Summary
We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri‐operative management of people with hip fracture. ...Importantly, these guidelines describe the core aims and principles of peri‐operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri‐operative care of people with hip and periprosthetic fractures during the COVID‐19 pandemic.
Summary
A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX.
...Introduction
The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD).
Methods
We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted
β
-coefficients.
Results
A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72–2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69–2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63–2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62–2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination.
Conclusion
A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.
Summary
The country-specific risk of hip fracture and the 10-year probability of a major osteoporotic fracture were determined on a worldwide basis from a systematic review of literature. There was a ...greater than 10-fold variation in hip fracture risk and fracture probability between countries.
Introduction
The present study aimed to update the available information base available on the heterogeneity in the risk of hip fracture on a worldwide basis. An additional aim was to document variations in major fracture probability as determined from the available FRAX models.
Methods
Studies on hip fracture risk were identified from 1950 to November 2011 by a Medline OVID search. Evaluable studies in each country were reviewed for quality and representativeness and a study (studies) chosen to represent that country. Age-specific incidence rates were age-standardised to the world population in 2010 in men, women and both sexes combined. The 10-year probability of a major osteoporotic fracture for a specific clinical scenario was computed in those countries for which a FRAX model was available.
Results
Following quality evaluation, age-standardised rates of hip fracture were available for 63 countries and 45 FRAX models available in 40 countries to determine fracture probability. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries.
Conclusions
Worldwide, there are marked variations in hip fracture rates and in the 10-year probability of major osteoporotic fractures. The variation is sufficiently large that these cannot be explained by the often multiple sources of error in the ascertainment of cases or the catchment population. Understanding the reasons for this heterogeneity may lead to global strategies for the prevention of fractures.
Summary
We evaluated the relationship of bone mineral density (BMD) by computed tomography (CT), to predict fractures in a multi-ethnic population. We demonstrated that vertebral and hip fractures ...were more likely in those patients with low BMD. This is one of the first studies to demonstrate that CT BMD derived from thoracic vertebrae can predict future hip and vertebral fractures.
Purpose/Introduction
Osteoporosis affects an enormous number of patients, of all races and both sexes, and its prevalence increases as the population ages. Few studies have evaluated the association between the vertebral trabecular bone mineral density(vBMD) and osteoporosis-related hip fracture in a multiethnic population, and no studies have demonstrated the predictive value of vBMD for fractures.
Method
We sought to determine the predictive value of QCT-based trabecular vBMD of thoracic vertebrae derived from coronary artery calcium scan for hip fractures in the Multi-Ethnic Study of Atherosclerosis(MESA), a nationwide multicenter cohort included 6814 people from six medical centers across the USA and assess if low bone density by QCT can predict future fractures. Measures were done using trabecular bone measures, adjusted for individual patients, from three consecutive thoracic vertebrae (BDI Inc, Manhattan Beach CA, USA) from non-contrast cardiac CT scans.
Results
Six thousand eight hundred fourteen MESA baseline participants were included with a mean age of 62.2 ± 10.2 years, and 52.8% were women. The mean thoracic BMD is 162.6 ± 46.8 mg/cm
3
(95% CI 161.5, 163.7), and 27.6% of participants (
n
= 1883) had osteoporosis (T-score 2.5 or lower). Over a median follow-up of 17.4 years, Caucasians have a higher rate of vertebral fractures (6.9%), followed by Blacks (4.4%), Hispanics (3.7%), and Chinese (3.0%). Hip fracture patients had a lower baseline vBMD as measured by QCT than the non-hip fracture group by 13.6 mg/cm
3
P
< 0.001. The same pattern was seen in the vertebral fracture population, where the mean BMD was substantially lower 18.3 mg/cm
3
P
< 0.001 than in the non-vertebral fracture population. Notably, the above substantial relationship was unaffected by age, gender, race, BMI, hypertension, current smoking, medication use, or activity. Patients with low trabecular BMD of thoracic vertebrae showed a 1.57-fold greater risk of first hip fracture (HR 1.57, 95% CI 1.38–1.95) and a nearly threefold increased risk of first vertebral fracture (HR 2.93, 95% CI 1.87–4.59) compared to normal BMD patients.
