Minimal Trauma Hip Fracture Research Articles

Minimal trauma hip fracture hospitalisations among older Indigenous and non-Indigenous Australians: Aretrospective population-based cohort study.

To compare minimal trauma hip fractures (MTHF) between older Indigenous and non-Indigenous Australians. Epidemiological study of retrospective New South Wales hospitalisation data (2005-2016) for MTHF among Indigenous and non-Indigenous Australians over 40 years of age. Estimated age-standardised rates of MTHF were lower among Indigenous Australians than non-Indigenous Australians (142.2 vs. 161.7 per 100,000) with a direct standardised rate ratio of 0.887 (95%CI 0.78-0.99, p= 0.031). However, for both male and female Indigenous Australians, MTHF occur at a younger age than in non-Indigenous Australians (age 40-74: 52% vs. 19%, p< 0.001). Proportions of MTHF are higher among women and were almost double among rural Indigenous Australians compared with rural non-Indigenous Australians (59% vs. 31%, p< 0.001). New South Wales Hospitalisation data showed that estimated age-standardised rates of MTHF appear lower among Indigenous Australians than in non-Indigenous Australians but also occur at a younger age for Indigenous people. MTHF are more common among rural Indigenous Australians and women.

Trends in osteoporosis diagnosis and management in Australia

SummaryTrends in bone mineral density monitoring, and drug treatment for osteoporosis, in Australia were examined. Rates of DEXA scanning have increased in response to changes to government policy affecting reimbursement. The drug denosumab is being utilised at an increasing rate, while bisphosphonate use has declined. Osteoporosis prevalence remained stable over the same timeframe, while rate of hip fractures declined, suggesting that introduction of osteoporosis screening was associated with a reduction in adverse osteoporosis outcomes, but may also have been associated with overutilisation.IntroductionRadiology interventions to diagnose and medications to manage osteoporosis in Australia are reimbursed under the Medicare benefits schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). Monitoring of these databases enables changes in utilisation of these practices to be monitored over time. MethodsThis study examined rates of utilisation for bone mineral density (BMD) measurement and osteoporosis pharmacotherapy subsidised under the MBS. Rates of osteoporosis and hip fracture were estimated using data reported by the Australian Bureau of Statistics (ABS) and Australian Institute for Health and Welfare (AIHW). ResultsRates of BMD measurement increased since the technology was first reimbursed, with changes to policy regarding reimbursement for screening for individuals over 70 leading to an increase in BMD measurement after 2007. Prescribing rates also increased over time, initially with the introduction of oral bisphosphonates and subsequently for denosumab, which has subsequently become the most commonly prescribed agent for osteoporosis management in Australia, while bisphosphonate use has declined. Osteoporosis prevalence in Australia has remained relatively static at 3–4% of the population since 2001 to 2017, while rates of minimal trauma hip fracture hospitalisations have declined from 195 per 100,000 to 174 per 100,000 in the same timeframe. ConclusionAvailable data indicates that osteoporosis screening rates changed over time from 2001 to 2018 and that changes to government policy had a significant effect on the rates at which screening was performed. Over the same timeframe, there was a sustained reduction in hip fracture hospitalisation rates, with no change to reported osteoporosis prevalence. This suggests that policy changes permitting unlimited access to BMD measurement were associated with a reduction in osteoporotic fractures, but may also have been associated with overutilisation. Prospective studies to assess the efficacy of specific policies to ensure screening is performed in accordance with best-practice guidelines may be desirable.

Uptake of osteoporosis treatment recommended by an orthogeriatrics service after hip fracture: Retrospective cohort study of prevalence and potential barriers and enablers at a tertiary referral hospital in Sydney.

