The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation. With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key. This study assesses the validity of the NHFS in predicting mortality after fragility DFFs. A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases. Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded. All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT. Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk. 285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes. 30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively. Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714). The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF.
Tranexamic acid (TXA) is an inexpensive antifibrinolytic. Currently there are no national guidelines in the UK that promote the use of TXA in femoral fragility fracture (FFF) management. The aim of the study was to determine whether intra-operative intravenous TXA affects the requirement for post-operative blood transfusion following FFF surgery. A prospective non-randomized case-control study of consecutive FFF admitted to the study centre was performed. 361 patients were included in the study (mean age 81.4yrs; mean BMI 23.5; 73.7% female). TXA was given at the discretion of the operating surgeon, with 178 (49%) patients receiving TXA. Patient demographics, surgical management, peri-operative haemoglobin (Hb) and haematocrit, intravenous TXA use, and requirement for blood transfusion were recorded prospectively. Percentage fall in Hb from preoperative level was calculated at postoperative day one. Calculated-blood-loss (CBL) was determined using the Nadler and Gross formulae. The groups were well matched in terms of patient demographics, injury types and surgical management. The requirement for postoperative blood transfusion was significantly reduced in the TXA group: 15/178 (8.4%) compared to 58/183 (31.7%) (p<0.001; Chi square). TXA significantly reduced both the percentage fall in Hb (mean difference 4.3%, p<0.001) and the CBL (mean difference -222ml, p<0.001). There was no difference in venous thrombosis embolism events between the groups. Intra-operative intravenous TXA during the surgical management of FFF significantly reduced rate of transfusion, CBL and the percentage drop in HB.
An audit was carried out to assess the management of patients with fragility fractures in fracture clinic and primary care. NICE guidelines advise these patients require treatment for osteoporosis if 75 years or older, and a DEXA scan if below this age. Distal radius and proximal humeral fractures were identified in a retrospective review of letters from 10 fracture clinics. Current medication of all patients ≥ 75 years was accessed and DEXA scan requests identified for patients < 75 years. There were 69 fragility fractures: 53 distal radius and 16 proximal humerus. 4 letters (6%) mentioned fragility fracture and advised treatment and 3 (3%) correctly advised a DEXA scan. Only 3 of 25 (10%) patients ≥ 75yrs not previously on osteoporosis medication had treatment started by their GPs. 3 of a possible 29 (10%) patients < 75 years were referred for a DEXA scan. A text box highlighting fragility fractures and NICE guidelines was added to all clinic letters for patient ≥ 50 years old. Re-audits showed an improvement in management of these fractures, with 45% of patients ≥ 75 years being started on treatment and 39% of patients < 75 years being referred for a DEXA scan.
Orthopaedic surgeons frequently assess fragility fractures (FF), however osteoporosis (OP) is often managed by primary care physicians (PCP). Up to 48% of FF patients have had a previous fracture (Kanis et al., 2004). Discontinuity between fracture care and OP management is a missed opportunity to reduce repeat fractures. This studied aimed to evaluate current OP management in FF patients presenting to cast clinic. A single centre, prospective observational study where seven traumatologists screened for FF in cast clinic. FF was defined as a hip, distal radius (DR), proximal humerus (PH), or ankle fracture due to a ground level fall. Patients completed a self-administered questionnaire for demographics, fracture type and treatment, medical and fracture history, and previous OP care. The primary outcome was number of FF patients who received OP investigation and/or treatment. Secondary outcomes included Fracture Risk Assessment Tool (FRAX), repeat fracture rate, and anti-resorptive related fractures. Descriptive statistics were used for analysis. Between November 17, 2014 and October 13, 2015, a total of 1,677 patients attended cast clinic for an initial assessment. FF were identified in 120 patients (7.2%). The FF cohort had a mean age of 65.3 (± 14.3) years, mean BMI of 26.1 (± 5.3), and was comprised of 83.3% females. Fracture distribution was 69 (57.5%) DR, 23 (19%) ankle, 20 (16.5%) PH, and seven (5.8%) hip fractures, with 24 of the FF (19.8%) treated operatively. Thirteen (10.8%) were current smokers and 40 (33.3%) formerly smoked. A history of steroid use was present in 13 patients (10.8%). Ninety (n = 117; 76.9%) of patients ambulated independently. Twenty-two patients (18.3%) reported prior diagnosis of OP, most often by a PCP (n = 19; 73.7%) over 5 years previously. Calcium (n = 59; 49.2%) and Vitamin D (n = 70; 58.3%) were common and 26 patients (21.5%) had a prior anti-resorptive therapy, with Alendronate (n = 9) being most common. One patient had an anti-resorptive-related fracture. Raloxifene was used in ten patients. Forty-seven patients (39.2%) had a prior fracture at a mean age of 61.3 (± 11.9) years, with DR and PH fractures being most common. Eleven patients had two or more prior fractures. A family history of OP was found in 34 patients (28.1%). Mean FRAX score was 20.8% (± 10.8%) 10-year major fracture risk and 5.9% (± 6.6%) 10-year hip fracture risk (n = 30 bone densiometry within one-year). Of the 26 patients with a Moderate (10–20%) or High (> 20%) 10-year major fracture risk, only eight (30.8%) reported a diagnosis of OP and only three (11.5%) had seen an OP specialist. Cast clinics provide an opportunity for OP screening, initiation of treatment, and patient education. This cohort demonstrated a high rate of repeat fractures and poor patient reporting of prior OP diagnosis. This study likely underestimated FF and calls for resource allocation for quantifying true burden of disease and outpatient fracture liaison service.
