Subsequent hip fracture among older adults

Impact of Stroke History on the Risk of Recurrent Hip Fracture or Major Osteoporotic Fractures among Patients with Incident Hip Fracture: A Nationwide Cohort Study

Considerable uncertainty prevails regarding risk factors for recurrent fracture among older patients with hip fracture. We aimed to investigate the relationship between prefracture stroke history, baseline mobility, and the risk of recurrent hip fracture. This cohort study was based on the Danish Multidisciplinary Hip Fracture Registry, 2011-2018 (n = 48,230). We estimated cumulative incidence (competing risk of death) of recurrent hip fracture and major osteoporotic fractures within 1 and 2 years comparing patients with/without prefracture stroke history. Analyses were performed overall and stratified on baseline mobility status (good mobility: Cumulated Ambulation Score ≥ 5 versus poor mobility: Cumulated Ambulation Score < 5). Using Cox regression, adjusted cause-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were obtained. The 1-year cumulative incidence was 4.6% (95% CI: 3.9-5.4) among patients with stroke history and 4.3% (95% CI: 4.1-4.5) among patients without stroke history. For patients with good mobility, the cumulative incidence of recurrent hip fracture was 5.8% (95% CI: 4.3-7.5) versus 3.7% (95% CI: 3.4-4.0) for patients with versus without stroke history. Corresponding numbers for patients with poor mobility were 4.4% (95% CI: 3.6-5.5) and 5.0% (95% CI: 4.7-5.3). Stroke history was associated with an adjusted HR of 1.55 (95% CI: 1.15-2.10) for recurrent fracture among patients with good mobility. In contrast, no association was observed among patients with poor mobility (adjusted HR 0.88 [95% CI: 0.70-1.10]). The associations were attenuated after 2 years of follow-up and for major osteoporotic fractures. In conclusion, stroke history was associated with slightly higher risk of recurrent fracture among patients with first-time hip fracture in the overall analysis, although the CI included a null result. The association was modified by baseline mobility: Patients with stroke history and good mobility had a markedly higher risk, whereas patients with stroke and poor mobility did not. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Association between self-rated health and the risk of hip fracture and mortality in a cohort of older women during a 10-year follow-up

Fragility fracture of the hip is associated with reduced functional status and mortality. Poor self-rated health (SRH) might be such an indicator. Our aim was to study if SRH was associated with hip fractures and all-cause mortality within the next 10 years in community-dwelling older women. A population-based sample of 350 women aged between 69 and 79 years (median 72.4) assessed their SRH by answering the question "How would you rate your health right now" by putting a mark on a visual-analogue scale (0-100 mm). Information on hip fracture and mortality over the next 10 years was retrieved from health care registers. The association between SRH and hip fracture and all-cause mortality was tested with a Cox proportional hazards regression model. SRH was divided into low, intermediate, and high (reference) assessed SRH. During the study, 40 hip fractures and 72 deaths occurred. The median value of SRH was 62 mm (IQR 50-81 mm). The age-adjusted hazard ratio (HR) for hip fracture was significantly higher in the group with low and intermediate SRH; HR: 3.17 (95% CI 1.25-8.01), and HR: 2.75 (95% CI 1.08-7.04), compared with high SRH. Adding bone mineral density (at the femoral neck) gave even greater risk. We did not find the hypothesized association between SRH and mortality. In our study, SRH indicated a higher risk of future hip fracture in older women. SRH might be a marker that could add information about the risk of hip fracture independently of bone mineral density.

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.

Patterns of Prescription Drug Use Before and After Fragility Fracture

IMPORTANCE

Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture.

OBJECTIVE

To describe the use of prescription drugs associated with fracture risk before and after fragility fracture.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period.

EXPOSURES

Prescription drug use during the 4-month period before and after a fragility fracture.

MAIN OUTCOMES AND MEASURES

Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked.

RESULTS

A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture.

CONCLUSIONS AND RELEVANCE

Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.

Can radiographs of hip fractures predict subsequent hip fractures? A shape modelling analysis

INTRODUCTION

The geometrical shape of the proximal femur has previously been shown to predict primary hip fractures. Hip fractures are routinely diagnosed on plain radiographs of the pelvis, and these have both hips viewable. We have investigated if statistical shape modelling of the uninvolved hip on plain radiographs, at the time of the first hip fracture episode, could predict a subsequent 'second fracture' on that (uninvolved) side.

