Female Hip Fracture Research Articles

Predictors of outcomes after internal fixation of periprosthetic femoral hip fractures Subgroup analysis of the peri-implant and peri-prosthetic fractures Spanish registry (PIPPAS)

To identify risk factors predisposing patients to poor outcomes after fixation of periprosthetic hip fractures around femoral stems. Prospective multicentre cohort study of fractures around a hip replacement stem managed by internal fixation. The primary outcome was one-year mortality, while secondary outcomes were local complications and healthcare burden-related outcomes (nursing facility utilization and hospital length of stay). One-year mortality was 16.2%. Age-adjusted Charlson Comorbidity Index score (OR=1.17; 95%CI=1.03-1.33)), Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) score (OR=1.16; 1.06-1.28), prosthetic dysfunction (OR=1.90; 1.00-3.61), and postoperative medical complications (OR=1.97; 1.06-3.68) were predictors of mortality. Patients with prior prosthetic dysfunction, lower Pfeiffer SPMSQ scores, Vancouver A fractures, and fractures fixed only using cerclages were at higher risk of local complications, which occurred in 9.3% of cases. Medical (OR=1.81; 1.05-3.13) and local complications (OR=5.56; 2.42-3.13) emerged as consistent risk factors for new institutionalization. Average hospitalization time was 13.9±9.2 days. Each day of fixation delay led to an average 1.4-day increase in total hospitalization. Frail periprosthetic hip-fracture patients with poorer functional status, dysfunctional replacements, and postoperative complications are at increased risk of mortality. Postoperative complications are more common in patients with dysfunctional arthroplasties, Vancouver A fractures, and fixation using cerclages alone. Postoperative complications were the most consistent predictor of higher healthcare resource utilization.

Prevalence and risk factors for atypical femoral fracture among Lebanese patients with hip and shaft fractures.

This retrospective study investigates the prevalence of atypical femoral fractures (AFFs) among patients admitted with hip and shaft fractures at a tertiary referral center in Beirut, Lebanon. We analyzed electronic medical records and radiology studies of patients aged above 40 admitted with hip and shaft fractures between January 2006 and December 2019. Fractures were confirmed by ICD9 or ICD10 codes. All cases were reviewed by radiologists, and AFFs were identified according to the 2013 revised ASBMR criteria. We identified 1366 hip and shaft fracture patients, of which 14 female patients had 19 AFFs. This represents a prevalence of 1.0% among all hip and shaft fractures patients and 1.7% among all female hip and shaft fracture patients. Bilateral AFFs were found in 5 of the 14 patients. Patients with AFF tended to be younger, with a mean age of 74.3 (±8.6) yr compared to 78.0 (±10.6) for patients with non-AFF fractures. A total of 36% of AFF patients had a prior history of non-traumatic fracture at first admission. A high percentage of patients with AFFs reported intake of proton pump inhibitors (42.9%) and glucocorticoids (21.4%). Bisphosphonate exposure was noted in 64.3% of AFF patients. None of the AFF patients were active smokers or consumed alcohol regularly. BMD assessments were available for 7 AFF patients, indicating osteoporosis in 4 and osteopenia in 3 cases. Hip axis length measurements showed no significant difference between AFF patients (N = 7) and sex and age-matched controls (N = 21). The study underlines the prevalence and characteristics of AFFs in Lebanon, which is consistent with the numbers reported in the literature (0.32%-5%). A larger prospective study that includes hospitals across the nation is needed to gain a more comprehensive view of the prevalence of AFFs in the Lebanese population.

Patients with Periprosthetic Femoral Hip Fractures are Commonly Classified as Having Osteoporosis Based on DXA Measurements

