Abstract
Context
Although physical activity (PA) is recognized to reduce fracture risk, whether its benefits differ according to glycemic status remains unknown.
Objective
We investigated the effect ...of PA on incident hip fracture (HF) according to glycemic status.
Methods
We studied 3 723 097 patients older than 50 without type 1 diabetes mellitus (DM) or past fractures. HF risks were calculated using Cox proportional hazard regression. Participants were categorized by glycemic status into 5 groups: normal glucose tolerance, impaired fasting glucose, new-onset type 2 DM, type 2 DM less than 5 years, and type 2 DM of 5 years or greater. PA was evaluated using the Korean adaptation of the International Physical Activity Questionnaire Short Form.
Results
The highest HF risk were associated with the lowest PA level (<500 metabolic equivalent task MET-min/wk). While similar risks emerged across MET 500 to 1000, 1000 to 1500, and greater than 1500 categories, the relationship showed variations in different glycemic status groups. Exceptions were particularly noted in women with normoglycemia. However, a consistent inverse pattern, with few exceptions, was observed both in men and women with type 2 DM of 5 years or greater. Furthermore, the benefit of PA in the prevention of HFs was most evident in participants with type 2 DM of 5 years or greater. Compared to the reference group (lowest physical activity level <500 MET-min/wk within type 2 DM ≥5 years), the adjusted hazard ratios were 0.74 (0.62-0.88) in men and 0.74 (0.62-0.89) in women, suggesting a significant reduction in risk.
Conclusion
Higher PA levels are associated with a lower risk of HF. This protective effect of PA on fracture risk is greatest in patients with DM, particularly in those with DM of 5 years or greater.
Background
Hip fractures are associated with diminished quality of life and survival especially amongst the elderly.
Objective
All‐cause mortality after hip fracture was investigated to assess its ...magnitude.
Methods
A total of 122 808 participants from eight cohorts in Europe and the USA were followed up for a mean of 12.6 years, accumulating 4273 incident hip fractures and 27 999 deaths. Incident hip fractures were assessed through telephone interviews/questionnaires or national inpatient/fracture registries, and causes of death were verified with death certificates. Cox proportional hazards models and the time‐dependent variable methodology were used to assess the association between hip fracture and mortality and its magnitude at different time intervals after the injury in each cohort. We obtained the effect estimates through a random‐effects meta‐analysis.
Results
Hip fracture was positively associated with increased all‐cause mortality; the hazard ratio (HR) in the fully adjusted model was 2.12, 95% confidence interval (CI) 1.76–2.57, after adjusting for potential confounders. This association was stronger amongst men HR: 2.39, 95% CI: 1.72–3.31 than amongst women HR: 1.92, 95% CI: 1.54–2.39, although this difference was not significant. Mortality was higher during the first year after the hip fracture HR: 2.78, 95% CI: 2.12–3.64, but it remained elevated without major fluctuations after longer time since hip fracture HR (95% CI): 1.89 (1.50–2.37) after 1–4 years; 2.15 (1.81–2.55) after 4–8 years; 1.79 (1.57–2.05) after 8 or more years.
Conclusion
In this large population‐based sample of older persons across eight cohorts, hip fracture was associated with excess short‐ and long‐term all‐cause mortality in both sexes.
Summary
Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented ...and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization.
Introduction
Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports.
Method
Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes.
Results
Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits.
Conclusions
National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other’s practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.
•There was no statistically significant difference in complications associated between patients first and contralateral second hip fracture.•Patients with a second hip fracture had higher rates of ...cognitive impairment.•Surgical costs and operative times were not significantly different between patients first and contralateral second hip fracture.
Hip fractures are an increasingly common occurrence among the aging population. With increased life expectancy and advancements in medicine, patients sustaining a hip fracture are at an increasing risk of sustaining a contralateral hip fracture. Efforts are being made to better understand the environment of these hip fractures so that secondary prevention clinics and guidelines can be made to help prevent recurrent osteoporotic hip fractures. The estimated incidence of a contralateral hip fracture varies from 2 to 10% and is reportedly associated with a higher incidence of complications. Previous studies evaluating contralateral hip fractures compared a single cohort of patients sustaining a second hip fracture with patients who sustained only one hip fracture. We aimed to investigate the overall complications and associated costs as it relates to a patients first hip fracture and contrast this to the same patient's contralateral, second hip fractures.