MATERIALS AND METHODS

60 radiographs taken at the time of the index hip fracture were blinded and separated into two arms; patients sustaining one hip fracture only (n=30), and those who went on to sustain a second fracture (n=30), over the three-year follow-up period. Two separate shape models were used for these groups and compared using t-tests or Mann-Whitney U-tests, along with Cohen's d to measure the effect size of each measure.

RESULTS

We found no statistically significant difference in the shape of the femur between the first fracture and second fracture group (p>0.05) and no results reached a "medium" effect size (Cohen's d <0.5).

CONCLUSIONS

Shape modelling is feasible and can be applied in the routine clinical setting. However, we were unable to elucidate any predictive value in this relatively small sample. A reliable radiograph-based method of identifying patients at risk of second fracture would be of value in planning prevention, service provision, and cost analysis. Further work is required and a study with more patients might exclude the type 2 error in our work.

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.

Factors influencing length of stay and mortality after first and second hip fractures: an event modeling analysis

OBJECTIVE

The aim of this study was to investigate factors influencing length of stay and mortality in first and second hip fractures.

DESIGN

This was a retrospective study with data analysis.

SETTING

The study was conducted at a level 1 trauma center.

PATIENTS

Six hundred and seventy-two patients treated for hip fractures (OTA 31-A, 31-B, 32-A1.1) over 30 months were split into 2 groups. 1FG: Six hundred and ten patients (90.8%) suffered a fracture for the first time. 2FG: Sixty-two patients (9.2%) had previously sustained contralateral fractures.

INTERVENTION

Dynamic hip screws or cephalomedullary nails (31-A fractures); cephalomedullary nails (32-A1.1); dynamic hip screws or cannulated screws (undisplaced 31-B fractures); and hemiarthroplasty (displaced 31-B fractures) were used.

MAIN OUTCOME MEASURES

Postoperative lengths of stay on trauma ward (LOS-T) on the rehabilitation unit (LOS-R) and in hospital (LOS-H) were calculated. Dates of death were recorded. Event analysis and structural equation modeling were used to assess the impact of second fractures, fracture types, age, gender, and ASA grades on these.

RESULTS

: The 2 groups were comparable in gender distribution, ASA grades, fracture types, LOS, and mortality at 120 days. 2FG patients were older than 1FG (mean 83.3 vs 80.2 years) with a higher proportion being discharged to institutional care (35.5% vs 18.5%). Event modeling analysis showed that LOS-T was dependent on ASA grade, whereas mortality was dependent on ASA grade, age, and gender. Second fractures were not related to the risks of increased LOS-T, LOS-R, and mortality.

CONCLUSIONS

Second fractures per se do not increase the risk of longer postoperative stay or higher mortality. Any observed effect on these outcomes in second fractures represents the influence of increasing age.

LEVEL OF EVIDENCE

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

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.

Post-discharge management following hip fracture--get you back to B4: a parallel group, randomized controlled trial study protocol

BACKGROUND

Fall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes.

METHODS/DESIGN

This is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture. We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service. Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01254942.

Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008

OBJECTIVES

To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.

DESIGN

Retrospective analysis.

SETTING

Acute care hospitals in California.

PATIENTS

All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.

MAIN OUTCOME MEASURE

Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.

RESULTS

Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.

CONCLUSION

Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.

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.

Is prophylactic fixation a cost-effective method to prevent a future contralateral fragility hip fracture?

OBJECTIVE

: A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture.

METHODS

: A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation.

RESULTS

: In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure.

CONCLUSION

: Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.

2008 Santa Fe Bone Symposium: update on osteoporosis

The Ninth Annual Santa Fe Bone Symposium was held on August 1-2, 2008, in Santa Fe, New Mexico, USA. The symposium faculty presented the current best evidence on selected topics of clinical relevance in the fields of osteoporosis, metabolic bone disease, and assessment of skeletal health. The educational venues were in the form of didactic presentations, panel discussions, challenging cases, and numerous interactive discussions. Knowledge of basic science and clinical trials was applied to real-world patient scenarios that were discussed by faculty experts and clinician participants. Topics included an update on the rationale and development of new agents for the treatment of osteoporosis, the use of bone turnover markers in clinical practice, hospital-based pathways for the management of hip fracture patients, injectable bisphosphonates for the treatment of osteoporosis, combination therapy with anabolic and antiresorptive agents, and assessment of skeletal health with devices other than central dual-energy X-ray absorptiometry. This is a collection of scientific essays based on presentations and discussions at the 2008 Santa Fe Bone Symposium.