Periprosthetic femoral hip fractures are subject to an increasing incidence and are often considered to be related to osteoporosis. However, there are no available studies that have determined the frequency of osteoporosis in affected patients using gold standard dual-energy X-ray absorptiometry (DXA). In this retrospective comparative study, we analyzed the DXA results of 40 patients with periprosthetic femoral hip fractures who were treated surgically in our department. DXA measurements were performed at the total hip and the lumbar spine to determine bone mineral density T-scores. Data were compared to two age-, sex-, and BMI-matched control groups in which patients underwent DXA prior to aseptic revision surgery for other causes or primary THA (consisting of 40 patients each). The mean T-score in the periprosthetic fracture cohort was significantly lower (− 1.78 ± 1.78) than that of the aseptic revision (− 0.65 ± 1.58, mean difference − 1.13 [95% CI − 1.88 to − 0.37]; p = 0.001) and the primary THA cohort (− 0.77 ± 1.34, mean difference − 1.01 [95% CI − 1.77 to − 0.26]; p = 0.005). Accordingly, osteoporosis was detected more frequently (45%) in the fracture cohort compared to patients undergoing aseptic revision (12.5%) and primary THA (10%). In conclusion, almost half of the patients with periprosthetic femoral hip fractures have osteoporosis according to DXA measurements. A regular assessment of bone health in THA enables identification of patients with osteoporosis who likely benefit from initiation of osteoporosis medication and cemented stem fixation.

Associated factors of stress, urgency, and mixed urinary incontinence in a geriatric outpatient assessment of older women with hip fracture

Key Summary PointsAimThe aim was to examine factors associated with different subtypes (stress, urgency and mixed) of urinary incontinence among older female hip fracture patients using a cross-sectional design.FindingsUrinary incontinence was frequent, and the most common type was urgency incontinence. Stress incontinence and urgency incontinence were associated with different modifiable risk factors, all of which were associated also with mixed incontinence.MessageDifferent risk factors converge in mixed urinary incontinence. Comprehensive geriatric assessment is key in the assessment of UI in older hip fracture patients.

Postfracture survival in a population-based study of adults aged ≥66yr: a call to action at hospital discharge.

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85yr, 51.9%-63.9%; ≥86yr, 34.5%), followed by vertebral fractures in males (66-85yr, 53.2%-69.4%; ≥86yr, 35.5%), and hip fractures in females (66-85yr, 69.8%-79.0%; ≥86yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.

Association of Handgrip Strength with Hip Fracture and Falls in Community-dwelling Middle-aged and Older Adults: A 4-Year Longitudinal Study.

Hip fracture and falls are significant health concerns. Handgrip strength (HGS) is closely associated with overall muscle strength and physical health. However, the longitudinal relationship between HGS and the risk of hip fractures and falls remains unclear, particularly regarding gender differences. This longitudinal study aimed to investigate the association between HGS and the risk of hip fracture and falls in individuals aged 45 years and above, considering gender-specific differences over a 4-year period. This study included 10,092 participants (4471 men and 5621 women) aged 45 years and above from the China Health and Retirement Longitudinal Study (CHARLS). Incidents of hip fractures and falls were recorded during a 4-year follow-up, along with various demographic and clinical factors. Participants were categorized into five groups based on their HGS quintiles. Logistic regression models were employed to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to assess the relationship between HGS and hip fracture/fall risk. During the 4-year follow-up period, 223 cases of hip fracture (2.2%) and 1831 cases of falls (18.1%) were documented. Notably, higher HGS demonstrated a strong inverse association with the risk of hip fracture in both males and females (p < 0.05). In comparison to the lowest HGS quintile, the adjusted odds ratios (ORs) for hip fracture were 0.46 (0.27-0.78) for the total population, 0.4 (0.19-0.81) for males and 0.48 (0.23-0.98) for females in the highest HGS quintile. Furthermore, a profound and statistically significant negative correlation between HGS and falls was detected (p < 0.05). The adjusted ORs for falls in the highest HGS quintile, compared to the lowest quintile, were 0.62 (0.51-0.76) in the overall population, 0.59 (0.44-0.78) in males, and 0.78 (0.62-0.99) in females. Our findings highlight the significant inverse association between HGS and the risk of hip fracture and falls in both males and females aged 45 years and above. Assessing handgrip strength may serve as a valuable tool for predicting fracture and fall risk.