We performed a retrospective review of all patients in our health systems electronic database who were found to have surgically treated hip fractures between January 2004 and July 2019. Patients with surgically treated hip fractures (CPT Codes: 27235, 27236, 27245, 27244), who sustained a second contralateral hip fracture were included. Medical complications within 30 days of either procedure (such as pneumonia, UTI, altered mental status and others), length of stay, orthopedic complications (such as wound complications, infection, hardware failure, nonunion), type of implants, costs, comorbidities, and ASA Class as well as Mortality were reviewed.
A total of 4,870 hip fractures were identified during the study period where 137 (2.8%) patients sustained a second hip fracture, and 47 (0.9%) of which were sustained within the first year after their index hip fracture. There was no statistical difference in length of stay (p = 0.68), medical (p>0.99) or orthopedic complications (p>0.99) between patients first and second hip fractures. There was an increased incidence of cognitive impairment with the second hip fracture (P = 0.0002). For patients that underwent operative treatment of a second hip fracture, the total cost of care was higher for the second surgery (mean difference 757. 38 USD) however the difference wasn't statistically significant (p = 0.31). The overall 1-year mortality rate was 14.9 percent.
Our study demonstrates there is no statistical difference between the first and second surgery regarding length of stay, medical or orthopedic complications and cost.
Summary
In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These ...data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs.
Purpose
This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients.
Methods
A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017.
Results
Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture.
Conclusion
A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.
Summary
Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the duration that is effective in preventing a second hip fracture. Our ...study demonstrated that risk can be reduced when the prescription is ≥ 6 months for the year following the index hip fracture.
Introduction
Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the accurate medication possession ratio (MPR) that is effective in preventing a second hip fracture. Our objective was to compare the risk of second hip fracture in patients treated with different MPR of alendronate.
Methods
In this population-based cohort study, data from National Health Insurance Research Database of Taiwan were analyzed. Patients 50 years and older who had an index hip fracture and were not receiving any osteoporotic medications before their fracture during 2000–2010 were included. The cohort consisted of 88,320 patients who were new alendronate users (
n
= 9278) and non-users (
n
= 79,042). Those without alendronate were matched 4:1 as the control group. Patients were subdivided into those with no medication, MPR < 25%, MPR 25–50%, MPR 50–75%, and MPR 75–100%. Cox proportional hazard models were used to calculate the adjusted hazard ratios for different MPRs of alendronate.
Results
After matching, 38,675 patients were included in this study; 20,363 (52.7%) were women, and 30,940 (80%) patients were without medication of alendronate. During follow-up on December 31, 2012, 2392 patients had a second hip fracture, for an incidence of 1449/100,000 person-years. Patients with alendronate MPR 50–75% had a lower risk of a second hip fracture compared to non-users (hazard ratio 0.66). When the MPR increased to 75–100%, the hazard ratio decreased to 0.61.
Conclusions
In this population-based cohort study, risk of a second hip fracture can be reduced when the alendronate MPR is ≥ 50% for the year following the index hip fracture. As the MPR increases, the risk of a second hip fracture decreases.
This study aimed to develop and validate clinical prediction models using machine learning (ML) algorithms for reliable prediction of subsequent hip fractures in older individuals, who had previously ...sustained a first hip fracture, and facilitate early prevention and diagnosis, therefore effectively managing rapidly rising healthcare costs in China.
Data were obtained from Grade A Tertiary hospitals for older patients (age ≥ 60 years) diagnosed with hip fractures in southwest China between 1 January 2009 and 1 April 2020. The database was built by collecting clinical and administrative data from outpatients and inpatients nationwide. Data were randomly split into training (80%) and testing datasets (20%), followed by six ML-based prediction models using 19 variables for hip fracture patients within 2 years of the first fracture.
