Hip fracture

The results of our study implies to the conclusion that gender is not significant predictor for motor functional re- covery measured by mFIM test in patients with hip fracture, although the admittance mFIM (degree of injury) is a good indicator for mFIM capacity recovery in women of certain age groups (first and third age groups).

Background/Aim. Osteoporotic fractures are a major cause of morbidity in the population. Therefore, fracture prevention strategies should be a major concern, and one of the priorities in the primary health care system. The aim of the study was to assess fracture and fall risk factors, and fracture risk level in patients with acute hip fracture, and to evaluate if there had been adequate osteoporosis treatment prior to fracture in this group of patients. Methods. Frac- ture and fall risk factors were assessed in 342 patients, • 65 years old, hospitalized due to acute hip fracture at the Clinic for Orthopedic Surgery and Traumatology, Clinical Centre of Serbia in a 12-month period. Fall risk factors were assessed with the Fracture Risk Assessment (FRAX ® )

as admitted for any reason or if he/she was decea- sed. Only after all these unsuccessful attempts pa- tients were considered lost to follow up. The tele- phone interview included questions regarding cur- rent health status of the patient, discharge details, treatment after discharge and also health-related quality of life, briefly assessed using the first two questions of the Medical Outcomes Study Short Form-36, and independence in activities of daily li- ving, using the Katz’s Index of Independence in Ac- tivities of Daily Living. With regard to activities of daily living, we have classified the response options for each question in 4 categories: able to do without difficulty (Cat1), able to do with some difficulty (Cat2), able to do with much difficulty (Cat3), and unable to do without assistance (Cat4). In the case of deceased patients, answers were gi- ven by relatives and caregivers and correspond to the last known condition prior to death. The pro- portion of response to the questions of daily living was 86.2% in males and 99.2% in female patients. The follow-up period was calculated for each individual from the date of admission with the in- dex fracture to the date of telephone interview or the date of death, in deceased patients. Survival throughout the first year after hip fracture was an- alyzed using the Kaplan-Meier method and the sig- nificance of gender differences was evaluated using the log-rank test. The magnitude of sex-spe- cific, age-adjusted associations between potential prognostic factors and mortality were estimated using hazard ratios (HR) and respective 95% con- fidence intervals (95%CI), calculated using Cox’s proportional hazards model.

15. González-Zabaleta J, Pita-Fernandez S, Seoane-Pillado T, López-Calviño B, Gonzalez-Zabaleta JL. Dependence for basic and instrumental activities of daily living after hip fractures. Arch Gerontol Geriatr. 2015;60(1):66-70. 16. Peiris C, Shields N, Kingsley M, Yeung J, Hau R, Taylor N. Maximum toler- ated dose of walking for community-dwelling people recovering from hip fracture: a dose-response trial. Arch Phys Med Rehabil. 2017;98(12):2533-9. 17. Ariza-Vega P, Lozano-Lozano M, Olmedo-Requena R, Martín-Martín L,

Statistical heterogeneity was evaluated using Cochrane Q test (significance level at <0.10). The degree of heterogeneity was quantified using I 2 statistic, which represents the percentage of the total variability across studies [18]. Studies with an I 2 statistic of 25% to 50% have low heterogeneity, those with 50% to 75% have moderate heterogeneity, and those with >75% have high heterogeneity. An I 2 value > 50% indicates significant heterogeneity. Fixed-effects model was used as pooling method for moderate or low heterogeneity (I 2 < 50%), whereas random- effects model (REM) was used for significant heterogeneity (I 2 > 50%). Given that patient characteristics, study design, and other confounding factors were inconsistent among studies, we further conducted sensitivity analyses to explore possible explanations for heterogeneity and to examine the influence of various exclusion criteria on the overall pooled estimate. We also investigated the influence of individual studies on the overall risk estimate. We performed meta-regression to explore the sources of heterogeneity in the association between exposure to fluoride in drinking water and hip fracture risk as reported in individual studies, particularly the effects of five study-level characteristics (country, gender, quality of Newcastle—Ottawa Scale scores, adjustment for covariates and sample size). The presence of publication bias was assessed using Begg’s and Egger’s tests [19, 20]. A P value < 0.05 was considered statistically