Do urinary and double incontinence predict changes in living arrangements and mobility in older women after hip fracture? – a 1-year prospective cohort study

BackgroundContinence problems are known to be associated with disability in older adults. Costs of disability and resulting need for more supported living arrangements are high after a hip fracture. The aim was to examine pre-fracture urinary incontinence (UI) and double incontinence (DI, concurrent UI and fecal incontinence) as predictors of changes in mobility and living arrangements in older female hip fracture patients in a 1-year follow-up.MethodsStudy population comprised 1,675 female patients aged ≥ 65 (mean age 82.7 ± 6.8) sustaining their first hip fracture between 2007–2019. Data on self-reported pre-fracture continence status was collected. The outcomes were declined vs. same or improved mobility level and need for more assisted vs same or less assisted living arrangements 1-year post-fracture. Separate cohorts of 1,226 and 1,055 women were generated for the mobility and living arrangements outcomes, respectively. Age- and multivariable-adjusted logistic regression models were used to determine the associations of UI, DI, and other baseline characteristics with the outcomes.ResultsOf the patients, 39% had declined mobility or more assisted living arrangements at 1-year follow-up. Adjusting for age, both pre-fracture UI and DI were associated with changes in mobility and living arrangements. In the multivariable analysis, UI (OR 1.88, 95% CI 1.41–2.51) and DI (1.99, 95% CI 1.21–3.27) were associated with decline in mobility level while only DI (OR 2.40, 95% CI 1.22–4.75) remained associated with the need for more assisted living arrangements.ConclusionsBoth pre-fracture UI and DI in older women are risk factors for declining mobility level, but only DI for more supported living arrangements 1-year post-hip fracture. UI likely develops earlier in life and might not necessarily be strongly associated with the onset or increasing disability in later years. DI may indicate more marked vulnerability and burden to patients as well as to formal and informal caregivers.

Hip Fracture Patterns, Hospital Course, and Mortality Differ Between Males and Females.

The purpose of this study was to describe how hip fractures differentially affect male and female patients regarding fracture pattern, hospital course, and postoperative course. This retrospective case series was performed in a metropolitan healthcare system involving 2996 hip fracture patients >59years old who underwent surgical management (eg, intramedullary nail, hemiarthroplasty, percutaneous pinning, etc.). Male patients were matched to female patients using 1:2 nearest neighbor matching on the basis of age and Charlson Comorbidity Index. Outcomes of interest included AO/OTA fracture classification, 30- and 90-day readmission, and 30-day and 1-year mortality rates. The cohort was predominantly female (64.5%). Female patients were more likely to sustain a type 31A fracture compared to males (P = .016). The average CCI was higher for males vs females (3.0 ± 2.5 vs 2.6 ± 2.3, P < .001). Males were more likely to be readmitted at 30 (P < .001) and 90 (P = .015) days after discharge. The 30-day mortality was higher for males vs females (6.6% vs 4.5%, P = .015). Approximately 19.9% of male patients vs 15.1% of females died within a year of surgery (P < .001). The average time to surgery was longer for males vs females (23.8 ± 18.8 vs 22.5 ± 21.9h, P = .048). Males were more likely to die within a year if they underwent surgery >24h after admission (P = .029). Hip fractures have different implications for male and female patients. With age, the incidence of IT fractures increased in females, while it decreased in males. On average, males with hip fractures are sicker than females, which likely contributes to the longer time to surgery as well as increased readmission and mortality rates seen in males. Male and female hip fracture patients are not similar in baseline health status, fracture pattern, or postoperative morbidity and mortality. Orthogeriatricians and other providers that care for this patient population should be aware of these differences when implementing treatment strategies to optimize the recovery of their patients, and while educating patients and their families about postoperative expectations.

Post-traumatic osteoarthritis: the worst associated injuries and differences in patients' profile when compared with primary osteoarthritis

BackgroundThe estimated prevalence of post-traumatic osteoarthritis (PTOA) is 10–12% and in this study 12.4%. Different knee and hip injuries have been identified as risk factors for PTOA, but there is no consensus regarding the most painful and disabling injuries. Identifying these injuries might help in the prevention of PTOA. Additionally, patients with PTOA have a higher risk for complications after arthroplasty than patients with primary OA, perhaps due to differences in the profile and comorbidity that might help to explain the difference. This work aims 1) to identify the most common past injuries associated with the most painful and disabling PTOA cases in non-athlete patients and 2) to compare the comorbidities and characteristics between PTOA and primary OA.MethodsRetrospective hospital-based cohort study with 1290 participants with joint complaints or who received arthroplasty. Medical records included demographic information, diagnosis, medication, smoking, alcohol history and comorbidities. Data from January 2012 orthopaedic consults till December 2019 was reviewed and had the type and date of injury, pain score by the numerical rating scale and walking disability. Odds Ratio (OR) and 95% confidence intervals are presented.ResultsThere were 641 cases with primary OA (65% females) and 104 with PTOA (61% males). Patients with PTOA were 7.5 years younger (P < 0.001), reported more alcohol consumption (P = 0.01) and had higher odds of osteoporotic fractures (OP) and psychosis than patients with primary OA (OR = 2.0, CI = 1.06–3.78 and OR = 2.90, CI = -0.91–9.18, respectively). Knee fractures were most common in males and hip fractures in females (31% and 37.5%, respectively, P < 0.005). The PTOA-associated injuries with the highest pain and disability scores were meniscal injuries and hip fractures. Besides, in the group with primary OA, there were more diabetes, hypertension and hypothyroidism cases than in PTOA. However, after adjustment, differences were only significant for diabetes (ORadj = 1.78, CI = 1.0–3.2).ConclusionsPast meniscal injuries and hip fractures were the most relevant PTOA-associated injuries regarding pain and walking disability. This, together with differences in their profile when compared with primary OA, might help to decide the orthopaedic management of these injuries to prevent complications such as PTOA and recurrence, with appropriate preoperative planning, surgery choice and comorbidity treatment.

