Aims: Secondary prevention in patients suffering neck of femur fractures is an effective but under utilised strategy in reducing subsequent fragility fractures. Published BOA guidelines recommend patients aged 75 or over with fragility fractures should receive bisphosphonates, falls risk assessment, and vitamin D supplements if there are concerns regarding deficiency. This audit aimed to determine the effectiveness of implementing secondary prevention strategies in patients admitted with neck of femur fractures. Methods: Patients aged 75 or above admitted to a local trauma unit with neck of femur fractures were identified over a two-year period. In-hospital mortality was recorded. Discharge letters for the remaining patients were obtained. Data was collected on whether patients were commenced on bisphosphonates and vitamin D supplements in hospital, or whether advice was given for these therapies to be initiated in the community. Patients undergoing falls risk assessment prior to discharge were also noted. Results: Overall 549 patients met the inclusion criteria. Eighty patients died during admission giving an in-hospital mortality rate of 14.6% per year. A further 238 patients were excluded due to missing data leaving 231 patients in the final study population. Mean age was 84.4 yr (range 75–97 yr) and 77.9% (n=180) were female. Bisphosphonate therapy was commenced or recommended in 22.9% (n=53), vitamin D supplements in 46.3% (n=107), and 16.5% (n=38) underwent falls risk assessment. Only 4.3% (n=10) were commenced on bisphosphonates and underwent falls risk assessment. Conclusions: Despite evidence that secondary prevention is effective in reducing subsequent fragility fractures our findings demonstrate these strategies are poorly implemented with less than one in twenty patients receiving the recommended falls assessment and antiresorptive therapy. A standardised discharge letter for patients with neck of femur fractures would provide more effective communication between hospitals and primary care thereby assisting the implementation of secondary prevention strategies

Introduction: Fragility fractures are taking up an increasing amount of resources within Trauma departments. Women have a 1 in 3, men a 1 in 12 lifetime risk of sustaining an osteoporotic fracture with a previous fracture being the strongest independent predictor of sustaining a further fragility fracture, often within one year. Secondary prevention is therefore particularly important. Many guidelines give advice on secondary prevention in women, but very few mention men even though men have a higher morbidity and mortality after hip fractures. Methods: A retrospective review was carried out including 91 patients (48 females, 43 males) who were admitted with a fragility hip fracture between March 2003 and April 2004. Data about age, sex, investigations and medication were collected from the case notes, GP surgeries and the bone densitometry database. Investigations and treatment were compared with current guidelines (SIGN 2003, NICE 2005). Data was analysed using SPSS Version 13.0. Results: 33% of women and only 8% of men < 75 years of age were investigated for osteoporosis (DEXA scan) following their hip fracture (Fishers Exact Test, p = 0.32). In patients ≥ 75 years 25% of women and only 6% of men were treated with bisphosphonates (χ. 2. = 4.18, p < 0.05). There was also a statistically significant difference in overall treatment including bisphosphonates and calcium/vitamin D between the sexes (χ. 2. = 6.81, p < 0.05). Discussion: This study shows that there is a great need for improvement in secondary prevention of osteoporotic fragility fractures in both sexes, but men are far less likely to receive investigations and treatment than women. It is therefore essential to include recommendations for men in future guidelines and to increase awareness of male osteoporosis. Orthopaedic surgeons should take responsibility for initiating the process of secondary prevention

