Epidemiology of hip fracture: Worldwide geographic variation

Molecular mechanisms and treatment strategies for estrogen deficiency-related and glucocorticoid-induced osteoporosis: a comprehensive review

Osteoporosis, a debilitating condition characterized by reduced bone mass and increased fracture risk, is notably influenced by estrogen deficiency and glucocorticoid treatment. This comprehensive review elucidates the molecular mechanisms underpinning estrogen deficiency-related osteoporosis (EDOP) and glucocorticoid-induced osteoporosis (GIOP). The role of estrogen in bone metabolism is critically examined, highlighting its regulatory effects on bone turnover and formation through various signaling pathways. Conversely, this review explores how glucocorticoids disrupt bone homeostasis, focusing on their impact on osteoclast and osteoblast function and the subsequent alteration of bone remodeling processes. The pathogenesis of both conditions is intertwined, with estrogen receptor signaling pathways and the role of inflammatory cytokines being pivotal in driving bone loss. A detailed analysis of pathogenetic and risk factors associated with EDOP and GIOP is presented, including lifestyle and genetic factors contributing to disease progression. Modern therapeutic approaches emphasize pharmacologic, non-pharmacologic, and herbal treatments for managing EDOP and GIOP. In summary, current therapeutic strategies highlight the efficacy and the safety of various interventions. This review concludes with future directions for research, suggesting a need for novel treatment modalities and a deeper understanding of the underlying mechanisms of osteoporosis. By addressing the multifaceted nature of EDOP and GIOP, this work aims to provide insights into developing targeted therapeutic strategies and improving patient outcomes in osteoporosis management.

Association between markers of inflammation and outcomes after hip fracture surgery: analysis of routinely collected electronic healthcare data

BACKGROUND

Risk assessment tools such as the Nottingham Hip Fracture Score (NHFS) are crucial in guiding prognostic discussions and benchmarking in hip fracture care. These scores have scope to be improved, which may help identify higher-risk patients at admission. We investigated the role of inflammatory biomarkers, which are routinely collected at admission, in predicting post-operative outcomes following hip fracture. We subsequently combined these biomarkers with the NHFS to see if we could enhance risk prediction.

METHODS

We analysed data from patients admitted to a trauma unit with hip fracture between 2015 and 2020 who underwent operative management. National hip fracture database (NHFD) data, including the NHFS, were linked with admission biomarkers: albumin, C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR). Following univariate and multivariate analyses, the discrimination of the NHFS with and without each biomarker was assessed for 30-day mortality, length of stay (LOS), and failure to return home at 30 days.

RESULTS

We analysed 1039 patients, 719 (69.2%) were female and the mean age was 82.5 years (SD 8.1, range 60-104). In multivariate analysis, higher CRP was associated with higher 30-day mortality (odds ratio (OR) 1.23, 95%, confidence interval (CI) 1.04-1.44, p = 0.013); higher albumin was associated with lower 30-day mortality (OR 0.86, 95%CI 0.81-0.91, p < 0.001). Independent predictors of not returning home at 30 days included albumin (OR 0.94, 95% CI 0.91-0.98) and NLR (OR 1.44, 95% CI 1.14-1.81). NLR and MLR were significantly associated with prolonged LOS but not 30-day mortality. A composite variable of NHFS and albumin had better discrimination for 30-day mortality than NHFS alone (c-statistics 0.74, 95% CI 0.68-0.80 vs. 0.68, 95% CI 0.62-0.75, respectively). CRP, NLR and MLR did not improve discrimination for any outcome when added to NHFS.

CONCLUSIONS

Albumin, but not other markers of inflammation, enhances risk prediction after hip fracture when added to the NHFS. Routine recording of albumin at admission may have a future role in an enhanced risk scoring system for prognostication in hip fracture surgery.

Concurrent effects of high-intensity interval training and vitamin D supplementation on bone metabolism among women diagnosed with osteoporosis: a randomized controlled trial

BACKGROUND

Osteoporosis is often responsible for bone fragility and increased fracture risk due to the micro-architectural deterioration of bone tissue. In addition to nutritional supplements, exercise is considered an adjunct factor in safeguarding bone health. This study aimed to investigate the effects of 16-week high-intensity interval training (HIIT) and vitamin D supplementation on bone mineral density (BMD) in women with osteoporosis.

TRIAL DESIGN

This study used a four-arm pretest-posttest experimental randomized controlled design.

METHODS

One hundred twenty sedentary women aged (30-50 years), diagnosed with osteoporosis were recruited in this study. Patients were randomly classified into four groups with 30 patients in each group: control group (normal daily activities), exercise group (HIIT-exercise for 16 weeks), Vitamin D group (vitamin D 800IU/ day for 16 weeks), and concurrent group (HIIT exercise plus vitamin D for 16 weeks). Anthropometric measurements, BMD, and serum levels of vitamin 25-(OH) D, Osteocalcin, s-BAP, and calcium were estimated in all participants before and after exercise training.

RESULTS

Serum samples revealed that bone resorption markers, osteocalcin, total calcium, s-BAP, and vitamin 25(OH) D significantly improved in all groups; there was greater improvement in the HIIT training-vitamin D group than in the HIIT training, vitamin D, and control groups. Furthermore, the HIIT training-vitamin D group showed improvements in hip (right and left) and lumbar spine BMD than the HIIT training, Vitamin D, and Control groups. BMD improvements correlated positively with serum osteocalcin levels and total calcium and negatively with BMI and s-BAP.

CONCLUSIONS

Sixteen weeks of HIIT and vitamin D consumption showed greater benefits for BMD levels in women with osteoporosis than either vitamin D consumption or HIIT training alone. Therefore, HIIT plus vitamin D consumption may be a strategic option to prevent BMD reduction with aging or to slow demineralization.

TRIAL REGISTRATION

The study protocol was retrospectively registered at 'ClinicalTrials.gov PRS' under the trial identifier NCT06624657, dated 1/10/2024.

Anatomical structure of the medullary cavity of proximal femur with three-dimensional computed tomography

BACKGROUND

The lateral femoral wall is an important anatomical parameter of the proximal femur, but intramedullary nail fixation for intertrochanteric fractures may cause iatrogenic lateral wall fractures due to population-based design differences. This study aims to measure the anatomical parameters of the proximal femoral medullary cavity and provide data to help design intramedullary nails tailored to the Chinese population to reduce the risk of complications such as lateral wall fractures.

METHODS

Consecutive patients undergoing full-length or upper half CT scans of the femur were included from January 2010 to December 2021. The anatomical parameters of medullary cavity were defined and measured, including prominence length, canal-shaft angle and proximal minimum diameter. Intraclass Correlation Coefficient (ICC) was used to estimate the inter- and intra-observer agreements.

RESULTS

A total of 168 patients, comprising 78 men and 90 women, were included. The mean prominence length was 67.4 ± 4.9 mm (males: 70.8 ± 3.6 mm, females: 64.4 ± 3.9 mm). The mean canal-shaft angle was 5.5° ± 0.7° (males: 5.6 ± 0.8°, females: 5.5 ± 0.7°). The mean proximal minimum diameter was 22.7 ± 1.8 mm (males: 24.0 ± 1.5 mm, females: 21.6 ± 1.4 mm) at the level of 1/3 prominence length from bottom to top. Gender differences were observed in these parameters (p < 0.001) except for the canal-shaft angle (p = 0.45). The mean proximal minimum diameter was significantly larger in the group aged 50 years and older (23.1 ± 1.7 mm) compared to the group younger than 50 years (22.4 ± 1.9 mm) (p = 0.02). Inter- and intra-observer agreement was almost perfect for all the parameters (all ICC values > 0.8).

CONCLUSIONS

Males have a longer prominence length and larger proximal minimum diameter than females. The proximal minimum diameter is larger in the older population than in the younger population. The measurement results help support the design of intramedullary nails tailored to the Chinese population.

CLINICAL TRIAL NUMBER

Not applicable.

Factors Associated with Mortality and Short-Term Patient Outcomes for Hip Fracture Repair in the Elderly Based on Preoperative Anticoagulation Status

Background: The one-year mortality risk for elderly patients undergoing proximal femur fracture repair surgery is three to four times higher compared to the general population. Other than time to surgery, risk factors for postoperative morbidity and mortality following surgery are poorly understood in the elderly. We sought to identify risk factors associated with morbidity and mortality in geriatric patients by anticoagulation status undergoing hip fracture repair. Methods: Patients aged ≥65 years undergoing surgery for hip fracture repair were included (2009-2019) from a US-based hip fracture registry. Factors associated with 90-day mortality were determined using multivariable logistic regression and stratified by antithrombotic agent medication use prior to surgery. Direct oral anticoagulation (DOAC) medications were the largest group, and all antithrombotic agents were included in the delineation. Results: A total of 35,463 patients were identified, and 87.1% (N = 30,902) were DOAC-naïve. Risk factors for 90-day mortality in DOAC-naïve patients were an American Society of Anesthesiologist's (ASA) classification ≥3 (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 2.24-2.93), preoperative myocardial infarction (OR = 1.87, 95% CI = 1.33-2.64), male gender (OR = 1.73, 95% CI = 1.59-1.88), congestive heart failure (CHF) (OR = 1.64, 95% CI = 1.50-1.80), psychoses (OR = 1.27, 95% CI = 1.15-1.42), renal failure (OR = 1.29, 95% CI = 1.19-1.40), smoking history (OR = 1.19, 95% CI = 1.09-1.29), chronic pulmonary disease (OR = 1.14, 95% CI = 1.05-1.25), increasing age (OR = 1.07, 95% CI = 1.06-1.07), and decreasing body mass index (BMI) (OR = 1.06, 95% CI = 1.05-1.08). Identified factors for mortality in the DOAC group also included ASA classification ≥3 (OR = 2.15, 95% CI = 1.44-3.20), male gender (OR = 1.68, 95% CI = 1.41-2.01), CHF (OR = 1.45, 95% CI = 1.22-1.73), chronic pulmonary disease (OR = 1.34, 95% CI = 1.12-1.61), decreasing BMI (OR = 1.04, 95% CI = 1.02-1.06), and increasing age (OR = 1.02, 95% CI = 1.01-1.03). Conclusions: Regardless of preoperative DOAC status, ASA classification, gender, CHF, chronic pulmonary disease, lower BMI, and higher age are associated with an increased risk of mortality. Some of these comorbidities can be utilized for risk stratification prior to surgery.

Who breaks their hip? A decade of traumatic hip fracture data

Aims & objectives

Hip fractures lead to significant morbidity, mortality, and healthcare costs, particularly in elderly populations. Understanding the mechanisms underlying these fractures is crucial for developing targeted prevention strategies and counseling patients.