A total of 40,237 patients with a median age of 66.0 years, who were admitted to acute-care hospitals for hip fractures, were randomly split into a training dataset (32,189 patients) and a testing dataset (8,048 patients). Our results indicated that three of our ML-based models delivered an excellent prediction of subsequent hip fracture outcomes (the area under the receiver operating characteristics curve: 0.92 (0.91-0.92), 0.92 (0·92-0·93), 0.92 (0·92-0·93)), outperforming previous prediction models based on claims and cohort data.
Our prediction models identify Chinese older people at high risk of subsequent hip fractures with specific baseline clinical and demographic variables such as length of hospital stay. These models might guide future targeted preventative treatments.
The Nottingham Hip Fracture Score (NHFS) was developed and validated in a single centre in 2007 as a predictor of 30 day mortality. It has subsequently been shown to predict longer term and ...functional outcomes. We wished to assess the ability of NHFS to predict outcomes in other centres and to investigate the change in outcome after hip fracture over time.
The NHFS was calculated for all patients with data from three UK hip fracture units: Peterborough (1992-2009), Brighton (2008-9), and Nottingham (2000-9) including 4804, 585, and 1901 patients, respectively. The logistic regression was used to recalibrate the NHFS to 30 day mortality across the three units using a random selection of 50% of the data set. Calibration was assessed using the Hosmer-Lemeshow goodness of fit.
The median (inter-quartile range) NHFS values were Peterborough 4.0 (1-6), Brighton 5.0 (3-7), and Nottingham 5.0 (3-7). There was no correlation between 30 day mortality and time (R(2)=0.05, P=0.115). The proportion of patients with NHFS ≥ 4 showed a weak correlation with time (R(2)=0.2, P=0.003). The original NHFS equation overestimates mortality in the higher-risk groups. A modified equation shows good calibration for all three centres {30 day mortality (%)=100/1+e((5.012 × (NHFS × 0.481))}. The hospital was not a predictor of 30 day mortality.
The NHFS, with an updated equation, is a robust predictor of 30 day mortality after hip fracture repair in geographically distinct UK centres.
Summary
The Women's Health Initiative (WHI) double-blind, placebo-controlled clinical trial randomly assigned 36,282 postmenopausal women in the U.S. to 1,000 mg elemental calcium carbonate plus ...400 IU of vitamin D
3
daily or placebo, with average intervention period of 7.0 years. The trial was designed to test whether calcium plus vitamin D supplementation in a population in which the use of these supplements was widespread would reduce hip fracture, and secondarily, total fracture and colorectal cancer.
Introduction
This study further examines the health benefits and risks of calcium and vitamin D supplementation using WHI data, with emphasis on fractures, cardiovascular disease, cancer, and total mortality.
Methods
WHI calcium and vitamin D randomized clinical trial (CT) data through the end of the intervention period were further analyzed with emphasis on treatment effects in relation to duration of supplementation, and these data were contrasted and combined with corresponding data from the WHI prospective observational study (OS).
Results
Among women not taking personal calcium or vitamin D supplements at baseline, the hazard ratio HR for hip fracture occurrence in the CT following 5 or more years of calcium and vitamin D supplementation versus placebo was 0.62 (95 % confidence interval (CI), 0.38–1.00). In combined analyses of CT and OS data, the corresponding HR was 0.65 (95 % CI, 0.44–0.98). Supplementation effects were not apparent on the risks of myocardial infarction, coronary heart disease, total heart disease, stroke, overall cardiovascular disease, colorectal cancer, or total mortality, while evidence for a reduction in breast cancer risk and total invasive cancer risk among calcium plus vitamin D users was only suggestive.
Conclusion
Though based primarily on a subset analysis, long-term use of calcium and vitamin D appears to confer a reduction that may be substantial in the risk of hip fracture among postmenopausal women. Other health benefits and risks of supplementation at doses considered, including an elevation in urinary tract stone formation, appear to be modest and approximately balanced.
Summary
The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report ...concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures.
Introduction
The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture.
Methods
The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation’s Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized.
Results and Conclusion
The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.
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