The primary aim was to determine the 12-month period prevalence of and time to osteoporosis treatment following minimal trauma hip fractures in patients who were recommended treatment by an orthogeriatrics service. The secondary aim was to determine the factors associated with receiving treatment including the impact of osteoporosis clinic follow-up. A retrospective cohort study of patients with minimal trauma hip fractures admitted at a tertiary hospital in Sydney between 1 April 2017 and 31 March 2019 was performed. Baseline characteristics were collected from medical records. Osteoporosis treatment data were collected from patients and general practitioners. Univariate and multivariate logistic regression analyses were used to determine the factors associated with receiving osteoporosis treatment. There were 189 participants who consented to participate with a mean age of 84.6years. Most (76.7%) were females, 18.5% were nursing home residents, 70.9% had normal cognition, 20.6% were taking osteoporosis treatment prior to admission, 61.9% had osteoporosis treatment recommendations documented on the discharge summary, and 10.1% were followed up in the osteoporosis clinic. Ninety-eight patients (51.9%) received treatment within the first 12months after fracture with a median time to treatment of 90days. Factors associated with receiving osteoporosis treatment within 12months on multivariate analysis included normal cognition (p=0.03), taking osteoporosis treatment prior to admission (p<0.001), including treatment recommendations in the discharge summary (p=0.006) and osteoporosis clinic follow-up (p<0.001). Osteoporosis treatment after hip fracture remains suboptimal at this hospital. Patient and health service factors associated with treatment uptake could inform future quality improvement work.

Evaluation of a dedicated outpatient hip fracture clinic.

There is a lack of guidance on how to manage the multiple post-discharge issues of older people following minimal trauma hip fracture. We developed a geriatrician-staffed outpatient service for people aged ≥65years admitted with a hip fracture who were not discharged to a nursing home. We aimed to evaluate the potential benefits of the addition of a dedicated hip fracture follow-up clinic by measuring the actions performed by such a clinic. We evaluated the potential benefit of the clinic through a retrospective review of the medical records of all those referred to the clinic over a 2-year period. A total of 80 people were provided a clinic appointment, with 43 (54%) attending. The median age of clinic attendees was 81years. A total of 40/43 (93%) of attendees received inpatient rehabilitation in a sub-acute facility before discharge. At the dedicated outpatient clinic, multiple issues were identified and managed including further fall reduction strategies (n=12), commencement of anti-resorptive medications (n=11) and medication deprescribing (n=11). We found that the introduction of a dedicated hip fracture outpatient clinic identified and managed a broad range of issues. It is unclear if these needs would have been met by previously existing services. Further work is required to clarify whether managing these issues translates into improved patient outcomes and whether a dedicated clinic is a cost-effective practice of achieving this.

63 Impact of an Orthogeriatric Service on Osteoporosis Management in HIP Fracture Patients

Abstract Background Osteoporosis which is now treatable is the major risk factor for hip fractures in the elderly. Having a hip fracture increases morbidity and mortality. Hip fractures are costly. Incidence increases with age. Aims To examine how introduction of an orthogeriatric service (OGS) improves osteoporosis management. Method A dedicated OGS was established in the orthopaedic unit in an Australian tertiary teaching hospital in July 2014. Retrospective analyses were undertaken to compare osteoporosis diagnosis and treatment rates in patients ≥ 65 years old presenting with minimal trauma hip fractures (MTHF) before and after the OGS was established. Results 1. 108 MTHF (mean age 81 years) and 107 MTHF (mean age 82 years) were admitted in 2014 respectively before and after the OGS was established. 2. New osteoporosis diagnoses increased by 27%, new calcium &amp;/or vitamin D prescription increased by 17% and new antiresorptive treatment increased by 30%, after the OGS was established. 3. The odds ratio for receiving a new diagnosis of osteoporosis post MTHF with the OGS compared to pre-OGS was 4.4 (2.1 – 9.0), p&amp;lt;0.0001. 4. The odds ratio for initiating new antiresorptive treatment post fractured NOF with OGS compared to pre-OGS was 6.2 (3.0 – 12.7), p&amp;lt;0.0001. 5. Rates of new diagnoses of osteoporosis and initiation of antiresorptive treatments with the OGS were not affected by age or gender. Conclusion 1. Introduction of a dedicated OGS improved osteoporosis diagnoses and initiation of antiresorptive treatments. 2. Patients who received a new diagnosis of osteoporosis and/or started on antiresorptive treatment were also likely to be prescribed calcium and/or vitamin D supplements as well. 3. There did not appear to be any age or gender bias towards giving more new diagnoses of osteoporosis and/or more new antiresorptive treatments with a dedicated OGS. 4. These results may be useful for benchmarking and comparison purposes.

Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults

Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community. To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community. Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later. The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins. The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control. Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2). Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks. ClinicalTrials.gov Identifier: NCT01783704.

Changes over time in hip fracture risk: Greater improvements in men compared to women.