Methods

The National Electronic Injury Surveillance System (NEISS) was utilized to identify a cohort of 25,068 hip fractures from 2013 to 2022. The inclusion criteria mandated classification as a lower trunk fracture and explicit mention of hip fracture in the narrative. Patient age, race, sex, incident location, the time of year, and associated consumer products were compared using 95% confidence intervals and Chi-Squared tests of independence.

Results

A total of 25,068 hip fracture patients were included in this study. Females were more likely to fracture their hip (P < .001) representing 68.4% (95% CI 67.8%-69.0%) of all fractures. Patients were most likely to injure themselves at home (P < .001), accounting for 62.0 % (95% CI 61.4%-62.6%) of fractures. Falls to the floor represented 36.0 % (95% CI 35.4%-36.6%) of fractures, while fractures related to beds, stairs, and chairs emerged as other prevalent mechanisms at 11.2% (95% CI 10.8%-11.6%), 7.9% (95% CI 7.5%-8.2%), and 5.4% (95% CI 5.1%-5.7%), respectively. In the 50-60 age group, stairs present a prominent risk, representing 12.4% (95% CI 10.6%-14.5%) of fractures. Younger individuals suffered fractures most commonly due to high energy activities, such as falls from ladders, bicycles, and stairs (P < .001).

Conclusion

While falls remain the chief cause of hip fractures, many of these injuries stem from overlooked mechanisms. The heightened risk associated with falls from beds and chairs in the elderly, stair-related injuries in middle-aged individuals, and high-force modalities in younger people, highlights the necessity for tailored preventive measures. Providers should counsel their patients on risk reduction measures within the home, while Medicare and other insurers must work to expand coverage for these same measures.

Low-Dose Aspirin Is Safe and Effective for Prevention of Venous Thromboembolism After Femoral Neck Fracture

BACKGROUND

Although patients who undergo arthroplasty for hip fractures are at high risk of venous thromboembolism (VTE), current guidelines do not specify the optimal VTE prophylactic agent. Recent evidence demonstrates that aspirin (ASA) may be safe and effective for VTE prevention in these patients. The purpose of this study was to determine the safety and efficacy of low-dose ASA (81 mg) compared to non-ASA agents after arthroplasty for femoral neck fracture.

METHODS

A total of 36,576 patients who underwent arthroplasty for femoral neck fracture from January 2012 through December 2023 were identified in a national database. Patients were stratified by baseline VTE risk into high-risk and standard-risk groups and further categorized based on the type of VTE prophylaxis received - low-dose ASA only or non-ASA prophylaxis only. Rates and odds of deep vein thrombosis, pulmonary embolism (PE), and adverse events, including bleeding, blood transfusion requirements, and emergency department visits, were assessed in the 90-days postoperative period for propensity-matched cohorts.

RESULTS

Compared to non-ASA prophylaxis, use of low-dose ASA only was associated with significantly lower odds of deep vein thrombosis in both high-risk (odds ratio [OR]: 0.46; 95% confidence interval [CI]: 0.30 to 0.69) and standard-risk (OR: 0.37; 95% CI: 0.18 to 0.76) groups, and lower odds of PE in high-risk patients (OR: 0.27; 95% CI: 0.14 to 0.55). There were no significant differences in odds of PE in standard-risk patients (OR: 0.71; 95% CI: 0.32 to 1.61). Low-dose ASA was associated with lower odds of bleeding events, blood transfusion requirements, and emergency department visits.

CONCLUSIONS

Use of low-dose ASA is safe and effective in preventing VTE in patients undergoing arthroplasty for femoral neck fracture. As this population is at higher risk of mortality, prospective studies comparing VTE prophylaxis regimens are necessary to further improve clinical outcomes.

LEVEL OF EVIDENCE

III.

The Fragility of Statistical Findings Regarding Hemiarthroplasty Versus Total Hip Arthroplasty for Displaced Femoral Neck Fractures

There is debate over the treatment of displaced femoral neck fractures with either hemiarthroplasty or total hip arthroplasty. This study aimed to evaluate the fragility index (FI) of randomized controlled trials (RCTs) comparing these methods. We queried for these RCTs containing dichotomous outcomes, finding 11 RCTs with 63 dichotomous outcomes. The median FI for all outcomes was 6, signifying that 6 event reversals would change the statistical significance of an outcome. The median FI was 2 for significant outcomes and 6 for nonsignificant outcomes, indicating that outcomes favoring one surgical method are more statistically fragile than those demonstrating equivalency. [Orthopedics. 2025;48(2):69-73.].

Evaluation of Functional and Radiological Outcome of Different Cephalomedullary Nail Designs in Intertrochanteric Fractures of Femur

Introduction

The incidence of intertrochanteric (IT) fracture is rising because of increase in the survival of the elderly population with osteoporosis and also the increase in the number of motor vehicle accidents. The treatment of choice is normally surgical with internal fixation. The surgical options for these fractures commonly include fixation with dynamic hip screw (DHS) or cephalomedullary nailing. Due to its advantages over DHS, cephalomedullary nailing is the predominant procedure in many parts of the world. Various varieties of cephalomedullary nails are available. Short cephalomedullary nails are indicated for IT fractures not extending beyond lesser trochanter. There are limited studies on the comparison of short cephalomedullary nails for IT fracture. In this study, we are evaluating functional outcome, radiological union and complications of inter-trochanteric fractures of femur treated with three different short cephalomedullary nails: (1) Proximal femoral nail (PFN)-standard, (2) modified short PFN (MS-PFN) and (3) PFN-A2 of 240 mm.

Materials and Methods

Our study is a randomized control trial. Subjects are patients with IT fracture presenting to Srinivas Institute of Medical Sciences and Research Centre. After obtaining informed and written consent, as per inclusion and exclusion criteria, subjects are randomized into three groups (simple randomization) and treated with standard PFN (240 mm length), MS-PFN (180 mm length), and PFN-A2 of length 240 mm as per randomisation. Duration of the surgery and total intraoperative blood loss is noted. Patients are followed up till 1-year post-operative period, in different intervals. Functional outcome using Harris hip score, fracture union, complications are assessed and compared. Considering the lost to follow-up, the final study size obtained is 75 (25 in each group).

Results

In our study, the average age of the patients is 71.29 years with male predominance and right-side predominance. Majority of the fractures belong to Type 1 Group 2 and type 1 Group 4 of Evan's classification. The average operating time and average intraoperative blood loss is less in PFN-A2 group compared to PFN and MS-PFN groups. The fracture union time is earlier in PFN A2 group compared to PFN and MS-PFN group. Functional outcome is better in PFN-A2 group compared to PFN and MS-PFN groups. In PFN group and PFN A2 of 240 mm length group, there were significant patients with anterior thigh pain. Among 75 patients, 3 in PFN group, 2 in MS-PFN group, and 1 in PFN-A2 group had >1 cm of shortening. 2 patients in PFN group and 1 in MS-PFN group had complication of screw cut-out; 2 in PFN group and 2 in PFN-A2 group had surgical site infection; 1 in PFN group and 1 in PFN-A2 group had varus collapse; and 1 in PFN group and 2 in MS-PFN group had Z effect/reverse Z effect.

Conclusion

In our study, on comparing three short nails - PFN, MF-PFN, and PFN-A2, PFN-A2 is superior in terms of operating time, intraoperative blood loss, functional outcome and fracture union. MS-PFN is next to PFN-A2 in the above parameters. Hence, PFN-A2 is superior to MS-PFN and MS-PFN is superior to PFN. Moreover, to avoid anterior thigh pain, we recommend the use of shorter nails (180 mm).

Comparison of Hemiarthroplasty, total hip arthroplasty, and internal fixation for hip fractures in patients over eighty years of age: factors affecting mortality: a nationwide cohort study of fifty three thousand, four hundred and ninety five patients from Türkiye

PURPOSE

Hip fractures are a common cause of mortality in elderly patients. This study aimed to determine the predictive factors affecting mortality among patients over the age of 80 who underwent surgical treatment for hip fractures.

METHODS

We searched the Turkish Ministry of Health's e-health database to identify patients over 80 years old who had undergone surgery for proximal femoral fractures from 2016 to 2022. This process yielded 53,495 patients. Demographic data as well as comorbidities, blood transfusions, postoperative 90 days medical complications, and mortality was investigated. Multivariate logistic regression analysis was performed to identify risk factors for one year mortality in patients undergoing surgical treatment for proximal hip fractures.

RESULTS

The mortality rate was 37.2% in the first year. The mean Charlson comorbidity index(CCI) was 6.8 (range: 4-22). In the postoperative period, 68.6% of the patients received blood transfusions. Logistic regression analysis identified significant predictors of one-year mortality in surgical patients, including male gender, increased age, higher CCI scores, AKI, PE, pneumonia, electrolyte imbalance, gastrointestinal bleeding, blood transfusion, and increased mortality risks with hemiarthroplasty and internal fixation compared to total hip arthroplasty. (p < 0.001 for all).

CONCLUSIONS

This large cohort study demonstrated that the mortality rate is high and that the type of surgery, male gender, older age, blood transfusion requirements, and high CCI score are associated with mortality in patients over 80 years of age who have undergone surgery for hip fractures. Preoperative optimization and postoperative care are critical for these vulnerable elderly patients.

Demographic Insights into One-Year Mortality Following Proximal Femur Fracture Surgery in India

Introduction

Proximal femur fractures are a significant public health issue and a leading cause of morbidity and mortality in the elderly. It poses a remarkable burden on healthcare resources.

Materials and Methods

Records of patients with proximal femur fracture operated during the study period (July 01, 2017-May 31, 2020) in our institution were obtained from hospital management system and analyzed retrospectively.

Results

Out of 1189 patients, 1101 met the inclusion criteria. About 66.21% were intertrochanteric, 28.52% were neck femur, and 5.26% were sub-trochanteric fractures. About 60.85% of patients were female. The mean age was 74.1 ± 9.22 years. Most injuries were domestic falls (89%) and left-sided (55%). The average delay in presentation to the hospital was 2.5 ± 6.62 days with mean length of stay being 11.34 ± 6.22 days and average pre-operative wait being 6.89 ± 3.34 days. Hypertension was the most common comorbid condition associated (45%) followed by diabetes (27%). About 4% also sustained other fractures; most common were distal end radius and proximal humerus fracture. Majority (63.7%) were operated between 3 and 7 days post-admission and the most common surgery performed was osteosynthesis with proximal femoral nail (39.69%). For mortality assessment, 34 patients died during hospital stay, 785 patients could be assessed and 282 were lost to follow-up. In-hospital mortality was 3.08%, 30-day mortality was 8.05% and 1-year mortality was 18.92%.