Introduction: Osteoporotic fracture care is on the increase in healthcare systems worldwide. In the UK the British Orthopaedic Association (BOA) recommends all patients > 60 presenting with fragility fracture (FF) should be evaluated for osteoporosis by axial Dual Energy X-ray Absortiometry (DEXA) scan. All patients < 60 should be assessed for osteoporosis risk factors and DEXA scanned if present. The National Institute for Clinical Excellence (NICE) recommends all woman > 75 with FF should be prescribed secondary prevention bisphosphonates for osteoporosis 1st line without the need for DEXA scan. Aim: To evaluate how often patients with FF were appropriately managed in fracture clinic using BOA and NICE guidelines for the secondary prevention of FF. Methods: and Results: Over a two month period 18 of 184 new patients admitted to fracture clinic were identified as having FF (16 females, 2 males with age ranges 61–89). They were followed up over six months. According to BOA and NICE guidelines only 33% (6 of 18 patients) and 42% (3 of 7 > 75’s) respectively were appropriately managed for secondary prevention. Following this a FF prevention strategy was implemented. This consisted of fracture clinic infrastructure changes, a staff awareness teaching programme and the assignment of an osteoporosis nurse specialist. A re-audit six months later identified 16 of 175 new patients as having FF. According to BOA and NICE guidelines 88% (14 of 16 patients) and 75% (6 of 8 > 75’s) respectively were appropriately managed for secondary prevention. Fisher’s Exact Test showed a significant improvement in secondary prevention management according to BOA guidelines (p< 0.05), but not NICE guidelines (p=0.2), as a consequence of these interventions. Conclusion: Osteoporosis is an important cause of fracture in elderly patients. Changes to fracture clinic infrastructure, educational teaching initiatives and osteoporotic nurse specialists can improve uptake of secondary prevention measures in fracture clinic aimed at reducing risk of future fragility fractures in elderly patients

Patients most at risk of osteoporosis are post-menopausal women. However, for many such women, presentation of osteoporosis is only made following their first fragility fracture. Often in the UK, osteoporosis investigation occurs following discharge, and any subsequent secondary prevention starts in the community. This may result in patients with osteoporosis not being investigated or not receiving correct prophylactic treatment. 143 post-menopausal women (av. age 77.7 years) starting secondary osteoporosis prophylaxis following fragility fractures requiring operative intervention were included in this retrospective study. Osteoporosis was defined by DEXA scan using the WHO criteria (122 hip fractures and 21 wrist fractures), following the UK's national guidelines for osteoporosis prophylaxis. Treatment was started following discussion and explanation of treatment with each patient, and either commenced by the surgical team during the acute hospital admission with the fracture, or in an out-patient setting within 6 weeks of the fracture by an orthopaedic specialist nurse. To check compliance, either the patient themselves or the patients' family physician was contacted. Results showed that 120 of the women (83.9%, 102 hip fractures, and 18 wrist fractures) were still compliant with secondary osteoporosis prophylaxis at an average follow-up of 200 days (5 hip fractures lost to follow-up, 0 wrist fractures). 12 women with hip fractures died (0 wrist fractures), and 6 women stopped taking their prophylaxis (3 hip fractures, 3 wrist fractures): 4 for medical reasons, and 2 for unknown reasons. No women sustained further fractures. Few studies have previously investigated compliance of osteoporosis secondary prevention, and our results compare favorably. We therefore recommend the prompt commencement of secondary prevention treatment by the orthopaedic surgical team following osteoporotic fractures

To discover whether orthopaedic surgeons follow the BOA guidelines for secondary prevention of fragility fractures, a retrospective audit on neck of femur fractures treated in our hospital in October/November 2003 was carried out. There were 27 patients. Twenty-six patients (96%) had full blood count measured. LFT and bone-profile were measured in 18 patients (66%). Only nine patients (30%) had treatment for osteoporosis (calcium and vitamin D). Only one patient was referred for DEXA scan. Steps were taken to create better awareness of the BOA guidelines among junior doctors and nurse practitioners. In patients above 80 years of age it was decided to use abbreviated mental score above 7 as a clinical criterion for DEXA referral. A hospital protocol based on BOA guidelines was made. A re-audit was conducted during the period August-October 2004, with 37 patients. All of them had their full blood count and renal profile checked (100%). The bone-profile was measured in 28 (75.7%) and LFT in 34 (91.9%) patients. Twenty-four patients (65%) received treatment in the form of calcium + Vit D (20) and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were already on bisphosphonates and 10 patients had an abbreviated mental score of less than 7. Among the remaining 23 patients, nine (40%) were referred for DEXA scan. This improvement is statistically significant (p=0.03, chi square test). The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation

Introduction: The main symptom of osteoporosis is fractures. Osteoporostic hip fractures are and increasing problem due to their morbid-mortality and health cost. The necessity of recommending treatment for osteoporosis upon discharge after hip fractures is generally accepted. The object of this study is to evaluate secondary prevention upon discharge and at 6 months after a hip fracture. MATERIAL AND Methods: Prospective observational study analyzing all osteoporòtica hip fractures among patients older than 50 treated during 2004, with telephonic follow-up. RESULTS: We attended 563 fractures in 556 patients, with a mean age of 82,96 years (50 – 105) and a female: male ratio of 2,9:1. Mortality was 7,8% in-hospital and 20,2% at 6 months. Though 52,1% had suffered a previous osteoporotic fracture an 13,7% a previous hip fracture, only 16,3% had at some time been treated for osteoporosis. Pharmacological treatment for osteoporosis (%, Upon discharge vs. at 6 months): Global (38,1 vs. 31%), Calcium +/− vitamin D (8,2 vs. 18%), Ca-VitD + biphosphonate (28,1 vs. 10,8%), Biphosphonate only (3,4 vs. 1,7%). The patients that had received treatment upon discharge were morle likely to receive it at 6 months (RR 2,2, CI95% 1,5 – 3,2). Women, patients that had been sent to a temporary nursing home and patients that had a better functional status were more likely to receive treatment (p< 0,05). There was no significant correlation with patient age or previous fractures. CONCLUSIONS: Our study’s patients are similar to other studies published. Treatment compliance with biphosphonate falls at 6 month after discharge. It is important to recommend treatment for osteoporosis upon discharge

Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were admitted to our Trauma Unit to identify if the NICE guidance was being followed.

Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Nice guidance from 2005 is clearly not being implemented in our area. A minority of patients will have contraindications or allergies to bisphosphonates (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.

Introduction: Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87).

We prospectively reviewed the medication of such patients who were discharged from our Trauma Unit to identify if the NICE guidance was being followed.

Method: Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture.

We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one.

Results: 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate.

6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Conclusions: Nice guidance from 2005 is clearly not being implemented in our area. Some patients will have contraindications or allergies to bisphosphonates, however, they will be a minority (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society).

We believe the results demonstrate a lack of health promotion opportunities to prevent future fracture. Although there is clear focus and impetus for developing falls prevention services nationwide, this enthusiasm has not been translated across to bone health, despite the potential savings in terms of morbidity, mortality and healthcare costs.

Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care.

This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.

Several studies document what we all know – that, in the vast majority of patients treated in fracture units for low-trauma fractures, there is no attempt to identify and treat factors predisposing to further fractures. We treat this fracture, send ‘em home and wait for the next. How mindless is that?

Equally, it is completely unrealistic to expect orthopaedic surgeons, focused on surgically treating a tide of challenging osteoporotic fractures, to assess the risk in each patient of further falls and the degree to which bone strength is compromised, and be responsible for prescribing treatments which will reduce risk in a cost-effective way. Yet the fracture unit is absolutely the best (and most cost-effective) place to identify the group of patients who will benefit most from preventive measures.

The answer is to work in a system, which connects up the right people to give each patient what they need. Surgeons to heal the current fracture (together with rehabilitationists to restore function and confidence) and physicians to assess and treat falls risk and osteoporosis.

Making this happen in practice requires answers to questions only you can answer:

who are the best physicians for our fracture unit to work with?

This is an issue in which it is worth us investing a lot of effort: we will ourselves soon be old and we must get this right in time for when we need it!