Associations between living alone, social interactions, and physical performance differ by sex: Results from the Baltimore Hip Studies.

There is mixed evidence on whether living arrangements and social interactions are associated with poorer health outcomes after hip fracture repair. Distinct social profiles among male and female older adults may explain some of the differences. However, prior studies did not evaluate these differences by sex. This article aims to assess if the associations between living alone, social interaction, and physical performance differ by sex among hip fracture survivors. This prospective cohort study is part of the Baltimore Hip Studies seventh cohort, with 168 male and 171 female hip fracture patients assessed at baseline (≤22 days after hospitalization) and at 2, 6, and 12 months post admission. Living arrangements and interaction with children or siblings and others in the past 2 weeks were collected at all visits. Physical performance was measured in the follow-up visits with the Short Physical Performance Battery (SPPB). Linear mixed models tested associations of living alone and social interaction with SPPB over time adjusted for age, education, comorbidities, physical functioning pre-fracture, cognitive function, self-rated health, and time. For men only, living alone was associated with worse performance (0.7 points lower SPPB scores, p = 0.05). Higher social interaction was associated with 0.8 and 1.2 point higher SPPB scores for men and women, respectively (p < 0.05). Visiting with friends was significantly associated with better function among males, while visiting with children or siblings was associated with worse SPPB among females. Living arrangements and types of social interaction are differentially associated with physical function for older men and women. Screening for social isolation/integration and including interventions that promote social interaction and participation should be considered in healthcare programs for hip fracture survivors.

Urinary and double incontinence in older women with hip fracture - risk of death and predictors of incident symptoms among survivors in a 1-year prospective cohort study

ObjectivesTo investigate the association of urinary incontinence (UI) and double incontinence (DI, concurrent UI and fecal incontinence) with one-year mortality among older female hip fracture patients and to identify predictors of incident UI and DI. DesignA prospective cohort study Setting and subjects1,468 female patients aged ≥ 65 treated for their first hip fracture during the period 2007–2019 MethodsContinence status was elicited at baseline and one-year post-fracture. Age- and multivariable-adjusted Cox proportional hazards and multinomial logistic regression models were used to determine the associations of incontinence with one-year mortality and to examine the associations of baseline predictors with incident UI and DI respectively. ResultsOf the women with no incontinence, UI and DI, 78 (13%), 159 (23%) and 60 (34%), died during follow-up. UI (HR 1.72, 95% CI 1.31–2.26) and DI (HR 2.61, 95% CI 1.86–3.66) were associated with mortality after adjusting for age. These associations lost their predictive power in multivariable analysis while age over 90, living in an institution, impaired mobility, poor nutrition, polypharmacy, and late removal of urinary catheter remained associated with mortality. Of continent women, 128 (21%) developed UI and 23 (4%) DI during follow-up. In multivariable analysis, impaired mobility was associated with incident UI (OR 2.56, 95% CI 1.48–4.44) and DI (OR 4.82, 95% CI 1.70–13.7), as well as living in an institution (OR 3.44, 95% CI 1.56–7.61 and OR 3.90, 95% CI 1.17–13.0). Conclusions and ImplicationsUnderlying vulnerability likely explains differences in mortality between continence groups and development of incident UI and DI.

Prevalence of sarcopenia and mortality rate in older adults with hip fracture.