The aim of this study was to determine whether there has been a change in the mean age and age-standardized incidence of minimal trauma hip fractures in the Newcastle and Lake Macquarie population of Australia between 1998 and 2015. Patients with neck of femur fractures over 50 who presented to the regional referral centre were retrospectively identified using the ICD-9 and ICD-10 coding system. There were 233 and 308 eligible patients in 1998 and 2015, respectively. For females, the mean age for hip fracture of 83.2years in 1998 was not significantly different from the mean age of 84.5years in 2015 (P=.16). For males, the mean age for hip fracture was significantly older at 84.6years in 2015 compared to 80.4years in 1998 (P=.005). For females, the decrease in the rate of hip fracture from 1998 to 2015 was 13% and was weakly statistically significant (IRR=0.86, P=.05). For males, there was a statistically significant decrease in the rate of hip fractures from 1998 to 2015 by 33% (IRR=0.67, P=.001). Our study shows a decrease in age-standardized rates of hip fractures for men and women and suggests that men are demonstrating a greater improvement in bone health compared to women.

Osteoporotic hip fractures in Black South Africans: a regional study.

Developing countries are predicted to bear the burden of osteoporosis in the coming decades. This study was undertaken to review earlier reports that osteoporotic hip fractures are rare in Black Africans. In an observational study, the incidence rates and relative risk ratios (RRR) of osteoporotic hip fractures were calculated in the Black population, aged 60years and older, residing in the eThekwini region of South Africa. All Black subjects, presenting with a minimal trauma hip fracture to five public hospitals in the region, entered the study. Descriptive statistics were applied to show differences in age and sex. Eighty-seven subjects were enrolled in the study with a mean age of 76.5 ± 10.5years and the sex ratio of women to men was 2.5:1. Although men were younger than women, this was not significant (74.2 ± 12.3 vs. 77.4 ± 9.6years, p = 0.189). The age-adjusted rate was 69.2 per 100,000p.a. for women and 73.1 per 100,000p.a. for men. There was a significant increase in the relative risk ratios for hip fractures after the age of 75years in the total cohort and in women and men. Except for the 65-69-year age group, there was no significant difference in the age-adjusted RRR between women and men. This study represents the largest number of hip fractures recorded in Black Africans. Although the incidence rate is approximately tenfold higher than previously recorded, it remains amongst the lowest globally. A national registry inclusive of private and public sector is required to establish the true incidence rate of hip fractures in Black Africans.

Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up.

There is a paucity of literature examining minimal trauma hip fractures in young adults, despite extensive management guidelines for older patients. This study aims to characterise risk factors, complications and follow-up of hip fractures to guide management pathways. This is a retrospective study of patients presenting with hip fracture to a single institution from 2009 to 2015. Hip fractures were identified using ICD-10 codes and clinical information documented from medical records. Patients were categorised into minimal trauma (MTF) and high-energy fracture (HEF) groups based on mechanism of injury. Of 2512 patients admitted with hip fracture, 2.5% (n=62) were aged 15-49years. Two patients were excluded with pathological fractures, and seven were excluded with no recorded mechanism of injury. MTF occurred in 43 patients and 10 sustained HEF. These groups had similar demographics, fracture locations and treatments. The MTF group had higher American Society of Anaesthesiologists scores (MTF 2.44±0.9; HEF 1.43±0.5; p=0.025) and higher rates of chronic endocrine disease (MTF 34.9%; HEF 0%; p=0.046). Rates of post-operative surgical (MTF 24.0%; HEF 12.5%) and medical complications (MTF 27.8%; HEF 12.5%) were high in MTF patients. Subsequent fractures occurred in five (13.9%) MTF patients during the study period compared with none in the HEF group. Only 16 (44.4%) of the MTF patients were referred to endocrine care. Young adults with MTF of the hip have more severe systemic disease and are at risk of post-operative complications and subsequent fractures. Referral of patients to endocrine care is recommended to manage osteoporosis and comorbid diseases.