Objective: The FORWARD project intended to improve osteoporosis care in Fracture patients in Orthopedic WARDs (FORWARD) in the Belgian hospital care setting.

Methods: Orthopedic surgeons willing to participate in the program were requested to actively refer their patients with clinical fractures for bone densitometry and an osteoporosis specialist’s advice. Data collection was done by a short easy to complete summary questionnaire.

Results: Data from 7758 fracture patients were collected. In hospital patients and females represented respectively 84% and 75% of the cases. Fracture prevalence in the study population peaked at the age of 75 to 85 years both in men and women, respectively 35% and 42%. The main fracture type were hip (45%), other (25%), spine (9%), wrist (8%), pelvis (7%) and humerus (7%). Previous clinical fractures were reported in 22% of the patients. Appointments for DXA examination were made in 66% (n = 5112) of the patients and results were obtained from 55% (n = 4274). The WHO diagnostic classification was as follows: osteoporosis 56%, osteopenia 33% and normal bone density 11%. 3855 patients were referred for diagnostic confirmation of the problem by an osteoporosis specialist. Final clinical diagnosis of osteoporosis was accepted in 2150 cases (27% of all patients and 42% of DXA referrals). Treatment with calcium and vitamin D was started in 2510 patients (32%) and with bisphosphonates in 1717 patients (22%). No data about compliance to these treatments were obtained in the present project.

Conclusion: The FORWARD referral program for fracture patients in orthopedic wards for DXA investigation and osteoporosis specialists’ advice resulted in the identification of osteoporosis in 27% of all fracture patients. Implementing effective measures and treatments for (secondary) fracture prevention in this high risk population could lead to cost-savings in the short term. Initiatives to promote the patient flow needs to be elaborated and maintained by an active local care organisation.

Introduction. The purpose of this study was to establish whether men and women with a fragility hip fracture were equally investigated and treated for osteoporosis. Methods. A retrospective review was carried out including 91 patients (48 females, 43 males) who were admitted with a fragility hip fracture between March 2003 and April 2004. Data about age, sex, investigations and medication were collected from the case notes, GP surgeries and the bone densitometry database. Investigations and treatment were compared with current guideline recommendations (SIGN 2003, NICE 2005). Data were analysed using SPSS Version 13.0. Results. According to the guidelines patients < 75 years of age should be investigated and patients > 75 years should be treated for osteoporosis. In our review 33% of women and only 8% of men < 75 years were investigated with a DEXA scan following their hip fracture (Fishers Exact Test, p = 0.32). In patients > 75 years 25% of women and only 6% of men were treated with bisphosphonates (Chi-square = 4.18, p < 0.05). There was also a statistically significant difference in overall treatment including bisphosphonates and calcium/vitamin D between the sexes (Chi-square = 6.81, p < 0.05). Conclusion. This study shows that there is clearly a need for improvement in secondary prevention of fragility fractures in both sexes, but men are significantly less likely to be investigated and treated than women. It is important to include recommendations for men in future guidelines and increase the awareness of male osteoporosis. This is of particular importance as men have a higher morbidity and mortality following hip fractures than women. Orthopaedic surgeons should therefore take on responsibility for these fracture patients and ensure that the process of secondary prevention is initiated

Objectives. Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. Methods. We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. Results. Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. Conclusions. This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes. Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144–153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1