Several international study groups adopted appendicular skeletal muscle mass (ASM) index adjusted by (1) height squared, (2) weight, and (3) body mass index (BMI) in the diagnosis of sarcopenia. However, different prevalence rates of sarcopenia by each index and clinical implications were not well known. The purpose of this study was to compare the differences in (1) the percentage of sarcopenia in hip fracture patients and (2) the relative mortality rate according to the sarcopenia criteria of three ASM indices. Between January 2009 and December 2020, 1003 older adult hip fracture patients at a tertiary institution were eligible and retrospectively reviewed for this study. Based on the ASM measured on dual-energy X-ray absorptiometry, three indices were calculated, and sarcopenia was diagnosed. The proportion of sarcopenia was evaluated according to each index. One, two, and five-year mortality rates were compared between each sarcopenia group and a normal musculature group, based on ASM criteria. The proportion of sarcopenia patients differed according to three ASM indices. The proportion of sarcopenic patients by ASM/height2 index was higher than those of the other two indices in both male and female hip fracture patients. In male patients, 61% were sarcopenic by ASM/height2 index, 37% by ASM/weight index, and 44% by ASM/BMI index. In female patients, 26%, 11%, and 14% were sarcopenic, respectively. Among the three indices, only ASM/height2 had significant correlations with all 1-, 2-, and 5-year mortality rates. The prevalence of sarcopenia in hip fracture patients differed substantially according to ASM indices. Sarcopenic hip fracture patients had a higher mortality rate than those with normal musculature. The 1-year, 2-year, and 5-year mortality rates were discriminated by ASM/height2 criteria in both men and women. Future prospective studies in a larger cohort are warranted.

The STEP-HI Trial: Pragmatic Challenges and Design Issues

Multi-modal interventions present many implementation challenges, especially for studies of frail older adults. The STEP-HI study is an ongoing multi-center, randomized, controlled, double-blinded clinical trial that is evaluating whether six months of topical testosterone therapy combined with a supervised center-based exercise-training program can improve mobility, functional performance, and quality of life after hip fracture, compared to exercise training alone or Enhanced Usual Care. Female hip fracture patients ≥ 65 yrs. old who are living in the community or assisted living are being randomized within 26 weeks of surgical repair for the fracture, and re-evaluated 24 weeks later. This presentation discusses the rationale and study design, and modifications to the protocol in response to challenges, including the COVID-19 pandemic.

STEP-HI Study: A Multimodal Intervention of Exercise and Testosterone Therapy: Design and Real-World Challenges

Hip fractures are common among older women and can have a devastating impact on their ability to remain independent. Many women who were high functioning before the hip fracture do not return to their pre-fracture level of function, have persistent weakness and mobility impairments, and may require ongoing supportive services. Age-associated androgen deficiency may contribute to deficits in muscle mass, strength and power that are common in older female hip fracture patients. The Starting a Testosterone and Exercise Program after Hip Injury (STEP-HI ) Study is a three-group, randomized, double-blinded, placebo-controlled Phase III clinical trial designed to evaluate a multi-modal intervention aimed at improving functional outcomes in older female hip fracture patients. 168 female hip fracture patients, age 65 yrs. and older are being recruited from 6 clinical sites in the USA. Participants are being assigned to one of three groups: supervised exercise (EX) plus 1% testosterone topical gel; EX plus placebo gel; or enhanced usual care. The primary outcome is six-minute walk distance. This symposium will present information related to key aspects of the design of the STEP-HI trial, including recruitment of a frail patient population during a period of injury recovery, the testosterone and exercise interventions and related fidelity procedures, and implementation challenges for this multi-modal intervention prior to and during the COVID-19 pandemic. In addition, the underlying mechanisms by which testosterone and exercise are expected to have a synergistic effect on muscle strength and function will be discussed.

Causes of death among 93.637 hip fracture patients- data based on the Danish National Registry of causes of death.