Conclusion

An integrated multidisciplinary approach with fall prevention awareness should be promoted to decrease the overall morbidity and mortality rate.

Digital X-ray Tomography in the Clinical Diagnosis of Suspected Neck of Femur Fractures

Background Occult fracture of the neck of femur (NOF) is a challenging acute presentation for orthopaedic surgeons. This study aimed to evaluate the use of digital tomography in the diagnosis of occult NOF fractures not visible on plain radiographs. Materials and methods A total of 100 patients admitted with suspected NOF fractures but negative plain X-rays underwent digital tomography studies. In equivocal tomography studies, patients who are clinically moderate to high probability suspicious of a hip fracture underwent further MRI or CT scans. Result In this study, 100 patients with suspected NOF fractures underwent a digital tomography investigation. The tomography identified 43 patients with fractures, including 18 with NOF, and therefore, they were surgically treated. In addition, 14 additional patients had other pelvic fractures and were treated conservatively. Eleven patients with suspicious fractures identified on tomography underwent MRI/CT to delineate the fracture pattern. From this subgroup, two patients were found to have fracture extension to NOF. Moreover, eight patients underwent tomography but were inconclusive and underwent MRI/CT, which identified five NOF fractures. A total of 37 patients with a negative tomogram for fracture NOF and a low clinical probability of a fracture did not undergo additional MRI/CT scanning. At 12 months of follow-up, this group had no readmissions due to complications related to their initial injury. Conclusion Tomography is a novel imaging modality that can be used to diagnose NOF and other pelvic fractures. This is a promising imaging modality, especially in patients not suitable to undergo MRI/CT. It offers a cost-effective and accurate alternative, making it an effective tool for managing patients in economically disadvantaged regions, as it is relatively easier to interpret.

Perioperative methadone compared to placebo in elderly hip fracture patients: a study protocol for a randomized controlled trial (MetaHip trial)

BACKGROUND

Hip fractures are a source of severe pain among the elderly population and pose challenges due to limited analgesic tolerance. Perioperative methadone has shown promise in our pilot study suggesting a safe dose of 0.10 mg/kg, prompting further investigation into its benefits for elderly hip fracture patients.

METHODS

This study employs a double-blinded randomized controlled trial to assess the analgesic effects of a single dose of methadone during hip fracture surgery. Patients aged ≥ 60 years are consecutively enrolled and randomized to receive either perioperative methadone (treatment group) or a saline solution (placebo group). A sample size of 130 patients is required for 88% statistical power. The medication is administered intravenously at anesthesia induction and monitored until discharge. A follow-up observation is conducted 3 months post-surgery.

DISCUSSION

Primary outcome: Daily consumption of opioids within the first 3 days after surgery. Secondary outcomes include pain, mobility, nausea, vomiting, time to discharge, need for antidote, delirium, and constipation. The 3-month follow-up includes opioid use, pain, EQ-5D-5L scores, mobility, and persistent side effects. If statistically significant advantages are found in the treatment group, perioperative methadone could be considered as standard care for hip fracture patients, potentially enhancing their pain management. The study's outcomes will provide insights into the feasibility and effectiveness of incorporating methadone into routine clinical practices for this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06086171, submitted 4. October 2023.

EU-CT

2023-506252-24-00, UTN: U1111-1294-6125.

Osteoporosis in men-East and West: Can the twain meet? A perspective from Asia

Osteoporosis in men remains a significantly underrecognized condition, with notable differences in bone mineral density (BMD) and fracture risk between Asian and Western populations. Despite 30% of hip fractures globally occurring in men, they are less likely to be diagnosed or treated for osteoporosis, especially in resource-limited settings. Given these disparities, a deeper understanding of osteoporosis epidemiology and treatment efficacy in men is essential, particularly in Asian populations. This review synthesizes the latest evidence on the epidemiology, screening, and treatment of osteoporosis in men, with a focus on genetic, environmental, and epidemiological disparities between Eastern and Western populations. Additionally, the review examines existing controversies surrounding fracture risk screening in men and evaluates the efficacy and cost-effectiveness of pharmacological treatments such as bisphosphonates, denosumab, and anabolic agents. Asian men exhibit lower peak BMD compared to their Caucasian counterparts, leading to potential misdiagnoses when using Caucasian-based BMD reference ranges. Screening tools like the Fracture Risk Assessment Tool (FRAX)® show variability in performance across populations. Data on pharmacological treatment in men remain limited, although studies suggest comparable benefits to those observed in women. Larger studies, particularly in male and Asian populations, are urgently needed to refine diagnostic and therapeutic guidelines. Osteoporosis in men is underdiagnosed and undertreated globally, with pronounced disparities between populations. Current diagnostic tools and treatment protocols are not fully tailored to male and Asian populations. There is an urgent need for longitudinal studies focusing on male-specific osteoporosis management to reduce fracture risk and improve outcomes.

Racial Disparities in Outpatient Physical Therapy Use After Hip Fracture: A Retrospective Cohort Study

OBJECTIVE: To examine whether there was a racial disparity among Medicare beneficiaries in the likelihood of using outpatient physical therapy (PT) services following a hip fracture. METHODS: Our retrospective descriptive cohort study analyzed administrative claims data for 51 781 Medicare beneficiaries post hip fracture. We examined the association between race and PT use within the first 6 months post fracture using hierarchical logistic regression, adjusting for demographics, medical complexity, and socioeconomic factors. We used Poisson regression to examine the association between race and the number of PT visits. RESULTS: Only 31% of beneficiaries used outpatient PT after hip fracture with significant racial disparities. After controlling for demographics, medical complexity, and socioeconomic factors, Black beneficiaries had 42% lower odds of using PT (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI]: 0.51, 0.66) compared to White beneficiaries. Among PT users, Black beneficiaries received fewer visits than White beneficiaries (rate ratio [RR], 0.85; 95% CI: 0.82, 0.88) with this disparity persisting after adjustments (RR, 0.88; 95% CI: 0.85, 0.91). CONCLUSION: Even after adjusting for demographic, medical, and socioeconomic factors, Black beneficiaries were less likely to use outpatient PT following hip fractures. Conditional on an initial PT evaluation, Black beneficiaries received fewer sessions. J Orthop Sports Phys Ther 2024;54(12):1-7. Epub 9 October 2024. 10.2519/jospt.2024.12641.

Effects of pericapsular nerve group block on early postoperative cognitive function in older people undergoing hip arthroplasty: a randomized controlled clinical trial

BACKGROUND

Pericapsular nerve group (PENG) block has emerged as a reliable analgesia technique for hip arthroplasty (HA). However, the effects of PENG block on perioperative neurocognitive disorder (PND) after HA has not yet been assessed. The present study aimed to investigate the effects of PENG block on early postoperative cognitive function in older people undergoing hip arthroplasty.

METHODS

Sixty older patients undergoing HA under spinal anesthesia were randomly assigned to group P (n = 30) receiving PENG block with ropivacaine and patient-controlled intravenous analgesia (PCIA) pump with sufentanil after surgery or group C (n = 30) only receiving PCIA pump with sufentanil after surgery. The primary outcome was the Mini-Mental State Examination (MMSE) score at 7 days postoperatively. Secondary outcomes consisted of the incidence of PND 7 days postoperatively, the static VAS pain scores at 6, 12, 24, and 48 h postoperatively; cumulative sufentanil consumption and the requirement of rescue analgesia during the 0-24 h period after surgery; quality of recovery-15 (QoR-15) scale scores at 24 h postoperatively; and the plasma levels of high mobility group box protein 1 (HMGB1) preoperatively and 1 day after surgery, and adverse events.

RESULTS

After surgery, the PENG block group had higher MMSE score than the control group at 7 days postoperatively (27.0 ± 1.8 vs. 26.1 ± 1.7, P = 0.048), with a mean difference of 0.9 (95%CI, 0.1-0.9). The incidence of PND at 7 days postoperatively was 6.7% in group P, lower than that of 30% in group C (P = 0.044). In group P, the static VAS scores at 6, 12, and 24 h postoperatively were significantly lower than those in group C (all P < 0.05). Compared with group C, the cumulative sufentanil consumption and the number of patients required rescue analgesia during the 0-24 h period after surgery were significantly lower in group P (all P < 0.05). The scores of QoR-15 scale were higher in group P at 24 h postoperatively than those in group C (P < 0.05). Patients in group P showed lower plasma levels of HMGB1 than group C at 1 day after surgery (P < 0.05), and the rate of complications didn't differ between both groups.

CONCLUSIONS

Older people undergoing HA receiving a PENG block for perioperative analgesia experience improved early postoperative cognitive function, reduced postoperative pain, higher quality of recovery, and less postoperative inflammatory response.

TRIAL REGISTRATION

Chictr.org.cn identifier ChiCTR2200061055 (Date of registry: 15/06/2022, prospectively registered).

Gender differences between smoking and the risk of hip fracture

OBJECTIVE

This study aimed to estimate the relation between cigarette smoking and hip fracture in men compared with women using a meta-analytic approach.

METHODS

On March 1, 2024, prospective cohort studies were searched from PubMed, Embase and Cochrane library systems. The gender difference in the relationship between smoking and hip fracture risk was evaluated by random effect model.

RESULTS

Eleven prospective cohort studies involving data from 2,689,620 individuals were selected for meta-analysis. The ratio of relative risk (RRR) of hip fractures in current smokers was significantly higher in men than in women (RRR: 1.10; 95%CI: 1.00 - 1.20; P = 0.047), while no evidence of sex differences in former smoking and hip fracture risk (RRR: 0.98; 95%CI: 0.88 - 1.10; P = 0.759).

CONCLUSIONS

The male-to-female RRR of hip fractures increased in current smokers, whereas no sex difference was found in the relationship between former smoking and the risk of hip fractures.

Technical Note in Case Series a Novel Recent Technique for the Removal of Broken PFNA-II Blade in Intertrochanteric Fractures is a Technical Challenge

Introduction

Proximal femoral nail antirotation - II (PFNA- II) is a common treatment for intertrochanteric fractures in the elderly. Removing PFNA is difficult in rare circumstances due to blade head stripping or breaking. In this article, we endeavored to explain an easy methodology that can be utilized to remove stripped, damaged anti-rotation blades for which few had been formulated but other procedures have failed.

Materials and Methods

In four cases, one case is discussed 15 months following the prior fixation; the individual underwent PFNA removal surgery for a broken implant causing pain. We had trouble removing the anti-rotation blade with the standard equipment.

