

Conclusion

Distal radius fractures are connected with premature mortality. Men have higher mortality compared with women following distal radius fracture in population aged 50 years or above. Simple extra articular fractures classified as AO type A or Frykman type I may be predictors of higher mortality in DRF cohort.

Anaesthetic aspects in the treatment of fragility fracture patients

As longevity increases globally, the number of older, frailer, comorbid patients requiring fragility fracture surgery will increase. Fundamentally, anaesthesia should aim to maintain these patients' pre-fracture cognitive and physiological trajectories and facilitate early (ie day 1) postoperative recovery. This review describes the 10 general principles of anaesthesia for fragility fracture surgery that best achieve these aims: multidisciplinary care, 'getting it right first time', timely surgery, standardisation, sympathetic anaesthesia, avoiding ischaemia, sympathetic analgesia, re-enablement, data collection and training.

Comorbidities Only Account for a Small Proportion of Excess Mortality After Fracture: A Record Linkage Study of Individual Fracture Types

Nonhip, nonvertebral (NHNV) fractures constitute the majority of osteoporotic fractures, but few studies have examined the association between these fractures, comorbidity, and mortality. Our objective was to examine the relationship between individual nonhip, nonvertebral fractures, comorbidities, and mortality. The prospective population-based cohort of 267,043 subjects (45 and Up Study, Australia) had baseline questionnaires linked to hospital administrative and all-cause mortality data from 2006 to 2013. Associations between fracture and mortality were examined using multivariate, time-dependent Cox models, adjusted for age, prior fracture, body mass index, smoking, and comorbidities (cardiovascular disease, diabetes, stroke, thrombosis, and cancer), and survival function curves. Population attributable fraction was calculated for each level of risk exposure. During 1,490,651 person-years, women and men experienced 7571 and 4571 fractures and 7064 deaths and 11,078 deaths, respectively. In addition to hip and vertebral fractures, pelvis, humerus, clavicle, rib, proximal tibia/fibula, elbow and distal forearm fractures in both sexes, and ankle fractures in men were associated with increased multivariable-adjusted mortality hazard ratios ranging from 1.3 to 3.4. Comorbidity independently added to mortality such that a woman with a humeral fracture and 1 comorbidity had a similarly reduced 5-year survival as that of a woman with a hip fracture and no comorbidities. Population mortality attributable to any fracture without comorbidity was 9.2% in women and 5.3% in men. All proximal nonhip, nonvertebral fractures in women and men were associated with increased mortality risk. Coexistent comorbidities independently further increased mortality. Population attributable risk for mortality for fractures was similar to cardiovascular disease and diabetes, highlighting their importance and potential benefit for early intervention and treatment. © 2018 American Society for Bone and Mineral Research.

Global Forum: Fractures in the Elderly

Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.