Excess mortality among hip fracture patients is well documented. Less is known, however, about the causes of death in this group of patients, although existing literature suggests that bronchopneumonia and cardiovascular diseases constitute the leading causes of death. In this study, we investigated the causes of death in Danish hip fracture patients, who died within 30-days after sustaining a hip fracture, with a focus on differences in causes of death between men and women and between different age groups. Furthermore, the frequency of potentially preventable causes of death such as pneumonia, urinary tract infections and thromboembolic events was examined. All Danish patients aged 18 or more suffering from a hip fracture in the period 2002-2012 were examined for inclusion into the study. Data were collected from the Danish National Patient registry. The last month of 2012 being December was left out since we were looking at 30-days mortality. Logistic regression analysis was used to test the association between 30-day mortality with each of the causes of death adjusted for age, sex and CCI in multivariable models with results presented as odds ratios (OR) with 95% confidence intervals. During this period, 93,637 patients sustained a hip fracture. Of these, 9504 patients died within 30-days and were included in the study. For patients dead within 30-days after sustaining a hip fracture, the two leading medical causes of death were cardiovascular disease (21.1%) and pneumonia (10.5%) when looking at both genders. A frequent cause of death especially in the younger age group of women less than 50years old were infections (other than pneumonia) (18.2%) especially urinary tract infections. Pulmonary embolism accounted for 3.9% of causes of deaths in hip fracture patients. In this study, cardiovascular disease and pneumonia were overall the leading medical causes of death in patients dead within 30-days after sustaining a hip fracture. Apart from pneumonia, another potentially preventable infection in younger female hip fracture patients was urinary tract infections. Pulmonary embolism, another potentially preventable cause of death might be underreported in Danish death certificates.

The incidence of fragility hip fractures in a subpopulation of South Africa

Background. Fragility hip fractures (FHFs) are associated with significant morbidity, mortality and burden on the healthcare system. European and North American literature suggests that the worldwide incidence of FHFs is increasing, but very little is known about the incidence of FHFs in Africa and South Africa (SA). Historically FHFs were believed to be uncommon in black African populations, but recent studies have shown a marked increase in the incidence compared with the early literature. Objectives. To investigate the age-, gender- and population group-specific incidences of FHFs in a subpopulation in Eastern Cape Province, SA. Methods. A retrospective review of all patients presenting with FHFs was performed at a tertiary hospital in the Eastern Cape over a 1-year period. Age-, gender- and population group-specific incidence rates were calculated for 5-year age intervals using the age distribution data of the western region of the Eastern Cape (WREC) as a denominator for each age group. Overall crude incidence rates were calculated by using the sum total of FHFs, divided by the study population. All incidences were calculated as number of fractures per 100 000 people annually. Results. A total of 253 patients with FHFs were included. The crude incidence rate of low-energy hip fractures in the WREC was 19.3 per 100 000 (males 14.6, females 23.4) over the study period. Population group-specific incidences were 15.1, 18.7, 19.9 and 46.6 per 100 000 for black, coloured, Indian and white population groups, respectively. The highest number of low-energy hip fractures in females occurred in the ≥85-year (19.6%) and 70 - 74-year (16.5%) age groups, with the highest number of male cases observed in the 60 - 64-year group (20.2%). The highest frequency distribution of FHFs was observed in black males aged 60 - 64 years (5.5%; n =14) and black females aged 70 - 74 years (6.3%; n =16). Conclusions. The local incidence of FHFs is higher than initially reported, but when compared with other countries remains on the lower end of spectrum. A large proportion of FHFs are occurring in young patients (<65 years). These findings warrant further investigation that may prompt the development of preventive strategies and optimal treatment programmes.

A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic

BackgroundUp to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown. MethodsThe Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density. ResultsEnrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology. ConclusionsResults from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.

Serum uric acid is associated with incident hip fractures in women and men – Results from a large Austrian population-based cohort study

ObjectivesSerum markers that can be used to estimate the risk of bone fractures are rare, and findings for one candidate marker, uric acid, are heterogeneous. Our aim was to investigate the potential of serum uric acid (SUA) to predict hip fractures occurring in people aged 50 years and over. Study designDuring a medical prevention program over the period 1985–2005 in Vorarlberg, baseline data were collected on SUA levels and covariates (age, BMI, blood pressure, smoking status, diabetes, triglycerides and cholesterol) from 185,397 individuals, of whom 42,488 women and 35,908 men met the inclusion criteria of this population-based cohort study. Information on incident cancer and end-stage kidney disease was acquired from registries. Main outcome measureIncident hip fracture occurring in participants aged 50 years and over during the observation period 2003–2013. ResultsSUA was associated with a rise in female hip fracture risk by 6% per unit increase (HR 1.06, 95 %-CI 1.01−1.10), and risk in the highest vs. lowest SUA quartile was significantly increased (HR 1.17, 95 %-CI 1.01−1.35), but not at hyperuricemic (>5.7 mg/dl) vs. normouricemic (≤5.7 mg/dl) levels. In men, hip fracture risk rose by 15 % per unit increase (HR 1.15, 95 %-CI 1.08−1.22), and risk was significantly higher in the highest vs. lowest SUA quartile (HR 1.50, 95 %-CI 1.17−1.91) as well as at hyperuricemic (>7.0 mg/dl) vs. normouricemic (≤7.0 mg/dl) levels (HR 1.48, 95 %-CI 1.19−1.84). ConclusionsOur results link SUA with increased risk of hip fractures, particularly in men.

The Pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care.

The emergence of Covid-19 has caused a pandemic and is a major public health concern. Covid-19 has fundamentally challenged the global health care system in all aspects. However, there is a growing concern for the subsequent detrimental effects of continuing delays or adjustments on time-dependent treatments for Covid-19 negative patients. Patients arriving to the ED with STEMIs and acute CVA are currently presumed to have delays due to Covid-19 related concerns. The objective of this paper is to evaluate the implications of the Covid-19 pandemic on non-Covid19 patients in emergency care settings. We conducted a retrospective study from February 2020 to April 2020 and compared this to a parallel period in 2019 to assess the impact of the Covid-19 pandemic on three distinct non-Covid-19 ED diagnosis that require immediate intervention. Our primary outcome measures were time to primary PCI in acute STEMI, time to fibrinolysis in acute CVA, and time to femoral hip fracture correction surgery. Our secondary outcome measure included a composite outcome of length of stay in hospital and mortality. From 1 February 2020 to 30 April 2020, the total referrals to ED diagnosed with STEMI, Hip fracture and CVA of which required intervention were 197 within Covid-19 group 2020 compared to 250 in the control group 2019. Mean duration to intervention (PCI, surgery and tPA, respectively) did not differ between COVID-19 group and 2019 group. Among femoral hip fracture patients', the referral numbers to ED were significantly lower in Covid-19 era (p = 0.040) and the hospitalization stay was significantly shorter (p = 0.003). Among CVA patients', we found statistical differences among the number of referrals and the patients' age. Coping with the Covid-19 pandemic presents a challenge for the general healthcare system. Our results suggest that with proper management, despite the obstacles of isolation policies and social distancing, any negative impact on the quality of health care for the non-Covid-19 patients can be minimized in the emergency department setting.

Hip Fractures in Older Adults Are Associated With the Low Density Bone Phenotype and Heterogeneous Deterioration of Bone Microarchitecture.

Femoral neck areal bone mineral density (FN aBMD) is a key determinant of fracture risk in older adults; however, the majority of individuals who have a hip fracture are not considered osteoporotic according to their FN aBMD. This study uses novel tools to investigate the characteristics of bone microarchitecture that underpin bone fragility. Recent hip fracture patients (n= 108, 77% female) were compared with sex- and age-matched controls (n= 216) using high-resolution peripheral quantitative computed tomography (HR-pQCT) imaging of the distal radius and tibia. Standard morphological analysis of bone microarchitecture, micro-finite element analysis, and recently developed techniques to identify void spaces in bone microarchitecture were performed to evaluate differences between hip fracture patients and controls. In addition, a new approach for phenotyping bone microarchitecture was implemented to evaluate whether hip fractures in males and females occur more often in certain bone phenotypes. Overall, hip fracture patients had notable deterioration of bone microarchitecture and reduced bone mineral density compared with controls, especially at weight-bearing sites (tibia and femoral neck). Hip fracture patients were more likely to have void spaces present at either site and had void spaces that were two to four times larger on average when compared with non-fractured controls (p< 0.01). Finally, bone phenotyping revealed that hip fractures were significantly associated with the low density phenotype (p< 0.01), with the majority of patients classified in this phenotype (69%). However, female and male hip fracture populations were distributed differently across the bone phenotype continuum. These findings highlight how HR-pQCT can provide insight into the underlying mechanisms of bone fragility by using information about bone phenotypes and identification of microarchitectural defects (void spaces). The added information suggests that HR-pQCT can have a beneficial role in assessing the severity of structural deterioration in bone that is associated with osteoporotic hip fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).