Result

The procedure assisted us in removing the anti-rotation blade and provided a favorable outcome for the patient.

Conclusion

The insertion of a DHS guide wire with a coupling screw for inserting DHS screw in conjunction with a proximal femoral anti-rotation blade may be a cost-effective and simple approach to dealing with extraction failure.

The Second Hip Fracture is not an Independent Predictor of Poor Outcomes in Elderly Patients - A Case-Control Study

Introduction

Hip fracture is particularly seen in elderly patients with frailty and osteoporosis and leads to diminished functional independence and quality of life. Despite the susceptibility of these patients to a second hip fracture (SHF), the literature insufficiently discussed its impact leading to poor outcomes. This study aims to directly assess the outcomes of elderly patients with initial hip fractures (IHF) vs those experiencing an SHF within a well-matched group with similar characteristics.

Materials and Methods

This case-control study gathered data from the clinical hip fracture registry at a medical center from 2019 to 2022. Patients with SHF were matched with those with IHF in a 1:2 ratio according to the similarity of age, sex, and Charlson Comorbidity Index classification. Demographics at admission, baseline characteristics, and 1-year postoperative outcome were compared between the SHF and IHF groups.

Results

Thirty-two SHF patients were matched with 64 IHF patients (81.25% of women, median age of 86 years). Anthropometric measurements and socioeconomic factors were not significantly different between the two groups. No differences in baseline characteristics were observed, except IHF patients had a significantly lower T-score than SHF patients (-3.98 vs. -3.31, P = 0.016). At one-year follow-up, despite a notable decrease in Barthel Index scores and an uptick in EQ-5D measures among the patients, the IHF and SHF groups demonstrated similar quality of life and a high level of activities of daily living.

Discussions

In this case-control study, after matching for age, sex, and comorbidities, an SHF did not indicate poorer outcomes than an IHF, providing a more optimistic outlook for the patients and healthcare providers.

Conclusion

Despite the significant challenges presented by hip fracture, the one-year postoperative outcomes did not differ between IHF and SHF patients, suggesting that SHF is not an independent predictor of poor outcomes following hip fracture in the elderly population.

Periprosthetic and peri-implant femoral fractures and timeliness to surgery: A retrospective matched cohort study

Purpose

Periprosthetic (PPFF) and peri-implant femoral fractures (PIFFs) are troublesome complications of prosthetic and implant surgery, the prior being described to have a greater delay to surgery when compared with standard hip fractures. The implications of PPFF delay being disputed in the current literature and those of PIFF have not been investigated. The aim of this study was to determine whether the time from radiological examination to surgery differs between hip fractures and PPFF/PIFF, and the possible consequences of delay and group affiliation on morbidity, mortality, and readmissions.

Methods

One hundred and thirty-six participants were admitted to Danderyd hospital during 2020, cases exposed to PPFF or PIFF (n = 35) and hip fracture controls (n = 101) matched at 1:3 with respect to age and sex. Timestamps from radiology, surgery, and death were retrieved from the Swedish fracture registry, data on adverse events (AEs), and readmissions were collected through retrospective medical record review for 90-days postsurgery.

Results

Linear regression showed that time to surgery differed in case and control cohorts by a mean of 24.8 h, p < 0.001, and AEs were significantly more common in cases, p = 0.046. Unadjusted binary logistic regression indicated a possible relationship between time to surgery increasing the rate of AEs by 1.3% per hour of delay, 95% confidence interval [CI]: (1-1.03).

Conclusion

This study reveals a significant delay in surgery for PPFFs and PIFFs compared with standard hip fractures, leading to higher adverse event rates. While mortality and readmissions did not differ significantly, the delay underscores the need for timely intervention in these complex cases. Further research is needed to address these challenges and improve patient outcomes.

Level of Evidence

III.

Cemented Versus Noncemented Hemiarthroplasty for Femoral Neck Fractures: A Meta-Analysis of Randomized Control Trials

INTRODUCTION

The purpose of this study was to conduct a meta-analysis of the randomized controlled trials (RCTs) to compare the outcomes after cemented and noncemented hemiarthroplasty for femoral neck fractures.

METHODS

A literature search of three databases was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing cemented and noncemented hemiarthroplasty for femoral neck fractures were included. Clinical outcomes were compared using Revman, and a P-value < 0.05 was considered to be statistically significant.

RESULTS

Nine RCTs with 3,177 patients were included. Overall, 24.2% of patients treated with a cemented hemiarthroplasty and 28.6% of patients treated with cemented hemiarthroplasty died within 1 year (P = 0.01), but there was no significant difference in perioperative mortality or mortality at 30 days (P > 0.05 for both). A significantly lower rate of periprosthetic fractures with cemented hemiarthroplasty (0.9% versus 4.8%, P < 0.0001) was also noted, but there was no significant difference in the rate of revision surgery, dislocations, or wound infections (P > 0.05). Noncemented hemiarthroplasty resulted in significantly faster surgical times (61.7 versus 69.5 minutes, P = 0.007).

DISCUSSION

The current level 1 evidence shows that cemented hemiarthroplasty for femoral neck fractures offers improved 1-year mortality rates and less periprosthetic fracture compared with noncemented hemiarthroplasty. Despite the increase in surgical time, cemented hemiarthroplasty offers compelling clinical advantages compared with noncemented hemiarthroplasty for surgical management of displaced femoral neck fractures in the elderly.

LEVEL OF EVIDENCE

Level I; meta-analysis of Level I studies.

Association of Serum Lactate Levels Measured in the Emergency Department with 30-Day Mortality in Older Patients with Unilateral Hip Fractures

BACKGROUND

Hip fractures are frequent injuries in older patients and are associated with high mortality rates. This study assessed the association between serum lactate level and 30-day mortality in older patients with unilateral hip fractures and examined the prognostic value of this association on the clinical outcomes of these patients.

METHODS

This retrospective, single-center study included patients aged ≥65 years admitted to the emergency department due to low-energy trauma and diagnosed with unilateral hip fracture upon admission. The additional inclusion criteria were patients with independent ambulation or walker or cane assistance before the injury, with available data on serum lactate levels on venous blood gas analysis, and who underwent surgery.

RESULTS

Among the 330 included patients, 30.9% experienced postoperative complications and 10.3% died within 30 days. Using a lactate cut-off value of 2 mmol/L to distinguish between living and deceased patients, the sensitivity and specificity were 41% and 88%, respectively. Multivariate logistic regression analysis revealed that high lactate and low albumin levels and male sex were associated with mortality.

CONCLUSION

Identifying risk factors for mortality in geriatric patients with hip fractures is important. Male sex, low albumin levels, and particularly increased lactate levels were independent predictors of short-term mortality in these patients.

Disparities in Osteoporosis Prevention and Care: Understanding Gender, Racial, and Ethnic Dynamics

PURPOSE

Osteoporosis, the most prevalent metabolic bone disease, significantly impacts global public health by increasing fracture risks, particularly among post-menopausal women and the elderly. Osteoporosis is characterized by decreased bone mineral density (BMD) and deterioration of bone tissue, which leads to enhanced fragility. The disease is predominantly diagnosed using dual X-ray absorptiometry (DXA) and is significantly influenced by demographic factors such as age and hormonal changes. This chapter delves into the condition's complex nature, emphasizing the pervasive gender and racial disparities in its screening, diagnosis, and treatment.

RECENT FINDINGS

Recent findings highlight a substantial gap in the management of osteoporosis, with many individuals remaining under-screened and under-treated. Factors contributing to this include the asymptomatic early stages of the disease, lack of awareness, economic barriers, and inconsistent screening practices, especially in under-resourced areas. These challenges are compounded by disparities that affect different genders and races unevenly, influencing both the prevalence of the disease and the likelihood of receiving adequate healthcare services. The summary of this chapter underscores the urgent need for targeted strategies to overcome these barriers and improve health equity in osteoporosis care. Proposed strategies include enhancing public and healthcare provider awareness of osteoporosis, broadening access to diagnostic screenings, and integrating personalized treatment approaches. These efforts aim to align with global health objectives to mitigate the impacts of osteoporosis and ensure equitable health outcomes across all demographic groups.

Anesthesia Management of Hip Fracture Surgery in Geriatric Patients: A Review

Hip fractures are increasingly prominent concerns in healthcare, especially in light of a growing elderly population. These fractures contribute to mortality and morbidity in the elderly. Many hip fractures require emergent surgical intervention and may have consequences of serious postoperative complications. Multidisciplinary approaches of management have been utilized to optimize care and improve patient outcomes. Due to the myriad of multi-organ system comorbidities that are increasingly prevalent in the geriatric population, anesthetic management proves to be difficult to standardize. Enhanced Recovery After Surgery (ERAS) protocols have shown benefits for optimizing patient outcomes by focusing on premedication, nutritional support, and pain management; however, specific anesthetic management techniques are not discussed. This literature review aims to discuss ways to optimize hip fracture management in geriatric patients through effective preoperative evaluation, anesthetic considerations, and postoperative optimization and care. A review of currently available guidelines may help determine the optimal management for hip fractures in geriatric patients and improve immediate and lasting postoperative outcomes.

A staged approach using machine learning and uncertainty quantification to predict the risk of hip fracture

Hip fractures present a significant healthcare challenge, especially within aging populations, where they are often caused by falls. These fractures lead to substantial morbidity and mortality, emphasizing the need for timely surgical intervention. Despite advancements in medical care, hip fractures impose a significant burden on individuals and healthcare systems. This paper focuses on the prediction of hip fracture risk in older and middle-aged adults, where falls and compromised bone quality are predominant factors. The study cohort included 547 patients, with 94 experiencing hip fracture. To assess the risk of hip fracture, clinical variables and clinical variables combined with hip DXA imaging features were evaluated as predictors, followed by a novel staged approach. Hip DXA imaging features included those extracted by convolutional neural networks (CNNs), shape measurements, and texture features. Two ensemble machine learning models were evaluated: Ensemble 1 (clinical variables only) and Ensemble 2 (clinical variables and imaging features) using the logistic regression as the base classifier and bootstrapping for ensemble learning. The staged approach was developed using uncertainty quantification from Ensemble 1 which was used to decide if hip DXA imaging features were necessary to improve prediction for each subject. Ensemble 2 exhibited the highest performance, achieving an Area Under the Curve (AUC) of 0.95, an accuracy of 0.92, a sensitivity of 0.81, and a specificity of 0.94. The staged model also performed well, with an AUC of 0.85, an accuracy of 0.86, a sensitivity of 0.56, and a specificity of 0.92, outperforming Ensemble 1, which had an AUC of 0.55, an accuracy of 0.73, a sensitivity of 0.20, and a specificity of 0.83. Furthermore, the staged model suggested that 54.49 % of patients did not require DXA scanning, effectively balancing accuracy and specificity, while offering a robust solution when DXA data acquisition is not feasible. Statistical tests confirmed significant differences between the models, highlighting the advantages of advanced modeling strategies. Our staged approach offers a cost-effective holistic view of patient health. It can identify individuals at risk of hip fracture with a high accuracy while reducing unnecessary DXA scans. This approach has great promise to guide the need for interventions to prevent hip fracture while reducing diagnostic cost and exposure to radiation.

