Association of incident fragility fractures in patients hospitalised due to unexplained syncope and orthostatic hypotension

Background Fragility fractures are caused by low-energy insults such as falls from standing height or less and pose a growing health challenge as their incidence rises with increasing age. Impaired orthostatic blood pressure response and a number of cardiovascular biomarkers have been previously identified as risk factors for fractures. It is likely that severe episodes of syncope and orthostatic hypotension increase the risk of subsequent fragility fractures, however this relationship has not been thoroughly examined.PurposeTo investigate the relationship of hospital admissions due to unexplained syncope and OH with incident fragility fractures in a middle-aged population.MethodsWe analysed a large population-based prospective cohort of 30,446 middle-aged individuals (age, 57.5 ± 7.6; men, 39.8%). We included patients hospitalised due to unexplained syncope and OH. Cox regression analysis adjusted for age, sex, prevalent fractures, body mass index (BMI) were applied to assess the impact of unexplained syncope/OH hospitalisations on subsequent incident fragility fractures. Prevalent fractures occurring before syncope/OH hospitalisation were excluded (n = 39) as well as cases with no follow-up time after the event of syncope/OH (n= 8).ResultsThe mean follow-up from baseline to first incident fracture or end of follow-up was 17.8 + 6.5 years, and 8201 (27%) suffered incident fracture. The mean age of patients with unexplained syncope (n = 493) and OH patients (n = 406) at baseline was 61.5 ± 7.1 years (50.1%, male) and 62.6 ± 6.6 years (49.8% male), respectively. The mean time between baseline and first admission for syncope and OH was 12.3 ± 4.5 years, and the mean age at first hospitalisation was 74.4 ± 7.6 years. In the multivariable-adjusted Cox regression, the risk of subsequent incident fractures was increased among patients hospitalised due to unexplained syncope (HR: 1.20; 95% CI 1.03–1.40; p < 0.02) and OH (HR: 1.40; 95% CI 1.20–1.64; p < 0.001), respectively (Kaplan-Meier curves; Figure 1).ConclusionsPatients hospitalised due to unexplained syncope and OH demonstrate increased risk of subsequent fragility fractures. We suggest that patients who are hospitalised for unexplained syncope and OH should be clinically assessed for true syncope aetiology, systematically treated against fall risk, and evaluated for additional risk factors for fragility fractures

Prevalence of osteoporosis and incidence of hip fracture in women - secular trends over 30 years

<p>Abstract</p> <p>Background</p> <p>The number of hip fractures during recent decades has been reported to be increasing, partly because of an increasing proportion of elderly women in the society. However, whether changes in hip fracture annual incidence in women are attributable to secular changes in the prevalence of osteoporosis is unclear.</p> <p>Methods</p> <p>Bone mineral density was evaluated by single-photon absorptiometry at the distal radius in 456 women aged 50 years or above and living in the same city. The measurements were obtained by the same densitometer during three separate time periods: 1970-74 (n = 106), 1987-93 (n = 175) and 1998-1999 (n = 178), and the age-adjusted prevalence of osteoporosis in these three cohorts was calculated. Additionally, all hip fractures sustained in the target population of women aged 50 years or above between 1967 and 2001 were registered, whereupon the crude and the age-adjusted annual incidence of hip fractures were calculated.</p> <p>Results</p> <p>There was no significant difference in the age-adjusted prevalence of osteoporosis when the three cohorts were compared (P = 1.00). The crude annual incidence (per 10,000 women) of hip fracture in the target population increased by 110% from 40 in 1967 to 84 in 2001. The overall trend in the crude incidence between 1967 and 2001 was increasing (1.58 per 10,000 women per year; 95 percent confidence interval, 1.17 to 1.99), whereas the age-adjusted incidence was stable over the same period (0.22 per 10,000 women per year; 95 percent confidence interval, -0.16 to 0.60).</p> <p>Conclusions</p> <p>The increased number of hip fracture in elderly women is more likely to be attributable to demographic changes in the population than to secular increase in the prevalence of osteoporosis.</p

The benefits of collaboration:The Nordic Arthroplasty Register Association

□ The Nordic Arthroplasty Register Association (NARA) was established in 2007 by arthroplasty register representatives from Sweden, Norway and Denmark with the overall aim to improve the quality of research and thereby enhance the possibility for quality improvement with arthroplasty surgery. Finland joined the NARA collaboration in 2010. □ NARA minimal hip, knee and shoulder datasets were created with variables that all countries can deliver. They are dynamic datasets, currently with 25 variables for hip arthroplasty, 20 for knee arthroplasty and 20 for shoulder arthroplasty. □ NARA has published statistical guidelines for the analysis of arthroplasty register data. The association is continuously working on the improvement of statistical methods and the application of new ones. □ There are 31 published peer-reviewed papers based on the NARA databases and 20 ongoing projects in different phases. Several NARA publications have significantly affected clinical practice. For example, metal-on-metal total hip arthroplasty and resurfacing arthroplasty have been abandoned due to increased revision risk based on i.a. NARA reports. Further, the use of uncemented total hip arthroplasty in elderly patients has decreased significantly, especially in Finland, based on the NARA data. □ The NARA collaboration has been successful because the countries were able to agree on a common dataset and variable definitions. The collaboration was also successful because the group was able to initiate a number of research projects and provide answers to clinically relevant questions. A number of specific goals, set up in 2007, have been achieved and new one has emerged in the process