To describe the implication of Family Physicians (FPs) in the management of osteoporosis revealed by a fragility fracture. The impact and costs of fractures is straining the health system. A better collaboration between specialists and FPs should improve the evaluation and treatment of affected patients. Since January 2007, the OPTIMUS initiative is an attempt to reach that objective in the Estrie area of the Province of Quc. With OPTIMUS, rates of appropriate treatment of osteoporosis at one year in previously untreated patients more than double (53% vs 20%). In OPTIMUS, FPs remain responsible for investigation and treatment of their patients after identification of a bone fragility fracture. A coordinator based in orthopaedists outpatient clinics identifies fragility fractures in patients older than 50 y.o., informs them about bone fragility and its link to osteoporosis, and spurs them to contact their FPs to get treated; the importance of persistence on treatment is reinforced during phone follow ups. Initially and when patients remain untreated upon follow up, the coordinator sends a letter to the patients FP about the occurrence of the fracture, its predictive value for future fractures, and the need for investigation and treatment. This represents a personalized form of continuous medical education for FPs, in the hope that FPs become leaders in the prevention of fragility fractures. To evaluate the perception of FPs about OPTIMUS, we performed a mail survey targeting FPs reached at least once by OPTIMUS.Purpose
Method
Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance.
The quality of bone in the skeleton depends on the amount of bone, geometry, microarchitecture and material properties, and the molecular and cellular regulation of bone turnover and repair. This study aimed to identify material and structural factors that alter in fragility hip fracture patients treated with antiresorption therapies (FxAr) compared to fragility hip fracture patients not on treatment (Fx). Bone from the intertrochanteric site, femoral head (FH: FxAr = 5, Fx = 8), compression screw cores and box chisel were obtained from patients undergoing hemi-arthroplasty surgery, FxAr (6f, 2m, mean 79 and range [64–89] years), and Fx (7f, 1m, age 85 [75–93] years). Control bone was obtained at autopsy (9f, 4m, 77 [65–88] years). Treated patients were on various bisphosphonates. Samples were resin-embedded, for quantitative backscattered electron imaging of the degree of mineralisation and assessment of bone architecture. Trabecular bone volume fraction (BV/TV) and architectural parameters were not significantly different between FxAr and Fx groups. Both groups showed normal distributions of weight (wt) % Ca; however, the FxAr was less mineralised than the Fx and the control group (mean wt % Ca: FxAr = 24.3%, Fx = 24.8%, Control = 24.9%). When comparing the FH specimens only, we found that BV/TV in the FxAr was greater than the Fx group (18% vs 15%). All other parameters were not significantly different. In addition, the mineralisation was greater in the FxAr group compared to the Fx group (25.5 % vs 25.0%) but was not significantly different. Collectively, these data suggest the effect on bone of antiresorptives may be different for patients on antiresorptive treatment that do not subsequently fracture. Assessment of bone material property data together with other bone quality measures may hold the key to better understanding of antiresorptive treatment efficacy.
We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself. We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A&
E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan. Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment. Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.
The effect of the gut microbiota (GM) and its metabolite on bone health is termed the gut-bone axis. Multiple studies have elucidated the mechanisms but findings vary greatly. A systematic review was performed to analyze current animal models and explore the effect of GM on bone. Literature search was performed on PubMed and Embase databases. Information on the types and strains of animals, induction of osteoporosis, intervention strategies, determination of GM, assessment on bone mineral density (BMD) and bone quality, and key findings were extracted.Aims
Methods
Aims. National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The
Aims. The aim of this study was to explore current use of the Global
Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022
Aims. To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the