Treatment outcomes of concomitant ipsilateral neck and trochanteric fractures using Gamma3 nails with U-blade lag screws

This study aimed to investigate the outcomes of Gamma3 nails fitted with U-blade lag screws in the management of combined neck and trochanter fracture of the femur. Two hundred-fifty patients with fractures in the proximal femur underwent treatment using Gamma3 nails integrated with U-blade lag screws from 2015 to 2022. Among these cases, 33 had combined neck and trochanteric fractures; 8 patients were excluded because of follow-up for <1 year. The remaining data of 25 patients (7 males and 18 females) were reviewed. Bone mineral density (BMD), body mass index (BMI), tip-apex distance (TAD), extent of lag screw migration, femoral neck-shaft angle, callus formation, fracture type, and treatment failure were analyzed. The mean patient age was 76.3 (range, 61-91) years, and the mean follow-up duration was 17.3 (range, 12.5-57.3) months. The mean BMD T-scores for the spine and femoral neck were -2.3 ± 1.0 and -2.8 ± 0.7, respectively; 18 patients had T-scores ≤-2.5, indicating osteoporosis. The mean BMI was 23.2 ± 3.8 kg/m2 , and the mean operative time was 69.8 (range, 45-90) minutes. Twenty-one patients experienced injuries from slipping, 2 sustained injuries from falling, and 2 from car traffic accidents. The mean TAD was 21.6 ± 5.9 mm, with 16 patients showing <25 mm. The mean extent of lag screw migration was 5.7 ± 5.1 mm. The mean femoral neck-shaft angle on plain radiographs was 125.1 ± 8.6 degrees immediately postoperatively and 120.3 ± 9.5 degrees at the final follow-up. During the follow-up period, the first callus formation was observed at 3.8 months (range, 1.4-7.3) on plain radiographs in the anteroposterior and axial views. Based on our fracture criteria, 4 patients had a two-part fracture type, 12 patients had three-part, and 9 patients had four-part. Out of 25 patients, 3 exhibited treatment failure. No significant differences were observed between the groups with and without bone union regarding age, BMD, BMI, operative time, TAD of the lag screw, extent of lag screw migration, and femoral neck-shaft angle. The bone union was achieved in 88% of patients who underwent treatment utilizing the U-blade Gamma3 nail for concomitant ipsilateral neck and trochanteric fractures. Level IV, Therapeutic Study.

Barriers to Discharge of Hip Fracture Patients From An Academic Hospital: A Retrospective Data Analysis

Introduction

Adherence to best practices for care of hip fracture patients is fundamental to decreasing morbidity and mortality in older adults. This includes timely transfer from the hospital to rehabilitation soon after their surgical care. Hospitals experience challenges in implementing several best practices. We examined the potential barriers associated with timely discharge for patients who underwent a hip fracture surgery in an academic hospital in Ontario, Canada.

Methods

We conducted a retrospective cross-sectional review of a local database. We used descriptive statistics to characterize individuals according to the time of discharge after surgery. Multivariable binary logistic regression was used to evaluate factors associated with delayed discharge (>6 days post-surgery).

Results

A total of 492 patients who underwent hip fracture surgery between September 2019 and August 2020 were included in the study. The odds of having a delayed discharge occurred when patients had a higher frailty score (odds ratios [OR] 1.19, 95% confidence interval [CI] 1.02;1.38), experienced an episode of delirium (OR 2.54, 95% CI 1.35;4.79), or were non-weightbearing (OR 3.00, 95% CI 1.07;8.43). Patients were less likely to have a delayed discharge when the surgery was on a weekend (OR .50, 95% CI .32;.79) compared to a weekday, patients had a total hip replacement (OR .28, 95% CI .10;.80) or dynamic hip screw fixation (OR .49, 95% CI .25;.98) compared to intramedullary nails, or patients who were discharged to long-term care (OR .05, 95% CI .02;.13), home (OR .26, 95% CI .15;.46), or transferred to another specialty in the hospital (OR .49, 95% CI .29;.84) compared to inpatient rehabilitation.

Conclusions

Clinical and organizational factors can operate as potential barriers to timely discharge after hip fracture surgery. Further research is needed to understand how to overcome these barriers and implement strategies to improve best practice for post-surgery hip fracture care.

Subsequent fracture risk in Norwegians and immigrants with an index forearm fracture: a cohort study

The current study investigated subsequent fracture risk following a forearm fracture in three country of birth categories: Norway, Europe and North America, and other countries. Subsequent fracture risk was modestly higher in Norwegian-born individuals compared to the two other groups. Secondary fracture prevention should be recommended regardless of country background.

BACKGROUND

Fracture risk is higher in patients with a previous fracture, but whether subsequent fracture risk differs by origin of birth is unknown. This study explores subsequent fracture risk in patients with an index forearm fracture according to region of birth.

METHODS

Nationwide data on forearm fractures in patients ≥ 18 years in 2008-2019 were obtained from the Norwegian Patient Registry and Statistics Norway. Index fractures were identified by ICD-10 code S52, whereas subsequent fractures included any ICD-10 fracture code. Data on country of birth were from Statistics Norway and included three regional categories: (1) Norway, (2) other Europe and North America and (3) other countries. Direct age standardization and Cox proportional hazard regression were used to analyse the data.

RESULTS

Among 143,476 individuals with an index forearm fracture, 35,361 sustained a subsequent fracture. Norwegian-born forearm fracture patients had the highest subsequent fracture rates (516/10,000 person-years in women and 380 in men). People born outside Europe and North America had the lowest rates (278/10,000 person-years in women and 286 in men). Compared to Norwegian-born individuals, the hazard ratios (HRs) of subsequent fracture in individuals from Europe and North American were 0.93 (95% CI 0.88-0.98) in women and 0.85 (95% CI 0.79-0.92) in men. The corresponding HRs in individuals from other countries were 0.76 (95% CI 0.70-0.84) in women and 0.82 (95% CI 0.74-0.92) in men.

CONCLUSION

Individuals born outside Norway had a lower subsequent fracture risk than Norwegian-born individuals; however, subsequent fracture risk increased with age in all groups. Our results indicate that secondary fracture prevention should be recommended regardless of region of origin.

Genetic predisposition to bone mineral density and their health conditions in East Asians

Osteoporosis, a condition defined by low BMD (typically < -2.5 SD), causes a higher fracture risk and leads to significant economic, social, and clinical impacts. Genome-wide studies mainly in Caucasians have found many genetic links to osteoporosis, fractures, and BMD, with limited research in East Asians (EAS). We investigated the genetic aspects of BMD in 86 716 individuals from the Taiwan Biobank and their causal links to health conditions within EAS. A genome-wide association study (GWAS) was conducted, followed by observational studies, polygenic risk score assessments, and genetic correlation analyses to identify associated health conditions linked to BMD. GWAS and gene-based GWAS studies identified 78 significant SNPs and 75 genes related to BMD, highlighting pathways like Hedgehog, WNT-mediated, and TGF-β. Our cross-trait linkage disequilibrium score regression analyses for BMD and osteoporosis consistently validated their genetic correlations with BMI and type 2 diabetes (T2D) in EAS. Higher BMD was linked to lower osteoporosis risk but increased BMI and T2D, whereas osteoporosis linked to lower BMI, waist circumference, hemoglobinA1c, and reduced T2D risk. Bidirectional Mendelian randomization analyses revealed that a higher BMI causally increases BMD in EAS. However, no direct causal relationships were found between BMD and T2D, or between osteoporosis and either BMI or T2D. This study identified key genetic factors for bone health in Taiwan, and revealed significant health conditions in EAS, particularly highlighting the genetic interplay between bone health and metabolic traits like T2D and BMI.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis

BACKGROUND

The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications.

METHODS

A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes.

RESULTS

The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11).

CONCLUSION

The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Increased 1-Year Revision Rates Among Left-Sided Intertrochanteric Femur Fractures

OBJECTIVES

To compare 1-year revision rates among left-sided and right-sided intertrochanteric femur fractures.

METHODS

DESIGN

Retrospective.

SETTING

120+ contributing centers to multicentered database.

PATIENT SELECTION CRITERIA

Patients who sustained intertrochanteric femur fracture (ITFF) and had a cephalomedullary nail (CMN) from 2015 to 2022 were identified. Patients were then stratified based on left-sided or right-sided fracture. Patients were excluded if younger than 18 years with <1-year follow-up. The intervention investigated was CMN on left or right side.

OUTCOME MEASURES AND COMPARISONS

One-year revision surgery, comparing CMN performed on left or right side for ITFFs.

RESULTS

In total, 113,626 patients met inclusion criteria, with 55,295 in the right-sided cohort and 58,331 in the left-sided cohort. There was no difference between cohorts with respect to age, gender, diabetes, osteoporosis, chronic kidney disease, or congestive heart failure (P > 0.05 for all). Patients who sustained a left ITFF and treated with a CMN were more likely to have revision surgery at 1 year (Left: 1.24%, Right: 0.90%; OR: 1.24; 95% confidence interval [CI], 1.15-1.1.33) or develop a nonunion or malunion (Left: 1.30%, Right: 0.98%; OR: 1.31; 95% CI, 1.14-1.52). The most common revision surgery conducted for both cohorts was conversion total hip arthroplasty (Left: 70.4% and Right: 70.0%).