Conclusion
There is significant correlation between thoracic trabecular BMD and the incidence of future hip and vertebral fracture. This study demonstrates that thoracic vertebrae BMD, as measured on cardiac CT (QCT), can predict both hip and vertebral fractures without additional radiation, scanning, or patient burden. Osteopenia and osteoporosis are markedly underdiagnosed. Finding occult disease affords the opportunity to treat the millions of people undergoing CT scans every year for other indications.
Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. This review aims to quantify the impact of hip ...fracture on older people's abilities and quality of life over the long term.
Studies were identified through PubMed and Scopus searches and contact with experts. Cohort studies of hip fracture patients reporting outcomes 3 months post-fracture or longer were included for review. Outcomes of mobility, participation in domestic and community activities, health, accommodation or quality of life were categorised according to the World Health Organization's International Classification of Functioning and synthesised narratively. Risk of bias was assessed according to four items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Thirty-eight studies from 42 publications were included for review. Most followed a clearly defined sample from the time of fracture. Hip fracture survivors experienced significantly worse mobility, independence in function, health, quality of life and higher rates of institutionalisation than age matched controls. The bulk of recovery of walking ability and activities for daily living occurred within 6 months after fracture. Between 40 and 60 % of study participants recovered their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40-70 % regained their level of independence for basic activities of daily living. For people independent in self-care pre-fracture, 20-60 % required assistance for various tasks 1 and 2 years after fracture. Fewer people living in residential care recovered their level of function than those living in the community. In Western nations, 10-20 % of hip fracture patients are institutionalised following fracture. Few studies reported impact on participation in domestic, community, social and civic life.
Hip fracture has a substantial impact on older peoples' medium- to longer-term abilities, function, quality of life and accommodation. These studies indicate the range of current outcomes rather than potential improvements with different interventional approaches. Future studies should measure impact on life participation and determine the proportion of people that regain their pre-fracture level of functioning to investigate strategies for improving these important outcomes.
It is known that mortality after hip fracture increases compared to the general population; the trend in mortality is a controversial issue. The objective of this study is to examine incidence, ...trends, and factors associated with mortality in patients with osteoporotic hip fractures.
This is a retrospective cohort study that uses the Registry for Hospital Discharges of the National Health System of our hospital. Patients older than 45 having an osteoporotic hip fracture between 1999 and 2015 were identified. Demographic data and comorbidities were obtained. A survival analysis was performed (Cox regression and Kaplan-Meier). Incidence rate, standardized death rate (SDR), trend (Poisson regression), and risk (hazard ratio) were calculated.
During 1999-2015, in our hospital, there were a total of 3992 patients admitted due to osteoporotic hip fracture. Out of these 3992 patients, 3109 patients (77.9%) were women with an average age of 84.47 years (SD 8.45) and 803 (22.1%) were men with an average age of 81.64 years (SD 10.08). The cumulative incidence of mortality was 69.38%. The cumulative mortality rate for 12 months was 33%. The annual mortality was 144.9/1000 patients/year. The 1-year mortality rate increased significantly by 2% per year (IRR 1.020, CI95% 1.008-1.033). The median overall survival was 886 days (CI95% 836-951). The probability of mortality density for a period of 10 years following a hip fracture was 16% for women and 25% for men (first 90 days). The SDR was 8.3 (CI95% 7.98-8.59). Variables that showed statistically significant association with mortality were aged over 75, masculine, institutionalization, mild to severe liver disease, chronic kidney disease, COPD, dementia, heart failure, diabetes, the Charlson Index > 2 , presence of vision disorders and hearing impairment, incontinence, and Downton scale.
For the last 17 years, an increase of mortality for patients with hip fracture and a higher mortality rate in men than in women were observed. Institutionalization combined with comorbidities is associated with a higher mortality.
to evaluate orthogeriatric and nurse-led fracture liaison service (FLS) models of post-hip fracture care in terms of impact on mortality (30 days and 1 year) and second hip fracture (2 years).