Simultaneous bilateral hip fractures in a level I trauma center

BACKGROUND

Hip fractures are a common occurrence among the population today, especially in the elderly. However, the incidence of simultaneous bilateral hip fractures is very rare, and there is a paucity of data in the current literature documenting patients with these hip fractures.

METHODS

A retrospective case review was performed on all patients treated for hip fractures during the past ten years at our Level I trauma center.

RESULTS

From 1993 to 2002 there were eight patients who sustained simultaneous bilateral hip fractures. The mean age of the patients was 63 years (range, 34-88 years). The overall survival rate was 63%. In the patients of age group younger than 65, the survival rate was three out of four (75%). In the patients of age group 65 and older, the survival rate was two of four (50%). The length of hospital stay was shorter on average for the younger population, 19 days (range, 17-27 days). The average hospital duration for the older population was 29 days (range, 28-30).

CONCLUSION

Bilateral hip fractures are usually the result of a high-energy trauma and are associated with other injuries. The morbidity and mortality of this injury are quite high. Patient age, associated injuries, and comorbid conditions should be examined closely because they may influence the patient's recovery.

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.

Secondary prevention of hip fractures among the hospitalized elderly: are we doing enough?

BACKGROUND

Older individuals with hip fractures almost always have osteoporosis. Such individuals are at increased risk of experiencing other osteoporotic fractures, including recurrent hip fractures. The management of such patients should include assessing bone mineral density and treating osteoporosis.

OBJECTIVE

The objective of this study was to investigate if elderly (> or =65 years) patients with hip fractures were assessed and treated for osteoporosis.

METHODS

A retrospective chart review was conducted of all elderly patients who underwent hip fracture surgery at a university teaching hospital during the calendar years 1997 to 1999.

RESULTS

A total of 95 subjects were identified (29% males and 71% females). Subjects' age ranged from 65 to 96 years with a mean (+/-standard deviation) 81 +/- 7 years. Femoral neck fractures were the most common (51%), followed by intertrochanteric (43%) and subtrochanteric fractures (3%). Two subjects (2%) had fractures at multiple sites. The most common cause of a hip fracture was a fall (87%). Other causes included motor vehicle accidents (6%) as well as other trauma (4%). One subject had a spontaneous hip fracture. A history of hip fractures was obtained in 8% of subjects. Osteoporosis was diagnosed in 17% of subjects before admission. On admission, 9% of subjects were receiving calcium, 3% were receiving vitamin D, none were receiving alendronate, and 1 subject was receiving calcitonin. Approximately 3% of female subjects were receiving estrogen on admission. On discharge, 11% of subjects were prescribed calcium, 6% were prescribed vitamin D, none were prescribed alendronate, and 2% were on calcitonin. None of the female subjects were discharged on estrogen. During hospitalization, 88% of subjects who were admitted to nonmedical services were seen by either a geriatric or a general internal medicine consult. Obtaining a medical and/or geriatric consult did not have an apparent effect on the frequency of treating osteoporosis in this high-risk group of subjects.

CONCLUSION

Older adults with hip fractures are not adequately treated for osteoporosis. This places them at increased risk of other osteoporotic fractures, including recurrent 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.

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.

The patient with a fragility fracture: an evolving role for the orthopaedic surgeon

Osteoporosis can now be diagnosed readily, and treatments that increase bone mineral density and decrease fracture risk, even after fragility fracture has occurred, are now available. Clinical guidelines for management of osteoporosis unanimously recognize that fracture risk is highest among those who have already sustained a fracture, and encourage prompt evaluation and treatment of these individuals. Despite these guidelines, most women who experience fragility fractures remain untreated (for osteoporosis) by any of the physicians involved in their care. Barriers to diagnosis and treatment have been identified, including uncertainty about the responsibility for such management. The orthopaedic surgeon has a unique opportunity to initiate definitive osteoporosis evaluation and treatment in patients who present with fractures, and recent guidelines support the evolution of the role of the orthopaedist in this direction.