Low serum concentrations of Irisin are associated with increased risk of hip fracture in Chinese older women

ObjectiveIrisin derived from muscle in response to exercise may be the molecular entity responsible for muscle wasting-osteoporosis connectivity in the elderly. The objective of the study was to determine whether serum Irisin (sIrisin) provides information on hip fracture prediction which were independent of bone mineral density (BMD) and the fracture risk assessment tool (FRAX) algorithm. MethodsThis study enrolled 160 older women (ages, 70–90y) with minimal trauma hip fractures (MTHFs) and 160 age-matched women without fracture serving as controls. Clinical features, BMD and bone turnover markers including sIrisin levels were measured after fracture within 2 days as baseline. ResultssIrisin levels were significantly lower (361.5±140.0ng/mL vs 478.5±159.6ng/mL, P<0.001) in cases than controls. After multivariate analysis, sIrisin remained as an independent variable of BMD, which explained 17.8% of femoral neck BMD and 22.5% of lumbar spine BMD, respectively. The odds ratio (OR) of MTHFs comparing the lowest (<320.1ng/mL) to highest (>524.5ng/mL) quartiles was 1.95 (95% CI 1.23–3.79, P<0.05) for sIrisin. Adjustment for age, body mass index, time since menopause and exercise ≥30min/day yielded similar results, and BMD of femoral neck also did not change these associations. Taking FRAX score into account attenuated the association somewhat: OR of hip fracture was 1.81 (95% CI 1.26–3.49, P<0.05) in first versus fourth quartile of sIrisin. There was a negative gradient of risk by decreasing quartile in sIrisin. ConclusionsLow concentrations of sIrisin in older women were independently associated with increased risk of hip fractures when adjusted for BMD or FRAX score.

Improving community ambulation after hip fracture: protocol for a randomised, controlled trial

IntroductionAfter a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients.Primary objectiveTo evaluate the effect of a specific multicomponent physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation.DesignParallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants.Participants and settingA total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6 minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions.InterventionsParticipants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists’ adherence to the treatment protocol, and the participants’ receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period.MeasurementsThe primary outcome (community ambulation) is the ability to walk 300 m or more in 6 minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6 minutes, cognitive status, and nutritional status.AnalysisAnalyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks.DiscussionThis multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

Factors associated with receiving anti-osteoporosis treatment among older persons with minimal trauma hip fracture presenting to an acute orthogeriatric service

Background/AimThe aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period. DesignObservational study using prospectively collected data. MethodsDemographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment. Results91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23–1.70, p<0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30–5.49, p=0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08–0.54, p=0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25–0.98, p=0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment. ConclusionA significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden.

Femoral geometry, bone mineral density, and the risk of hip fracture in premenopausal women: a case control study.

BackgroundThe purpose of this study was to determine the relationships among hip geometry, bone mineral density, and the risk of hip fracture in premenopausal women.MethodsThe participants in this case–control study were 16 premenopausal women with minimal-trauma hip fractures (fracture group) and 80 age-and BMI-adjusted controls. Subjects underwent dual-energy X-ray absorptiometry (DXA) to assess BMD at the proximal femur and to obtain DXA-derived hip geometry measurements.ResultsThe fracture group had a lower mean femoral neck and total hip BMD than the control group (0.721 ± 0.123 vs. 0.899 ± 0.115, p <0.001 for the femoral neck BMD and 0.724 ± 0.120 vs. 0.923 ± 0.116, p <0.001 for the total hip BMD). In addition, participants in the fracture group had a longer hip axis length (HAL; p = 0.007), narrower neck shaft angle (NSA; p = 0.008), smaller cross sectional area (CSA; p < 0.001) and higher cross sectional moment of inertia (CSMI; p = 0.004) than those in control group. After adjusting for BMD, the fracture group still had a significantly longer mean HAL (p = 0.020) and narrower NSA (p = 0.006) than the control group.ConclusionsBMD is an important predictor of hip fracture in premenopausal women. Furthermore, HAL and NSA are BMD-independent predictors of hip fracture in premenopausal women. Hip geometry may be clinically useful for identification of premenopausal women for whom active fracture prevention should be considered.

Hip fractures among Indigenous Western Australians from 1999 to 2009

Minimal trauma hip fractures are prevalent in Australia. The incidence rate and trend of hip fractures in Indigenous Western Australians have not been formally reported. To evaluate incidence rates and trend of minimal trauma hip fractures in Indigenous and other Western Australians aged 40 years and over in 1999-2009 METHODS: Hip fracture data were obtained from an administrative database for all hospitalisations in Western Australia. Age-standardised incidence rates were calculated using direct standardisation, and standardised rate ratios were calculated using the indirect method. Trend in incidence rates were calculated using Poisson regression. In 1999-2009, 11,844 admissions for minimal trauma hip fractures were reported among Western Australians aged 40 years and over, of which 201 were recorded as indigenous. The age-standardised hip fracture rate was 273.0 (95% confidence interval (CI) 230.7-315.4) per 100,000 person-years for indigenous adults and 148.8 (95% CI 146.1-151.5) per 100,000 person-years for non-indigenous adults. The standardised morbidity ratio was 2.2 (95% CI 1.9-2.5). Over this period, age-standardised rates increased by an average of 7.2% per year among indigenous adults (P = 0.006), whereas non-indigenous rates fell by an average of 3.4% per year (P < 0.001). The relatively higher rates among indigenous adults were more evident in the younger age groups. There is a widening gap in minimal trauma hip fracture rates between indigenous and other Western Australians. This study demonstrates a need for public health review and management strategies to reduce falls and hip fracture in the indigenous community.