CONCLUSIONS

Patients who sustained a left intertrochanteric femur fracture and were treated with a CMN were more likely to undergo revision at 1 year due to nonunion. There were no differences in demographics and comorbidities between cohorts. Though left-sided versus right-sided confounding variables may exist, the difference in nonunion rate may be explained by clockwise torque of the lag screw used in most implants. Increased awareness, implant design, and improved technique during fracture reduction and fixation may help lower this disproportionate nonunion rate and its associated morbidity and financial impact.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors influencing hip fracture surgery after two days of hospitalization using a national administrative database

Globally, hip fractures represent a significant and growing public health concern, particularly as the elderly population increases. The timing for surgery following hospitalization for hip fractures is a crucial indicator of acute quality care following recommended surgical guidelines of within two days to minimize complications and mortality. However, factors influencing delayed surgery and its outcomes remain debated. This study, used a national administrative database in South Korea, aimed to examine surgery performed within two days of hospitalization and investigate factors affecting delayed surgical interventions and associated outcomes. Of the hip fracture patients analyzed, 40.6% underwent surgery within two days of hospitalization. Factors associated with delayed surgery included: male patients (OR 1.190; 95% CI 1.022 ~ 1.385), medical aid beneficiary (OR 1.385; 95% CI 1.120 ~ 1.713), higher comorbidity index (OR 1.365; 95% CI 1.163 ~ 1.603, OR 1.612, 95% CI 1.327 ~ 1.958), weekends admission (OR 2.384; 95% CI 2.804 ~ 2.729), admission via outpatient department (OR 1.298, 95% CI 1.071 ~ 1.574). ORIF (OR 0.823, 95% CI 0.691 ~ 0.980) was associated with a significantly low risk of late surgery. While early surgery did not significantly impact in-hospital mortality or complications, it was associated with short and postoperative lengths of stay. This study underscores the need for prompt surgical intervention, particularly in high-risk patient populations, as well as highlights the importance of further research to elucidate the relationship between the timing of surgery and postoperative outcomes.

One year "ADAPT system" use for proximal femoral fracture osteosynthesis with intramedullary nail . A case control study

Introduction

Proximal femoral fractures (PFF) are a significant health concern among the elderly, often leading to complications and high mortality rates. Intramedullary nailing is widely considered the most effective treatment for lateral proximal femoral fractures (LPFF), with the Tip Apex Distance (TAD) being a crucial predictor of surgical success. This study aimed to compare outcomes between patients treated with and without the ADAPT (ADAptive Positioning Technology) system, which aids in the precise placement of the cephalic screw.

Materials and Methods

A retrospective analysis was conducted on 97 patients with intertrochanteric fractures treated in 2022. Patients were divided into two groups: those treated with the ADAPT system (group I, n=34) and those treated without it (group II, n=63). Fractures were classified according to AO/OTA classification. The primary outcomes measured were operative time, cephalic screw angle, TAD, and incidence of lag screw cut-out. Statistical analyses included chi-square tests and t-tests, with significance set at P < 0.05.

Results

The ADAPT system did not significantly reduce TAD (18.21 mm in the ADAPT group vs. 19.94 mm in the control group, p=0.149). Operative times were similar between the groups. The incidence of lag screw cut-out was low in both groups, with no significant differences. The study confirmed a strong correlation between higher TAD and increased risk of screw cut-out, underscoring the importance of precise screw placement.

Discussion

Computer-assisted surgery, such as the ADAPT system, aims to enhance the accuracy of cephalic screw placement. In this study, the ADAPT system didn't demonstrate a statistically significant advantage in reducing TAD or preventing screw cut-out. Nevertheless, the critical role of TAD in preventing fixation failure was reaffirmed, emphasising the need for precise surgical techniques.

Conclusion

While the ADAPT system did not show a significant advantage in reducing TAD or preventing screw cut-out in this study, the importance of achieving optimal TAD in cephalomedullary nailing was reinforced. Future research should continue to explore the role of computer-assisted systems in enhancing surgical accuracy and improving outcomes for patients with LPFF.

Kinematic analysis of preparation for transferring from wheelchair to bed

This study aimed to clarify the kinematics, particularly of the shoulder and hip joints, during preparation for manual wheelchair-to-bed transfer (i.e. when flipping up the arm and foot supports). This cross-sectional study included 32 able-bodied individuals. The kinematics of the shoulder and hip joints when the arm and foot supports were flipped up of manual wheelchair, were evaluated using a markerless inertial sensor-based motion capture system. We found that flipping the arm support upwards involved a large amount of abduction, internal and external rotation, flexion, and extension at the shoulder joint, whereas flipping the foot support upwards involved a large amount of flexion at the hip joint. The findings suggest that it is necessary to consider the range of motion required to flip up the arm and foot supports of manual wheelchairs, particularly in those with limited shoulder and hip range of motion such as older people, neuromuscular disorders, and orthopedic disorders.

Comparative Analysis of Frailty Scores for Predicting Adverse Outcomes in Hip Fracture Patients: Insights from the United States National Inpatient Sample

The aim of the current investigation was to compare the ability of several frailty scores to predict adverse outcomes in hip fracture patients. All adult patients (18 years or older) who suffered a hip fracture due to a fall and underwent surgical fixation were extracted from the 2019 National Inpatient Sample (NIS) Database. A combination of logistic regression and bootstrapping was used to compare the predictive ability of the Orthopedic Frailty Score (OFS), the Nottingham Hip Fracture Score (NHFS), the 11-factor modified Frailty Index (11-mFI) and 5-factor (5-mFI) modified Frailty Index, as well as the Johns Hopkins Frailty Indicator. A total of 227,850 patients were extracted from the NIS. In the prediction of in-hospital mortality and failure-to-rescue (FTR), the OFS surpassed all other frailty measures, approaching an acceptable predictive ability for mortality [AUC (95% CI): 0.69 (0.67-0.72)] and achieving an acceptable predictive ability for FTR [AUC (95% CI): 0.70 (0.67-0.72)]. The NHFS demonstrated the highest predictive ability for predicting any complication [AUC (95% CI): 0.62 (0.62-0.63)]. The 11-mFI exhibited the highest predictive ability for cardiovascular complications [AUC (95% CI): 0.66 (0.64-0.67)] and the NHFS achieved the highest predictive ability for delirium [AUC (95% CI): 0.69 (0.68-0.70)]. No score succeeded in effectively predicting venous thromboembolism or infections. In summary, the investigated frailty scores were most effective in predicting in-hospital mortality and failure-to-rescue; however, they struggled to predict complications.

Retrospective evaluation of radiological and clinical outcomes after surgical treatment of proximal femoral fractures utilizing PFNA and PFNA augmented

INTRODUCTION

The primary aim of this study was to evaluate the clinical and radiological outcomes after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA), with the main focus on complications and reoperations. The secondary aim was to compare the outcomes of patients with and without cement augmentation of the cephalomedullary nails.

MATERIALS AND METHODS

All patients with an acute proximal femoral fracture consequently treated with a PFNA between January 2011 and Dezember  2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative radiographs were used to determine the position of the implant, and any migration, via Tip-Apex-Distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated according to Baumgaertners criteria.

RESULTS

Two hundred sixty-four consecutive patients (mean age 78.8 ± 12.0; 73.1% female) were included. The predominant OTA/AO fracture classification was 31A1 (153 cases, 58.0%). The average duration of surgery was 63.1 ± 28.0 min and showed no significant differences between PFNA and PFNA with augmentation. The implant positioning was rated as good in 222 cases (84.1%). Two hundred sixty-three patients (99.6%) showed evidence of healing within the time frame of three months postoperatively, one case of delayed union healed after secondary dynamization. During the observational period, 18 patients (6.8%) required a total of 23 additional surgeries. Overall, a lower reoperation rate was observed following the use of the augmentation option (2/86 patients (2.3%) vs. 16/178 patients (9.0%), p = 0.04). In particular, there were no cases of cut-out or cut-through among patients who underwent augmentation as part of osteosynthesis.

CONCLUSIONS

Overall reoperation rate after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA) was 6.8%, with 23 additional surgeries performed in 18 patients. The usage of the PFNA with augmentation showed equally good implant positioning, excellent healing rates and fewer postoperative complications compared to the PFNA implant alone with a similar overall duration of surgery.

Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial

PURPOSE

Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being.

DESIGN

Double-blind randomized controlled trial.

METHODS

The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications.

FINDINGS

Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present.

CONCLUSIONS

This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.

A Staged Approach using Machine Learning and Uncertainty Quantification to Predict the Risk of Hip Fracture

Hip fractures present a significant healthcare challenge, especially within aging populations, where they are often caused by falls. These fractures lead to substantial morbidity and mortality, emphasizing the need for timely surgical intervention. Despite advancements in medical care, hip fractures impose a significant burden on individuals and healthcare systems. This paper focuses on the prediction of hip fracture risk in older and middle-aged adults, where falls and compromised bone quality are predominant factors. We propose a novel staged model that combines advanced imaging and clinical data to improve predictive performance. By using convolutional neural networks (CNNs) to extract features from hip DXA images, along with clinical variables, shape measurements, and texture features, our method provides a comprehensive framework for assessing fracture risk. The study cohort included 547 patients, with 94 experiencing hip fracture. A staged machine learning-based model was developed using two ensemble models: Ensemble 1 (clinical variables only) and Ensemble 2 (clinical variables and DXA imaging features). This staged approach used uncertainty quantification from Ensemble 1 to decide if DXA features are necessary for further prediction. Ensemble 2 exhibited the highest performance, achieving an Area Under the Curve (AUC) of 0.9541, an accuracy of 0.9195, a sensitivity of 0.8078, and a specificity of 0.9427. The staged model also performed well, with an AUC of 0.8486, an accuracy of 0.8611, a sensitivity of 0.5578, and a specificity of 0.9249, outperforming Ensemble 1, which had an AUC of 0.5549, an accuracy of 0.7239, a sensitivity of 0.1956, and a specificity of 0.8343. Furthermore, the staged model suggested that 54.49% of patients did not require DXA scanning. It effectively balanced accuracy and specificity, offering a robust solution when DXA data acquisition is not always feasible. Statistical tests confirmed significant differences between the models, highlighting the advantages of the advanced modeling strategies. Our staged approach offers a cost-effective holistic view of patients' health. It could identify individuals at risk with a high accuracy but reduce the unnecessary DXA scanning. Our approach has great promise to guide interventions to prevent hip fractures with reduced cost and radiation.

