Surgery for fragility hip fracture—streamlining the process

published_or_final_versionSpringer Open Choice, 21 Feb 201

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

Patients with femoral or distal forearm fracture in Germany: a prospective observational study on health care situation and outcome

BACKGROUND: Distal radius and proximal femoral fractures are typical injuries in later life, predominantly due to simple falls, but modulated by other relevant factors such as osteoporosis. Fracture incidence rates rise with age. Because of the growing proportion of elderly people in Western industrialized societies, the number of these fractures can be expected to increase further in the coming years, and with it the burden on healthcare resources. Our study therefore assessed the effects of these injuries on the health status of older people over time. The purpose of this paper is to describe the study method, clinical parameters of fracture patients during hospitalization, mortality up to one and a half years after discharge in relation to various factors such as type of fracture, and to describe changes in mobility and living situation. METHODS: Data were collected from all consecutive patients (no age limit) admitted to 423 hospitals throughout Germany with distal radius or femoral fractures (57% acute-care, femoral and forearm fractures; 43% rehabilitation, femoral fractures only) between January 2002 and September 2003. Polytrauma and coma patients were excluded. Demographic characteristics, exact fracture location, mobility and living situation, clinical and laboratory parameters were examined. Current health status was assessed in telephone interviews conducted on average 6–7 months after discharge. Where telephone contact could not be established, at least survival status (living/deceased/date of death) was determined. RESULTS: The study population consisted of 12,520 femoral fracture patients (86.8% hip fractures), average age 77.5 years, 76.5% female, and 2,031 forearm fracture patients, average age 67.6 years, 81.6% female. Women's average age was 6.6 (femoral fracture) to 10 years (forearm fracture) older than men's (p < 0.0001). Only 4.6% of femoral fracture patients experienced changes in their living situation post-discharge (53% because of the fracture event), although less than half of subjects who were able to walk without assistive devices prior to the fracture event (76.7%) could still do so at time of interview (34.9%). At time of interview, 1.5% of subjects were bed-ridden (0.2% before fracture). Forearm fracture patients reported no change in living situation at all. Of the femoral fracture patients 119 (0.95%), and of the forearm fracture patients 3 (0.15%) died during hospital stay. Post-discharge (follow-up one and a half years) 1,463 femoral fracture patients died (19.2% acute-care patients, 8.5% rehabilitation patients), but only 60 forearm fracture patients (3.0%). Ninety percent of femoral fracture deaths happened within the first year, approximately 66% within the first 6 months. More acute-care patients with a pertrochanteric fracture died within one year post-discharge (20.6%) than patients with a cervical fracture (16.1%). CONCLUSION: Mortality after proximal femoral fracture is still alarmingly high and highest after pertrochanteric fracture. Although at time of interview more than half of femoral fracture patients reported reduced mobility, most patients (96%) attempt to live at home. Since forearm fracture patients were on average 10 years younger than femoral fracture patients, forearm fractures may be a means of diagnosing an increased risk of later hip fractures

Exercise and bone health across the lifespan

With ageing, bone tissue undergoes significant compositional, architectural and metabolic alterations potentially leading to osteoporosis. Osteoporosis is the most prevalent bone disorder, which is characterised by progressive bone weakening and an increased risk of fragility fractures. Although this metabolic disease is conventionally associated with ageing and menopause, the predisposing factors are thought to be established during childhood and adolescence. In light of this, exercise interventions implemented during maturation are likely to be highly beneficial as part of a long-term strategy to maximise peak bone mass and hence delay the onset of age- or menopause-related osteoporosis. This notion is supported by data on exercise interventions implemented during childhood and adolescence, which confirmed that weight-bearing activity, particularly if undertaken during peripubertal development, is capable of generating a significant osteogenic response leading to bone anabolism. Recent work on human ageing and epigenetics suggests that undertaking exercise after the fourth decade of life is still important, given the anti-ageing effect and health benefits provided, potentially occurring via a delay in telomere shortening and modification of DNA methylation patterns associated with ageing. Exercise is among the primary modifiable factors capable of influencing bone health by preserving bone mass and strength, preventing the death of bone cells and anti-ageing action provided

Pubertal bone growth in the femoral neck is predominantly characterized by increased bone size and not by increased bone density-a 4-year longitudinal study.

Fragility fractures are correlated to reduced bone size and/or reduced volumetric bone density (vBMD). These region-specific deficits may originate from reduced mineral accrual and/or reduced skeletal growth during the first 2 decades of life. Before pathological development can be defined, normal skeletal growth must be described. To evaluate growth of bone size, accrual of bone mineral content (BMC), areal bone mineral density (aBMD) and vBMD in a population-based cohort, 44 boys and 42 girls were followed by annual measurements from the age of 12 to 16 (attendance rates 90–100%). Segmental bone length, bone width, BMC, aBMD and vBMD were measured by dual-energy X-ray absorptiometry (DXA). Data were compared with predicted adult peak, as determined in 36 men aged 27.7±4.6 years and 44 women aged 26.8±4.9 years. Growth in width of the femoral neck precedes accrual of BMC in the femoral neck in both genders up to age 15. The girls were at all ages closer to their predicted adult peak in both bone width and BMC compared with the boys except in the femoral neck. As femoral neck vBMD had reached its predicted adult peak already at 12 years in both genders, the increase in femoral neck BMC and femoral neck aBMD from age 12 to 16 was most likely to be explained by the increase in bone size. In boys the peak velocity growth was recorded at ~14 years for BMC, height, width and lean mass. Growth from the age of 12 to 16 seems to build a bigger but not a denser skeleton in the femoral neck