‘Making a difference’ a clinical pathway for hip fractures and the advance practice role in managing patients with minimal trauma hip fractures

BackgroundIn 2006/2007 there were estimated over 16,500 patients with hip fractures in Australia, the majority (94%) were over 65 years. Patients with hip fractures nearly always require hospitalisation and surgery. AimThe aim of this study was to assess the impact of the hip fracture clinical pathway on care of the hip fracture patient. MethodThis study is a retrospective medical record audit of all minimal trauma hip fracture patients over 65 years in a large tertiary hospital over a three month period before and after implementation of the hip fracture clinical pathway. ResultsFor patients in the intervention group (n = 28, mean 86.0 years) compared with the control group (n = 33, mean 85.7 years) time to surgery was <24-h (92.9% vs. 51.5%, p = 0.001), the venous thromboembolism (VTE) risk assessment form was completed (21.4% vs. 0%, p = 0.004), VTE prophylaxis improved, fewer patients received no prophylaxis (0% vs. 33.3%, p = 0.001), pharmacological prophylaxis only (21.4% vs. 54.4%, p = 0.008) and more patients received pharmacological prophylaxis and graduated compression stockings (75.0% vs. 12.1%, p = 0.001) and were discharged with osteoporosis treatment calcium and vitamin D (35.7% vs. 6.1%, p = 0.008). ConclusionImplementation of the hip fracture clinical pathway improved time to surgery (<24 h), VTE risk assessment and prophylaxis, and osteoporosis treatment on discharge.

Barriers to the implementation of evidence in osteoporosis treatment in hip fracture

An audit at a private tertiary hospital showed low rates of assessment and treatment of osteoporosis in minimal trauma patients of hip fracture. A survey sent to all doctors involved in hip fracture care to establish medical beliefs about effective management of osteoporosis in minimal trauma hip fracture patients showed a lack of ownership for investigation and beliefs influencing treatment choices. Understanding the barriers to the translation of evidence into practice is vital to improve patient care.

Osteoporosis After Orchiectomy for Prostate Cancer

The possibility of increased osteoporosis and osteoporotic fractures following therapeutic orchiectomy in men with prostate cancer was investigated. A total of 235 men with nonstage A prostate cancer diagnosed between 1983 and 1990 was analyzed for therapeutic orchiectomy, other osteoporotic risk factors and subsequent hospital treatment for osteoporotic fractures. The 17 castrated men alive in 1995 were interviewed, and femoral neck bone mineral density was compared to that of 23 controls of similar age. Risk factors for osteoporosis, including smoking, slender habitus and atrophic testes, were common among men treated with orchiectomy. Of the men in the study cohort 10 had osteoporotic fractures: 8 of 59 treated with and 2 of 176 without orchiectomy (13.6 versus 1.1%, p < 0.001). First fracture cumulative incidence rates 7 years after castration or diagnosis were 28 and 1%, respectively (p < 0.001). Osteoporotic fractures were much more common than pathological fractures or those due to major trauma (1 each). Bone mineral density averaged 0.91, 0.84, 0.79 and 0.66 gm./cm.2 in 9 controls without prostate cancer, 14 men with prostate cancer before orchiectomy, 9 men at 9 to 60 and 8 men at 60 to 115 months after orchiectomy, respectively. Of the 16 men surviving for longer than 60 months after orchiectomy 6 had osteoporotic fractures, as did 5 of 6 and 5 of 7 with a bone mineral density of less than 0.70 gm./cm.2 and less than 75% of normal for age, respectively. Orchiectomy for prostate cancer is frequently followed by severe osteoporosis, some of which had developed before castration. Appropriate therapy should be identified that does not diminish the antitumorigenic effectiveness of androgen ablation.