Investigation of the predictive value of systemic immune inflammation index (SII) and prognostic nutritional index (PNI) on mortality in patients with endoprosthesis after hip fracture

In this research, we aimed to investigate the predictive value of the systemic immune inflammation index and prognostic nutritional index on mortality among patients with an endoprosthesis after a hip fracture. In this retrospective, cross-sectional study, a total of 915 patient files applied to our hospital between 2020 and 2023 with an endoprosthesis after a hip fracture were subjected to the study. The patients were divided into 2 groups: alive (n = 396; 43.3%) and deceased (n = 519; 56.7%). The eosinophil-to-lymphocyte ratio, hemoglobin-to-red cell distribution width ratio (HRR), mean platelet volume-to-platelet ratio (MPVPR), neutrophil-to-lymphocyte ratio, monocyte/lymphocyte ratio, platelet-to-lymphocyte ratio, MPV-to-lymphocyte ratio, monocyte-to-eosinophil ratio (MER), neutrophile-to-monocyte ratio, systemic inflammation index (SII), and prognostic nutritional index (PNI) parameters of the patients were evaluated. The mortality rate was higher among male patients, with a statistically significant difference (P < .05). The follow-up duration, albumin, HGB, eosinophil, lymphocyte, eosinophil %, eosinophil-to-lymphocyte ratio, HRR, and PNI means were significantly higher in the living group (P < .05). Age, MPV, MPVPR, neutrophil-to-lymphocyte ratio, monocyte/lymphocyte ratio, platelet-to-lymphocyte ratio, MPV-to-lymphocyte ratio, MER, and systemic inflammation index were significantly higher in the deceased group (P < .05). The predictive value of gender (B = -0.362; P < .01), age (B = 0.036; P < .01), HRR (B = -1.100; P < .01), MPVPR (B = 8.209; P < .01), MER (B = 0.006; P < .01), and PNI (B = -0.078; P < .01) were statistically significant at the multivariate level. The time of death was significantly predicted by gender (B = 0.10; P < .05), age (B = -0.02; P < 0 = 1), HRR (B = 0.61; P < .01), MPVPR (r = -4.16; P < .01), MER (B = -0.01; P < .05), and PNI (B = 0.03; P < .01). The predictive value of PNI for the 30-day mortality rate was statistically significant (AUC: 0.643; P < .01). For a PNI cutoff value of 34.475, sensitivity was 69.7%, and specificity was 51.1%. The PNI has predictive value both in estimating overall mortality and in predicting the 30-day mortality rates among patients undergoing endoprosthesis after a hip fracture.

A Comparison of the Clinicoradiological Outcomes of Intertrochanteric Fractures Treated Using Proximal Femoral Nail and Proximal Femoral Nail Anti-rotation

Background Managing intertrochanteric fractures presents challenges for orthopedic surgeons, not only in fixing the fracture but also in preventing and managing associated complications, especially in the vulnerable geriatric population. Cephalomedullary nails are commonly used for surgical fixation due to their favorable functional profile, which preserves the hip's abductor lever arm and proximal femur anatomy. However, there's a lack of data comparing two major options: proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFNA). This study aimed to compare the radiological fracture reduction and fixation as well as functional outcomes of these two implants in treating intertrochanteric fractures. Methods The study, spanning 24 months, involved a prospective comparative design. Participants included patients diagnosed with intertrochanteric femur fractures classified as AO Type 31 A1, AO Type 31 A2, and AO Type 31 A3. Fifty patients were evenly distributed into PFN and PFNA groups. Preoperatively, clinical and radiological assessments were conducted, along with serum vitamin D level measurements. Surgeries, performed under anesthesia with image intensifier guidance, followed defined reduction and implant insertion protocols for each group. Postoperatively, evaluations were conducted up to six months, examining parameters such as tip-apex distance (TAD), Cleveland index, and modified Harris hip score, while documenting intraoperative duration and blood loss. Data analysis utilized the statistical software Statistical Package for Social Sciences (SPSS), version 22.0 (IBM Corp., Armonk, NY), employing descriptive statistics, chi-square tests, independent t-tests, and paired t-tests, with significance set at p < 0.05. Results In our study, 50 patients were enrolled, with equal gender distribution (64.0% male, 36.0% female, p=1.000). The mean ages in the PFN and PFNA groups were 66.2 ± 9.8 years and 66.4 ± 11.3 years, respectively (p=0.936). All fractures united by six months, with no implant-related complications reported. PFNA showed significantly lower blood loss and shorter surgery durations (p<0.001). TAD and neck shaft angle were similar between groups (p=0.826, p=0.555). Cleveland index placement and modified Harris hip score improvement were comparable (p=0.836, p<0.001). Predominant vitamin D deficiency was observed in both groups. Conclusion PFNA offers measurable intraoperative benefits over conventional PFN in terms of operative time, blood loss, and need for fluoroscopic imaging. However, no statistically observable benefits were noted in postoperative functional outcomes or complications between the two implants.

The Impact of Concomitant Neck of Femur Fractures and Upper Limb Fractures on Length of Stay and Key Performance Indicators: A Single-Centre Study

Background Hip fractures are one of the most common serious injuries seen today and constitute one of the most serious healthcare problems affecting the elderly worldwide. Due to the elderly population, associated falls and osteoporosis increase the incidence of hip fractures. Patients may remain hospitalized for several weeks, leading to one and a half million hospital bed days used each year. The reported incidence of a concurrent upper limb and a lower limb fracture is between 3% and 5%. It has been shown in the literature that patients who sustain both a hip fracture and an upper limb fracture have difficulties with rehabilitation which causes prolonged stays. The available literature on concomitant hip fracture and upper extremity fracture is limited. This study aimed to review patients with concurrent upper limb injury and hip fractures and to analyse the pattern of associated upper limb fractures, management of these fractures, length of hospital stay, mortality rates, and complications. Methodology We performed a retrospective data collection of all patients with a concomitant upper limb fracture and hip fracture from January 2017 to December 2020 at the University Hospital of Wales, Cardiff, United Kingdom. Patients were identified from the registers maintained in the ward. All patients aged over 60 years with a fragility hip fracture (managed operatively) and a concurrent upper limb fracture were included in the study. Patients aged less than 60 years were excluded. The local research department registered and approved this study as a service evaluation and therefore did not need ethical committee approval. The anatomical location of the upper limb and hip fractures was confirmed using the imaging database (Synapse). Results Of the 760 patients admitted with neck of femur fractures during this period, 39 (5.1%) patients had concomitant upper limb fractures. Only one upper limb fracture was managed with fixation, and for this study, that patient was excluded. Our retrospective search identified 38 patients, of whom 11 were men and 27 were women. Distal radius fractures were the most commonly associated upper limb fractures (55%). There was a significant increase in length of stay (43.6 days vs. 16.6 days) and delay in mobilization (58.9% vs. 81%) compared to an isolated hip fracture. There was no difference in the 30-day mortality rates. We were unable to collect the data for the Key Performance Indicator (KPI) of the National Institute for Health and Care Excellence compliant surgery, and this KPI was excluded from our study. Of the remaining five KPIs, our group of patients displayed better averages in three of the five categories, including prompt orthogeriatric review (92%), not delirious postoperatively (87%), and return to original residence (79%). Conclusions Due to the ageing population, hip fractures are increasing, and within one year of operation, have shown higher mortality rates. Annually, reports show that the worldwide incidence of fractures in the adult population ranges between 9.0 and 22.8 per 1,000. These fractures are more frequent in osteoporotic patients with weak bone quality. Following hip fractures, upper extremity fractures are the second most common among the osteoporotic, elderly population, with distal radius fractures being the most common. With the length of stay almost tripled (from 16.6 to 44.4 days), one can see this has a very big effect on costs in the National Health Service system.

Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018

Importance

The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients.

Objectives

To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark.

Design, Setting, and Participants

This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024.

Main Outcomes and Measures

Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication.

Results

From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement.

Conclusions and Relevance

The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.

Effect of inflammatory response on joint function after hip fracture in elderly patients: A clinical study

BACKGROUND

Excellent hip joint function facilitates limb recovery and improves the quality of survival. This study aimed to investigate the potential risk factors affecting postoperative joint functional activity and outcomes in elderly hip fractures patients and to provide evidence for patient rehabilitation and clinical management.

AIM

To explore the relationship between inflammatory factors and hip function and the interaction between inflammation and health after hip fracture in elderly patients.

METHODS

The elderly patients who had hip fracture surgery at our hospital between January 1, 2021, and December 31, 2022 were chosen for this retrospective clinical investigation. Patients with excellent and fair postoperative hip function had their clinical information and characteristics gathered and compared. Age, gender, fracture site, surgical technique, laboratory indices, and other variables that could have an impact on postoperative joint function were all included in a univariate study. To further identify independent risk factors affecting postoperative joint function in hip fractures, risk factors that showed statistical significance in the univariate analysis were then included in a multiple logistic regression analysis. In addition to this, we also compared other outcome variables such as visual analogue scale and length of hospital stay between the two groups.

RESULTS

A total of 119 elderly patients with hip fractures were included in this study, of whom 37 were male and 82 were female. The results of univariate logistic regression analysis after excluding the interaction of various factors showed that there was a statistically significant difference in interleukin (IL)-6, IL-8, IL-10, C-reactive protein (CRP), and complement C1q (C1q) between the fair and excellent joint function groups (P < 0.05). The results of multiple logistic regression analysis showed that IL-6 > 20 pg/mL [(Odds ratio (OR) 3.070, 95%CI: 1.243-7.579], IL-8 > 21.4 pg/ mL (OR 3.827, 95%CI: 1.498-9.773), CRP > 10 mg/L (OR 2.142, 95%CI: 1.020-4.498) and C1q > 233 mg/L (OR 2.339, 95%CI: 1.094-5.004) were independent risk factors for poor joint function after hip fracture surgery (all P < 0.05).

CONCLUSION

After hip fractures in older patients, inflammatory variables are risk factors for fair joint function; therefore, early intervention to address these markers is essential to enhance joint function and avoid consequences.

Epidemiological features of 1,332 cases of hip fracture in Shanghai, China (2015-2020)

PURPOSE

This study aimed to analyze the epidemiological characteristics of hip fracture in all age groups in Shanghai, and to evaluate the hospitalization cost of patients with hip fracture.

METHODS

A total of 1,332 hip fracture patients admitted to a tertiary general hospital between January 2015 and May 2020 in Shanghai were included. Age, sex, diagnosis, cause of injury and site, fracture type, comorbidities, length of stay, treatment, outcomes (at discharge) and hospitalization expenses were recorded. The epidemiological characteristics of hip fracture were analyzed by using SPSS 26.0 software.

RESULTS

The average age of hip fracture was 77.24 ± 12.66 years, and 69.0% of the patients were female. Overall, 886 patients had femoral neck fracture, and 446 patients suffered from intertrochanteric fracture. Most of the fractures caused by falls at the same level and falls from a height occurred in those aged 81-90 years; and traffic accident injuries mostly took place in patients aged 50-60. Among the 1,302 hip fracture patients who underwent surgical treatment, hip replacement was the major choice for femoral neck fracture, accounting for 49.2%. Internal fixation was the main treatment choice for intertrochanteric fracture, making up 97.8%. The median length of hospital stay lasted 8 days and at cost of hospitalization was ¥49,138.18 RMB.