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.

A longitudinal evaluation of patients' perceptions of Parkinson's disease

PURPOSE

Parkinson's disease (PD) is a chronic progressive neurological disorder that frequently results in nearly total disability. This study examined changes over 3 years in patients' experiences living with PD, and explored how participants' health perceptions and predicted mortality at baseline related to their actual death by Year 3.

DESIGN AND METHODS

Data were obtained from a local sample of 109 participants by in-home interviews.

RESULTS

The collected results (1) suggested a disconnection between the participants' responses to open-ended questions about the disorder, compared with their responses to questions structured by the investigators; (2) demonstrated changes in responses to structured and open-ended questions; and (3) demonstrated that respondents who declined to predict whether they would be living in 10 years were three times more likely to die by Year 3 than those who answered the question.

IMPLICATIONS

Results demonstrate the importance of identifying the most important issues for the individual with PD and suggest that these issues may change over time. Results also raise issues surrounding how patients' perceptions influence the course of their disease.

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.

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.

How well are community-living women treated for osteoporosis after hip fracture?

OBJECTIVES

To examine whether women with recent hip fracture are receiving adequate treatment for osteoporosis. To examine patient and physician characteristics associated with adequate treatment for osteoporosis.

DESIGN

Cross-sectional study with prospective and retrospective data collection.

SETTING

Hartford County, Connecticut.

PARTICIPANTS

Sixty community-living women age 65 and older identified from hospital databases with an International Classification of Diseases, Ninth Revision, code for nontraumatic hip fracture.

MEASUREMENTS

Treatment for osteoporosis, healthcare utilization, primary care physician's specialty, Katz activities of daily living scale, Lawton instrumental activities of daily living scale, Short Portable Mental Status Questionnaire, Medical Outcomes Study Short Form 12, and Physical Activity Scale for the Elderly.

RESULTS

Only 13% of participants were receiving adequate treatment for osteoporosis as defined by the National Osteoporosis Foundation (NOF) guidelines for osteoporosis, 47% reported partial treatment that did not meet NOF guidelines, and 40% were receiving no treatment for osteoporosis. No patient or physician characteristics were associated with the adequacy of treatment for osteoporosis in this small sample.

CONCLUSIONS

Few of the women in our study were receiving adequate treatment for osteoporosis after hip fracture. There exists an opportunity to educate postmenopausal women and physicians about the importance of treatment for osteoporosis to increase the number of women offered and receiving osteoporosis treatment, especially older postmenopausal women with established, severe osteoporosis as evidenced by recent hip fracture.

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.

Identifying risk factors for and preventing hip fractures in elderly patients

Changing the mind-set of Americans to exercise more, eat right, and be responsible for their own health throughout the continuum of life is a challenge for all health care professionals. Through personal interaction with patients and participation in hospitalwide or communitywide education programs, perioperative nurses play a key role in educating the public about prevention of hip fractures in elderly patients.

The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study

OBJECTIVES

The purpose of this study was to prospectively assess the independent effect of hip fracture on mortalìty, hospitalization, and functional status.

METHODS

Among 7527 members of the Longitudinal Study of Aging who were over age 70 at baseline, 368 persons with hip fracture occurring between 1984 and 1991 were identified. Median length of follow-up was 831 days.

RESULTS

Hip fracture was significantly related to mortality (adjusted hazards ratio [AHR] = 1.83; 95% confidence interval [CI] = 1.55, 2.16) when treated as a time-dependent covariate. This effect was concentrated in the first 6 months postfracture (AHR = 38.93, 95% CI = 29.58, 51.23, vs AHR = 1.17; 95% CI = 0.95, 1.44). Hip fracture significantly increased the likelihood of subsequent hospitalization (adjusted odds ratio = 3.31, 95% CI = 2.64, 4.15) and increased the number of subsequent episodes by 9.4%, the number of hospital days by 21.3%, and total charges by 16.3%. Hip fracture also increased the number of functional status dependencies.

CONCLUSIONS

The health of older adults deteriorates after hip fracture, and efforts to reduce the incidence of hip fracture could lower subsequent mortality, morbidity, and health services use.