All permanent residents in Norway have a Personal Identification Number (PIN). The hos- pitals submitted PIN and the unique record key (and no medical information) to Statistics Norway. Statistics Norway prepared an encrypted PIN for all patients having a valid PIN and provided information from the National Registry: vital status (alive/dead/ emigrated) and date of death when applicable. We merged PAS data from hospitals and data from the National Reg- istry, using the unique record key. Thus, linking of medical information from current and pre- vious hospitalizations, date of death (in-or-out-of hospital) and tracking of patients between hospitals were possible. Ward admissions for each patient were linked into episodes of care when less than eight hours elapsed from time of discharge to the next ward admission. An epi- sode of care included stays at different wards within one hospital and stays at other hospitals if the patient was transferred between hospitals. Admission category (elective/acute) was identi- fied from the first ward admission in the episode of care. Each episode of care comprised diag- noses and procedure information from all ward stays within the same episode. One episode of care corresponded to one case in the analysis. Acute cases of hip fracture were identified according to ICD-10 codes S72.0–2, primary or secondary diagnosis, occurring at the first hos- pital if care at more than one hospital. Episodes following an initial hip fracture episode within 60 days were considered readmissions and excluded from the study population. Only patients aged 65 years and older were included.

Hip fracture is a major clinical and social problem, being one of the most frequent causes of hospitalization in developed countries. In the European Community about 500,000 people suf- fer from hip fracture every year and fewer than 70,000 cases per year are reported in Italy [1,2]. More than 90% of hip fractures are observed in people aged over 65 years and the risk of dis- ease doubles for every decade after 50. Early surgery (within 24–36 hours from trauma) has been reported to be associated with decreased 30-day and 1-year all-cause mortality [3,4]. However a major bias in the evaluation of these results is that delay to surgery may be a con- founding factor affecting survival, rather than an independent prognostic factor. Patients with delayed surgery may be more compromised, with a major number of comorbidities on admis- sion, thus requiring more time before clinical stabilization and surgery [5,6]. Heart failure, dementia, atrial fibrillation, diabetes and renal failure have been related to a higher in-hospital mortality after surgery[7–10]. Preoperative risk stratification in frail elderly patients with rele- vant clinical comorbidities may suggest the proper anaesthesiology strategy and perioperative treatment and decrease early mortality and morbidity in patients undergoing hip surgery.

Conclusion: The transcultural translation of the Hip Function Recovery Score will have an immediate impact on functional evaluations on patients over 60 years of age who underwent surgery due to hip fracture. It will subsequently be possible for other Brazilian scientific studies to use this questionnaire, which has been standardized and adapted to Brazilian culture, in order to make comparisons between results, thereby enriching Brazilian scientific production.

We did however, demonstrate that late AMD was associated with a 5.2 fold increased 10-year cumulative incidence of primary THR for #NOF. A US study using a 5% random sam- ple of Medicare beneficiaries from 1996–1999, which included 8,596 coded cases of exudative AMD, 26,942 coded cases of atrophic AMD, and 1,013,748 cases without AMD codes, reported a 4.6% 4-year cumulative incidence (1995–1999) of hip fracture. This study found atrophic AMD to be directly associated with an 11% increase in the four-year odds of hip fracture (OR 1.11, 95% CI 1.06 to 1.16, P >0.001), but there were no associations with exudative AMD (OR 1.03, 95% CI 0.95, 1.12)[18]. The accuracy of the International Classification of Diseases taxon- omy coding in the Medicare database has been reported to be high for hip fractures and exuda- tive AMD, however the accuracy of atrophic AMD was undetermined. Of note, in the United States, the Medicare health insurance programme does not have the same coverage as in Aus- tralia. The authors postulated that miscoding error could have biased the results towards null. A similar American longitudinal retrospective cohort study using 5% sample Medicare claims data found elderly individuals with newly diagnosed AMD (91.5% of AMD was coded dry or unspecified) in 1994 had higher rates of hip fracture than those without AMD during a 10-year follow-up period, OR 1.09 (1.04–1.14)[19].

were derived using both Canadian and US white tools for a large clinical cohort of 36.730 women and 2873 men age 50 years and older from Manitoba, Canada. Individuals were classified according to FRAX fracture probability and BMD T-scores alone. Results: Most individuals designated by FRAX as high risk of major osteoporotic fracture had a T-score in the osteoporotic range at one or more BMD measurement sites (85 % with Canadian tool and 83 % with US white tool). The majority of individuals deemed at high risk of hip fracture had one or more T-scores in the osteoporotic range (66 % with Canadian tool and 64 % with US white tool). Conversely, there were extremely few individuals (< 1 %) who were at high risk of major osteoporotic or hip fracture with