More intramedullary nails and arthroplasties for treatment of hip fractures in Sweden: Registry analysis of 144,607 patients, 1998–2007

Background and purpose The surgical methods for treatment of femoral neck fractures and trochanteric hip fractures vary. We describe the changes in Sweden over the period 1998-2007 and the regional differences in treatment. Patients and methods Data on 144,607 patients were drawn from the National Patient Register. Results The proportion of femoral neck fractures treated with arthroplasty increased from 10% in 1998 to 52% in 2007. The use of intramedullary (IM) nails for pertrochanteric fractures increased from 5% to 20%, at the expense of the use of different sliding hip screws. In subtrochanteric fractures, the use of IM nails increased from 32% to 72%. Re-admissions within 180 days due to hip complications were more common after internal fixation for femoral neck fractures than after arthroplasty, and more common after intramedullary nailing of pertrochanteric fractures than after use of sliding hip screws. Treatment varied substantially within Sweden, particularly regarding the use of IM nails. Interpretation An increase in arthroplasties reflects an evidence-based treatment rationale for femoral neck fractures, whereas the increase in use of IM nails in pertrochanteric fractures lacks scientific support. The geographic variations call for national treatment guidelines. Further clinical trials are needed to solve the treatment issues regarding per- and subtrochanteric fractures

Linking Swedish health data registers to establish a research database and a shared decision-making tool in hip replacement.

Sweden offers a unique opportunity to researchers to construct comprehensive databases that encompass a wide variety of healthcare related data. Statistics Sweden and the National Board of Health and Welfare collect individual level data for all Swedish residents that ranges from medical diagnoses to socioeconomic information. In addition to the information collected by governmental agencies the medical profession has initiated nationwide Quality Registers that collect data on specific diagnoses and interventions. The Quality Registers analyze activity within healthcare institutions, with the aims of improving clinical care and fostering clinical research.This article is freely available via Open Access. Click on the Additional Link above to access the full-text via the publisher's site

Femoral neck fractures. Aspects on treatment and outcome.

Hip fractures are a common cause of morbidity and mortality in elderly patients, with a high risk of functional impairment and institutionalization. The incidence and number of hip fractures have increased during the recent decades and hip fractures consume considerable health-care resources. The incidence of hip fractures in Malmö, Sweden, 1992–95, is described in Paper I. The annual incidence per 10,000 inhabitants in women and men over 50 years were 85 and 36, respectively. For women and men over 80 years, the corresponding numbers were 297 and 170. When comparing it to earlier Malmö studies, we found that the incidence is no longer increasing. An update on the incidence, covering 1999–2001, support this finding. In Paper II, a randomized, prospective, multicenter study, 450 patients with displaced femoral neck fractures were randomized to either internal fixation or primary arthroplasty. Criteria for inclusion were age over 70 years, living in own home, mentally unimpaired. Patients who had undergone arthroplasty had significantly better functional results, less pain and lower rates of failure and re-operation after two years. After five years the significant difference in failure rate remained. There were no difference in mortality between the groups. In Paper III the costs for each method were compared. The mean two-year cost for internal fixation was 210 000 SEK (21 000 USD) and for primary arthroplasty 150 000 SEK (15 000 USD), but the difference was not significant. In Paper IV, 103 demented and/or institutionalized patients, 80 years and older, with displaced femoral neck fractures, were treated with primary hemi-arthroplasty. They had a failure rate of 6% after one year, significantly lower than a control group treated with internal fixation, and good functional outcome. The results of a new treatment protocol are described in Paper V. When a majority of the displaced femoral neck fractures in patients over 70 years are treated with primary arthroplasty, the overall failure rate is reduced to 5% compared to earlier results of 42%, when all fractures were treated with internal fixation. The new protocol proved to be feasible in clinical use. The results of this thesis emphasize the need of a paradigm shift for the treatment of displaced femoral neck fractures in Sweden. There is an evidence-based rationale supporting both the use of total hip arthroplasty in vital patients, 70–80 years old, and the use of hemi-arthroplasty in the more frail, elderly patients