Does Hypogonadism Contribute to the Occurrence of a Minimal Trauma Hip Fracture in Elderly Men?

The risk of MTHF in hypogonadal elderly men was investigated with a case-control model. Cases and controls were selected from males age 65 years and older residing in the 120-bed McGuire Veterans Affairs Medical Center Nursing Home Care Unit over a 5-day interval. Historical data and serum free testosterone (fTe) were available on 17 subjects with MTHF and 61 controls. When groups were compared for differences in age, race, alcohol abuse, cigarette abuse, and diseases or drugs that may be associated with MTHF, only race was significantly different. Although 25.6% of residents were black, 100% of MTHF subjects were white (P = 0.004). Hypogonadism was defined as a random fTe less than 9 pg/mL (normal 9 to 46 pg/mL) and was found in 21 subjects (26.9%). Of cases with a MTHF, 58.8% were hypogonadal compared with only 18.0% of controls. Utilizing logistic regression, a highly significant association was found between hypogonadism and MTHF (P = 0.008), and using the odds ratio, subjects with hypogonadism were 6.5 times more likely to have a MTHF (95% CI 2.0 to 20.6). To adjust for race, the odds ratio was repeated excluding black subjects, and the results remained highly significant (4.6, 95% CI 1.3 to 16.2). We conclude that hypogonadal elderly white men may be at increased risk for MTHF.

Update on the use of distal radial bone density measurements in prediction of hip and Colles' fracture risk

A controversy has developed around the question as to whether bone density values from the distal radius can be used to accurately predict risk of future fractures. To address this question, two separate studies were undertaken: (a) Bone density was measured in 460 healthy ambulatory women living in retirement centers in the state of North Carolina; 83% of these women were followed for up to 60 months for occurrence of minimal trauma hip and wrist fractures. Thirty-one minimal trauma fractures were reported in our study population, representing 8% of those followed. The fracture incidence density rate showed a close inverse relationship with incremental changes in bone density at the distal site. Twenty-eight of the 31 fractures were reported in women with bone density values below the 325-mg/cm2 "at risk" value. (b) Bone density values of the distal radius and the lumbar spine from 360 women (aged 18-85 years) from the Chapel Hill area were used to analyze the error in predicting individual spinal density from the distal radial density. Although the overall correlation was high (r = 0.67) and the confidence intervals were narrow, the prediction intervals were quite wide. Thus, prediction of an individual value of spine density from the distal radius density would result in a value with a range too wide to be clinically useful. We conclude that single-photon absorptiometry appears to be a useful tool for screening normal populations of asymptomatic women for prediction of hip or Colles' fracture risk even though it has limited usefulness in prediction of spinal fracture risk or individual values for spinal density.

Melting-points of refractory metals

Irisin derived from muscle in response to exercise may be the molecular entity responsible for muscle wasting-osteoporosis connectivity in the elderly. The objective of the study was to determine whether serum Irisin (sIrisin) provides information on hip fracture prediction which were independent of bone mineral density (BMD) and the fracture risk assessment tool (FRAX) algorithm.This study enrolled 160 older women (ages, 70–90 y) with minimal trauma hip fractures (MTHFs) and 160 age-matched women without fracture serving as controls. Clinical features, BMD and bone turnover markers including sIrisin levels were measured after fracture within 2 days as baseline.sIrisin levels were significantly lower (361.5 ± 140.0 ng/mL vs 478.5 ± 159.6 ng/mL, P < 0.001) in cases than controls. After multivariate analysis, sIrisin remained as an independent variable of BMD, which explained 17.8% of femoral neck BMD and 22.5% of lumbar spine BMD, respectively. The odds ratio (OR) of MTHFs comparing the lowest (<320.1 ng/mL) to highest (>524.5 ng/mL) quartiles was 1.95 (95% CI 1.23–3.79, P < 0.05) for sIrisin. Adjustment for age, body mass index, time since menopause and exercise ≥30 min/day yielded similar results, and BMD of femoral neck also did not change these associations. Taking FRAX score into account attenuated the association somewhat: OR of hip fracture was 1.81 (95% CI 1.26–3.49, P < 0.05) in first versus fourth quartile of sIrisin. There was a negative gradient of risk by decreasing quartile in sIrisin.Low concentrations of sIrisin in older women were independently associated with increased risk of hip fractures when adjusted for BMD or FRAX score.