The common approach to the study of age, period (date of diagnosis) and cohort (date of birth) effects on hip fracture incidence has failed in an understanding of the separate role of these time dimensions. Few studies have reported the use of combined analysis to untangle the age–period–cohort (APC) effects [7–10]. The age effect in hip fracture incidence has been well described showing that the risk of fracture increases exponentially in the elderly [11]. However, period and cohort effects are more difficult to understand separately and can lead to a bias in hypothesis formulation. Interventions such as anti- osteoporosis medication are seen as period effects, which can modify the time trends of incidence rates [12–14]. In a previ- ous study, we identified a period effect with a turning point in 2003 in hip fracture incidence rates among women. Following that year, a sharp decrease was observed compatible with an increase in sales of anti-osteoporotic medication packages. In men, no such pattern was identified [15]. However, alterations in the prevalence of risk factors such as nutrition, smoking, alcohol or obesity can also be seen as period effects [16]. Cohort effects act differently on generations and can result from changes in wellbeing and quality of health care through- out life [7]. To obtain a reliable explanation for the time trends of hip fracture incidence, the APC dimensions should be addressed using a unique analysis that can provide a separa- tion of the individual effects.

The total number of fractures is greater with osteopenic and osteoporotic men than men with normal BMD. Although hip fracture is significantly greater in osteoporotic men, spine and wrist fractures are the same in both osteopenic and osteoporotic men. This finding can be supported by the Rotterdam study that emphasizes the impact of osteopenia when their data showed that after 55 years, osteopenic men were more likely to sustain a vertebral fracture compared with osteoporotic men [20]. The occurrence of vertebral fracture is not only a signifi- cant cause of back pain and functional limitation, but is also predictive of new fractures. As with hip fracture, vertebral frac- tures are associated with progressive increases in mortality within 5 years [21].

Brazilian studies on the topic are scarce. In a retrospective cohort study investigating a population living in the state of Ceará (equatorial region), Castro et al., reported annual hip fracture rates of 5.59/10,000 male and 12.4/10,000 female individuals aged over 50 years – lower than figures reported by Komatsu et al., in the Southeast region of the country (12.6/10,000 male and 28.8/10,000 female individuals aged over 60 years). (25,26)

ABSTRACT: Objectives: To estimate the risk of death and readmission of a cohort of elderly patients discharged after hip fracture treatment from hospitals of the public health system; to describe the causes of these events; and to compare the rates of readmission and death observed with those of the elderly population hospitalized in public hospitals of Rio de Janeiro city. Methods: Data on deaths and readmissions were obtained through the linkage of these two data sources: the Hospital Information System of the Sistema Único de Saúde and the Mortality Information System from the city of Rio de Janeiro. The time frame for the study was 2008 to 2011. The population consisted of 2,612 individuals aged 60 years or older with nonelective hospitalization for hip fracture who were followed for a year after discharge. Results: The readmission rate in one year, excluding the deaths in this period, was 17.8%, and the death rate was 18.6%. The most common causes of death were circulatory system diseases (29.5%). Approximately 15% of the causes of readmissions were surgical complications. The state hospitals showed lower readmission risks and higher death risks compared with the federal and municipal hospitals. It was observed that there is an excess risk of readmission and hospitalization of the study population compared with the elderly population hospitalized in the public hospitals of the city. Conclusion: Hospitalization of elderly individuals for hip fracture causes adverse outcomes such as readmissions and deaths. Many of these outcomes can be prevented from actions recommended in the National Policy for the Elderly Health.

Conceived and designed the experiments: HH KM. Analyzed the data: HH LB. Wrote the paper: HH LB KM. Recruited participants: AW. Figure 3. Association between coffee consumption and fracture risk. Multivariate-adjusted hazard ratios (HR) with 95% confidence intervals (CI) (dashed lines) of any fracture (Panel A) and hip fracture (Panel B) by coffee consumption. The vertical bars represent the distribution of coffee intake. The smoothed curves were fitted with a restricted cubic spline model with a consumption of ,1 cup of coffee as the reference. Adjustments were made for intake of energy, protein, calcium, retinol, vitamin D, phosphorus, potassium and alcohol, body mass index, height, physical activity (MET-24 h score) (all continuous), intake of any vitamins, cortisone use, educational level (#9, 12, .12 years, other), smoking status (never, former, current), previous fractures (yes or no) and Charlson’s comorbidity index (continuous).