CONCLUSION

This epidemiological study found that patients with hip fracture had certain distribution characteristics in age, sex, type of fracture, injury season, cause of injury, mode of operation, length of stay, cost, and so on. Proper medical management, social preventive measures, and prevention of falls are needed to reduce the risk of hip fracture and the socioeconomic burden.

Geographic variation in bone mineral density and prevalent fractures in the Canadian longitudinal study on aging

Awareness of the prevalence of osteoporosis and fractures across jurisdictions can guide the development of local preventive programs and healthcare policies. We observed geographical variations in total hip bone mineral density and in the prevalence of major osteoporotic fractures across Canadian provinces, which persisted after adjusting for important covariates.

PURPOSE

We aimed to describe sex-specific total hip bone mineral density (aBMD) and prevalent major osteoporotic fractures (MOF) variation between Canadian provinces.

METHODS

We used baseline data from 21,227 Canadians (10,716 women, 10,511 men) aged 50-85 years in the Canadian Longitudinal Study on Aging (CLSA; baseline: 2012-2015). Linear and logistic regression models were used to examine associations between province of residence and total hip aBMD and self-reported MOF, stratified by sex. CLSA sampling weights were used to generate the prevalence and regression estimates.

RESULTS

The mean (SD) age of participants was 63.9 (9.1) years. The mean body mass index (kg/m2) was lowest in British Columbia (27.4 [5.0]) and highest in Newfoundland and Labrador (28.8 [5.3]). Women and men from British Columbia had the lowest mean total hip aBMD and the lowest prevalence of MOF. Alberta had the highest proportion of participants reporting recent falls (12.0%), and Manitoba (8.4%) the fewest (p-value=0.002). Linear regression analyses demonstrated significant differences in total hip aBMD: women and men from British Columbia and Alberta, and women from Manitoba and Nova Scotia had lower adjusted total hip aBMD than Ontario (p-values<0.02). Adjusted odds ratios (95% confidence intervals, CI) for prevalent MOF were significantly lower in women from British Columbia (0.47 [95% CI: 0.32; 0.69]) and Quebec (0.68 [95% CI: 0.48; 0.97]) and in men from British Columbia (0.40 [95% CI:0.22; 0.71]) compared to Ontario (p-values<0.03). Results were similar when adjusting for physical performance measures and when restricting the analyses to participants who reported White race/ethnicity.

CONCLUSION

Geographical variations in total hip aBMD and in the prevalence of MOF between provinces persisted after adjusting for important covariates which suggests an association with unmeasured individual and environmental factors.

Implementation difficulties and solutions for a smart-clothes assisted home nursing care program for older adults with dementia or recovering from hip fracture

BACKGROUND

Wearable devices have the advantage of always being with individuals, enabling easy detection of their movements. Smart clothing can provide feedback to family caregivers of older adults with disabilities who require in-home care.

METHODS

This study describes the process of setting up a smart technology-assisted (STA) home-nursing care program, the difficulties encountered, and strategies applied to improve the program. The STA program utilized a smart-vest, designed specifically for older persons with dementia or recovering from hip-fracture surgery. The smart-vest facilitated nurses' and family caregivers' detection of a care receiver's movements via a remote-monitoring system. Movements included getting up at night, time spent in the bathroom, duration of daytime immobility, leaving the house, and daily activity. Twelve caregivers of older adults and their care receiver participated; care receivers included persons recovering from hip fracture (n = 5) and persons living with dementia (n = 7). Data about installation of the individual STA in-home systems, monitoring, and technical difficulties encountered were obtained from researchers' reports. Qualitative data about the caregivers' and care receivers' use of the system were obtained from homecare nurses' reports, which were explored with thematic analysis.

RESULTS

Compiled reports from the research team identified three areas of difficulty with the system: incompatibility with the home environment, which caused extra hours of manpower and added to the cost of set-up and maintenance; interruptions in data transmissions, due to system malfunctions; and inaccuracies in data transmissions, due to sensors on the smart-vest. These difficulties contributed to frustration experienced by caregivers and care receivers.

CONCLUSIONS

The difficulties encountered impeded implementation of the STA home nursing care. Each of these difficulties had their own unique problems and strategies to resolve them. Our findings can provide a reference for future implementation of similar smart-home systems, which could facilitate ease-of-use for family caregivers.

Inadequate harms reporting among randomized controlled trials cited as supporting evidence in the AAOS management of hip fractures in older adults clinical practice guideline recommendations

BACKGROUND

Recommendations within clinical practice guidelines (CPGs) are heavily influenced by results from randomized controlled trials (RCTs). Therefore, it is imperative that all RCT outcomes are reported thoroughly to ensure CPGs are created using accurate information. Here, we evaluate the quality of harms reporting using the CONSORT Extension for Harms in RCTs underpinning recommendations in the American Academy of Orthopedic Surgeons (AAOS) Management of Hip Fractures in Older Adults CPG.

METHODS

Each RCT cited as evidence for recommendations in the AAOS Management of Hip Fractures in Older Adults CPG was evaluated using the CONSORT Extension for Harms to determine the quality of harms reporting. Descriptive statistics (frequencies, percentages, 95 % confidence intervals) were used to summarize adherence to CONSORT Harms items. A linear regression model was used to evaluate the CONSORT Harms influence on the quality of reporting over time.

RESULTS

Among the 156 RCTs identified, there were a total of 31,848 participants. Most RCTs were conducted at a single center (137; 87.8 %) and in a single-blind manner (130; 83.3 %). Fifty-four (34.6 %) RCTs did not provide funding statements. Trials adequately reported an average of 6.65 out of 18 CONSORT Extension for Harms items (37.0 %). One RCT adequately reported all items, while five reported zero items. Forty-seven RCTs (30.1 %) reported ≥ 50 % of items and 73 (46.8 %) reported ≤ 33.3 % of items. The linear regression model demonstrated no significant increase in mean adherence over time (adjusted R2 = -0.006; p = 0.563).

CONCLUSION

Our results highlight inadequate harms reporting among RCTs in the AAOS Management of Hip Fractures in Older Patients CPG. While the CONSORT Harms Extension was intended to enhance reporting, the linear regression model did not demonstrate significant improvements over time.

Accuracy of detecting burst of the lateral wall in intertrochanteric hip fractures with plain radiographs: Is postoperative CT necessary?

Background

Postoperative burst of the lateral femoral wall is thought to be the main predictor of reoperation for intertrochanteric fractures, which is routinely evaluated using plain radiographs. We retrospectively compared computed tomography (CT) scans and radiographs regarding the ability to detect burst of the lateral wall. We also investigated whether intramedullary nails may cause iatrogenic burst of the lateral wall.

Methods

From January 2010 to December 2021, patients aged 65 years and older who undergone intertrochanteric fractures treated with the proximal femoral nail antirotation 2 (PFNA-Ⅱ) were included. The incidence of burst of the lateral wall was evaluated with two different imaging modalities by two observers. Two rounds of evaluation were performed: (1) with plain radiographs alone; and (2) with CT scans combined with radiographs. Interobserver and intraobserver agreement (κ value) for evaluation of the lateral wall burst was assessed.

Results

A total of 1507 patients were included (362 males and 1145 females). Compared with radiographs alone (12.0 %, 181/1507 patients), a higher rate of lateral wall burst was found by CT scans combined with radiographs (72.9 %, 1098/1507 patients) for observer 1 at first reading (P < 0.001). Similar results were seen in other evaluations. Interobserver and intraobserver agreement was substantial for radiographs alone (κ, 0.659-0.727) and almost perfect for CT scans combined with radiographs (κ, 0.847-0.926).

Conclusions

Computed tomography combined with radiographs is superior to radiographs alone for detecting burst of the lateral wall after intertrochanteric fracture fixation. Additionally, PFNA-Ⅱ could cause iatrogenic burst of the lateral wall for intertrochanteric fractures in the elderly.

QCT-based 3D finite element modeling to assess patient-specific hip fracture risk and risk factors

Early assessment of hip fracture risk may play a critical role in designing preventive mechanisms to reduce the occurrence of hip fracture in geriatric people. The loading direction, clinical, and morphological variables play a vital role in hip fracture. Analyzing the effects of these variables helps predict fractures risk more accurately; thereby suggesting the critical variable that needs to be considered. Hence, this work considered the fall postures by varying the loading direction on the coronal plane (α) and on the transverse plane (β) along with the clinical variables-age, sex, weight, and bone mineral density, and morphological variables-femoral neck axis length, femoral neck width, femoral neck angle, and true moment arm. The strain distribution obtained via finite element analysis (FEA) shows that the angle of adduction (α) during a fall increases the risk of fracture at the greater trochanter and femoral neck, whereas with an increased angle of rotation (β) during the fall, the FRI increases by ∼1.35 folds. The statistical analysis of clinical, morphological, and loading variables (αandβ) delineates that the consideration of only one variable is not enough to realistically predict the possibility of fracture as the correlation between individual variables and FRI is less than 0.1, even though they are shown to be significant (p<0.01). On the contrary, the correlation (R2=0.48) increases as all variables are considered, suggesting the need for considering different variables fork predicting FRI. However, the effect of each variable is different. While loading, clinical, and morphological variables are considered together, the loading direction on transverse plane (β) has high significance, and the anatomical variabilities have no significance.

Emerging trends and prospects in telerehabilitation for hip fracture: Bibliometric and visualization study

Background

Telerehabilitation provide distant physical rehabilitation services and help overcome the barriers associated with face-to-face interventions for hip fractures. This study aims to analyse the progress of the application of telerehabilitation in hip fracture and reveal its research profile, hotspots and development trends.

Methods

The articles and reviews related to telerehabilitation in hip fracture were retrieved from 1992 to 2024. A bibliometric visualization and comparative analysis of countries, institutions, journals, authors, references and keywords were conducted using Java-based CiteSpace and VOSviewer.

Results

A total of 79 documents were obtained. Spain was the most academically influential country. The University of Granada was the most prolific institution. The author Ariza-vega P listed first in terms of publications and citations. Most publications were published in high academic impact journals. The major frontier keywords were "older adults," "functional recovery," "reliability," "mortality," "rehabilitation," "mobility" and "quality of life." The most popular keywords from 2020 to 2024 were "geriatric medicine," "family caregiver" and "digital health."

Conclusions

The historical and prospective perspective in telerehabilitation following hip fracture were presented. A primary focus in the early years was the impact of telerehabilitation on functional independence for hip fracture patients. Future outcomes are expected to include patient satisfaction, health-related quality of life and psychiatric symptoms. Exercise was also designed to eliminate travel burdens and strengthen self-efficacy, and improve the physical and psychosocial function of hip fracture patients. This work will provide a fundamental reference as well as a directional guide for future research.