...Hospital Episode Statistics database linked to Office for National Statistics mortality records for 11 acute hospitals in a region of England.
patients aged over 60 years admitted for a primary hip fracture from 2003 to 2013.
each hospital was analysed separately and acted as its own control in a before-after time-series design in which the appointment of an orthogeriatrician or set-up/expansion of an FLS was evaluated. Multivariable Cox regression (mortality) and competing risk survival models (second hip fracture) were used. Fixed effects meta-analysis was used to pool estimates of impact for interventions of the same type.
of 33,152 primary hip fracture patients, 1,288 sustained a second hip fracture within 2 years (age and sex standardised proportion of 4.2%). 3,033 primary hip fracture patients died within 30 days and 9,662 died within 1 year (age and sex standardised proportion of 9.5% and 29.8%, respectively). The estimated impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) = 0.73 (95% CI: 0.65-0.82) and HR = 0.81 (CI: 0.75-0.87), respectively. Following an FLS, these associations were as follows: HR = 0.80 (95% CI: 0.71-0.91) and HR = 0.84 (0.77-0.93). There was no significant impact on time to second hip fracture.
the introduction and/or expansion of orthogeriatric and FLS models of post-hip fracture care has a beneficial effect on subsequent mortality. No evidence for a reduction in second hip fracture rate was found.
hip fracture is expensive in terms of mortality, hospital length of stay (LOS) and consequences for independence. Poor outcome reflects the vulnerability of patients who typically sustain this ...injury, but the impact of different comorbidities and impairments is complex to understand. We consider this in a prospective cohort study designed to examine how a patients' frailty index (FI) predicts outcome.
consecutive patients with low trauma hip fracture were assessed, excluding only those unfit for surgery. Comprehensive Geriatric Assessment (CGA) findings were used to derive a FI for each patient, which was examined alongside other assessment and outcome data from our National Hip Fracture Database (NHFD) submission for these individuals.
we describe 178 patients; mean age 81 years, 73.5% female. The mean FI was 0.34 (SD = 0.16), and logistic regression identified abbreviated mental test score and FI as the strongest predictors of poor outcome. When patients were stratified by FI, 56 (31.5%) were in the low-frailty group (FI ≤0.25), 58 (32.5%) in intermediate (FI >0.25-0.4), and 64 (36%) in the high-FI group (FI >0.4). All the patients in the low-FI group returned to their original residence within a mean of 21.6 days. The mean LOS for the intermediate group was 36.3 days compared with 67.8 days in the high-FI group (P < 0.01) while 30-day mortality was 3.4% for the intermediate group compared with 17.2% for the high-FI group (P < 0.001).
individual CGA findings proved disappointing as outcome predictors, while FI turned out to be a better predictor of mortality, 30-day residence and length of inpatient stay.
Summary
We examined age- and sex-specific hip fracture hospitalization rates among people aged 65 and older using 1990–2010 National Hospital Discharge Survey data. Trends calculated using Joinpoint ...regression analysis suggest that future increases in hip fractures due to the aging population will be largely offset by decreasing hip fracture rates among women. However, this trend will be counterbalanced by rising numbers of hip fractures among men.
Introduction
From 1990 to 2006, age-adjusted U.S. hip fracture rates among people aged 65 years and older declined significantly. We wanted to determine whether decreasing age group-specific hip fracture rates might offset increases in hip fractures among the aging population over the next two decades.
Methods
This study used data from the National Hospital Discharge Survey, a national probability survey of inpatient discharges from nonfederal U.S. hospitals, to analyze hip fracture hospitalizations, defined as cases with first diagnosis coded ICD-9 CM 820. We analyzed trends in rates by sex and 10-year age groups using Joinpoint analysis software and used the results and projected population estimates to obtain the expected number of hip fractures in 2020 and 2050.
Results
Based on current age- and sex-specific trends in hip fracture hospitalization rates, the number of hip fractures is projected to rise 11.9 %—from 258,000 in 2010 to 289,000 (Projection Interval PI = 193,000–419,000) in 2030. The number of hip fractures among men is expected to increase 51.8 % (PI = 15.9–119.4 %) while the number among women is expected to decrease 3.5 % (PI = −44.3–37.3 %). These trends will affect the future distribution of hip fractures among the older population.
Conclusions
Although the number of older people in the U.S.A. will increase appreciably over the next 20 years, the expected increase in the total number of hip fractures will be largely offset by decreasing hip fracture rates among women. However, this trend will be counterbalanced by rising numbers of hip fractures among men.
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