Methods: This was a case–control study in which serum samples of 25(OH)D were obtained from 110 proximal hip fracture inpatients and 231 control patients without fractures, all over 60 years of age. Levels of 25(OH)D lower than or equal to 20 ng/mL were considered deficient; from 21 ng/mL to 29 ng/mL, insufficient; and above 30 ng/mL, sufficient. Sex, age, and ethnicity were considered for association with the study groups and 25(OH)D levels. Results: Patients with proximal hip fracture had significantly lower serum 25(OH)D levels (21.07 ng/mL) than controls (28.59 ng/mL; p = 0.000). Among patients with proximal hip frac- ture, 54.5% had deficient 25(OH)D levels, 27.2% had insufficient levels, and only 18.2% had sufficient levels. In the control group, 30.3% of patients had deficient 25(OH)D levels, 30.7% had insufficient levels, and 38.9% had sufficient levels. Female patients had decreased serum 25(OH)D levels both in the fracture group and in the control group (19.50 ng/mL vs. 26.94 ng/mL; p = 0.000) when compared with male patients with and without fracture (25.67 ng/mL vs. 33.74 ng/mL; p = 0.017). Regarding age, there was a significant association between 25(OH)D levels and risk of fracture only for the age groups 71–75 years and above 80 years.

• P33 – Septic Arthritis: a reality of a Portuguese department of rheumatology 62 • P159 – Fragility hip fracture after the age of 90 – the experience of a fracture liaison service 105 • P176 – Contraceptive counseling and use among portuguese women with systemic lupus erythematosus 112 • P172 – Factors predicting difficulties with discharge to own home in patients with fragility hip fractures 111 • P48 – Characteristics and outcomes of prospectively reported pregnancies exposed to 67

The SAPOS study also revealed that menopause, family history of hip fracture, low BMD and advanced age were the main risk factors associated to low-trauma fracture. In contrast, regular physical activity in the previous 12 months was the only factor that played a protective role against osteoporotic fracture. Likewise, menopause, advanced age and previous fracture were significantly associated with greater likelihood of having low BMD, whereas higher BMI, hormonal replacement therapy and regular physical activity in the previous year had a positive effect on BMD, which corroborates previous studies. 4,31

This study evaluates the role of the number of secondary diagnoses for calculating the Charl- son comorbidity index (CCI) in risk adjustment of the 90-day mortality rate after hip fracture surgical repair. Comorbidities were selected by reviewing the medical records of 390 patients 50 years of age or older in a teaching hospital in Rio de Janeiro from 1995 to 2000. Logistic regres- sion models were fitted including the variables age, sex, and CCI. The CCI was calculated based on: (1) all patients’ comorbidities; (2) only the comorbidity with the highest weight; and (3) a single randomly selected comorbidity. There was a gradient in the prediction of the CCI mortality rate when all comorbidities were used (OR = 6.53; 95%CI: 2.27-18.77, for scores ≥ 3). The predictive capacity of the CCI was observed even when it was calculated using only one comorbidity: with the highest weight (OR = 2.83; 95%CI: 1.11-7.22); and randomly selected (OR = 2.90; 95%CI: 1.07- 7.81). Using all comorbidities for CCI calculation is important. Severity indices based on a single comorbidity can be useful for risk adjustment procedures.

On account of its various advantages including low cost, simplicity of performance, and absence of radiation, calcaneal quantitative ultrasound (QUS), has recently been widely studied and found to have potential for osteoporosis diagnosis. Langton et al. first introduced the use of QUS for clinical bone mineral density evaluation in 1984 [5]. Since then, many clinical stud- ies have found that certain QUS parameters, such as broadband ultrasound attenuation (BUA) and speed of sound (SOS), are significantly associated with fracture risk [6–8]. Furthermore, apart from the bone mineral density (BMD) and acoustic parameters, QUS examination can also provide mechanical information by means of calculating an index of stiffness, i.e., the quantitative ultrasound index (QUI). Huopio et al. found that the hazard ratio (HR) for frac- tures increased by 1.90 (95% CI, 1.25–2.91) per SD decrease in stiffness [9]. Based on a pooled meta-analysis of three prospective studies, Moayyeri et al. also determined that the BUA, SOS, and stiffness were significantly associated with fracture risk [10]. They reported that stiffness had the highest efficacy of fracture prediction, with HR of 2.26 (95% CI, 1.71–2.99) per SD decrease in stiffness. Specifically, several high-quality longitudinal studies have also demon- strated that calcaneal QUS can predict hip fracture risk in postmenopausal women [6,11,9]. Overall, recent studies have shown an intimate relationship between the parameters of calca- neal QUS and fracture risk.