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

A prior fragility fracture is one of the strongest predictors for a subsequent one, and this should be a target for secondary fracture prevention. All injured patients admitted to the emergency floor, Ume̊ University Hospital, Sweden, were registered. Between 1993–2004, there were 113,668 injury events, including 29,190 fracture events (one or more fractures at the same time), of whom 12,635 patients were _ 50 years. 1,994 of them had at least two fracture events; 500 had 3; 131 had 4; 35 had 5; and 11 had _ 6 fracture events. Mean age at the baseline fracture was 72.2 years and 75.5 at the second one. Thus, over 50 years of age, not less than 37% of all fractures were serial fractures, and 20% of the patients are serial fracturers. Hip and radius fracture were the most common ones, but 20% were fractures not traditionally labelled as fragility fractures. However, since more than 78% were caused by falls in the same level, most presumably have a fragility component. The interval between the two first fractures was longer than reported in several previous studies, mostly on patients participating in clinical trials. However, our material is population-based and unselected, since there is just one trauma facility in the area, and the general population is healthier than in-hospital or trial patients. On the other hand, there is a cut-off bias, so the interval is likely to be even longer. Interestingly, the difficult-to-treat hip fracture was the second common baseline fracture, the most common subsequent one, and hip-hip fractures were the most common combination, not less than 8.5% of the serial fractures. It is therefore clinically important to use the information provided by the fracture event, a fragility fracture may actually be regarded as a biomechanical test or a natural experiment. Trauma units, therefore, have an onus to screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients, but alas this is rarely done. A similar neglect of secondary prophylaxis and treatment after cardiovascular disorders would be an outrage! Secondary prevention is especially important since serial fractures are so common, often preventable, having a high impact on health-related quality of life

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 Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Aims

To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design.

The Purpose and background to Study. The purpose of the study is to develop a new and more effective approach to the management of the return to work process in employees troubled by musculoskeletal symptoms. For the last decade, secondary prevention of persistent pain and unnecessary disability has been identified as a major challenge. The importance in particular of psychosocial obstacles to recovery been recognised (Hopkinkon Conferemce, 2005) and stimulated the Decade of the Flags Think-Tank and Conference at Keele University in 2007, where clinical, occupational and wider contextual factors were explored leading to a number of publications on clinical Yellow Flags (Nicholas et al, 2011) and occupational Blue flags (primarily perceptions of work (Shaw et al.,2009) and organisational factors (Main et al, 2013), the conclusions and recommendations from which are the subject of this abstract. Methods and results. There are insufficient workplace-focused RCTs, systematic reviews or meta-analyses from which to develop an evidence-based intervention strategy and narrative review of the clinical and organisation literature into the management of work disability and return-to-work was undertaken of research. The review considers evidence of the efficacy of interventions for addressing absenteeism and presenteeism, distinguishing worker-centred and workplace-centred interventions, and continues with consideration of new ways in which these challenges might be addressed. Conclusion. It recommends a shift from sickness management to the enhancement of well-being, with an evaluation of new organisational research into the psychology of engagement Implications for re-integrating the injured worker into the working environment, are considered not only from a biopsychological but also from a social perspective. The presentation will conclude with consideration of issues of implementation with design of interventions using strategies such as intervention-mapping, a focus on the determinants of behaviour change and advocation of an integrated approach to the optimisation of successful and sustained return to work. No conflicts of interest. No funding obtained. I confirm that the abstract has not been previously published in whole or substantial part not has it been presented at a national meeting

Most people experience low back pain (LBP) at least once in their lifetime. A minority goes on to develop persistent LBP causing significant socioeconomic costs. Aim of this study was to identify factors that influence the progression of acute to persistent LBP at an early stage (Hilfiker et al. 2007). Prospective inception cohort study of patients attending a health practitioner for their first episode of acute LBP or recurrent LBP after a pain free period of at least six months. Patients were assessed at baseline addressing occupational and psychological factors as well as pain, disability, quality of life and physical activity, and followed up over six months. Baseline and follow-up questionnaires were based on the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement (Pincus et al. 2008). Variables were combined to the three indices ‘working condition’, ‘depression and maladaptive cognitions’ and ‘pain and quality of life’. The index ‘depression and maladaptive cognitions’ comprising of depression, somatisation, a resigned attitude towards the job, fear-avoidance, catastrophizing and negative expectations on return to work was found to be a significant baseline predictor for persistent LBP up to six months (OR 5.1; 95%CI 1.04–25.1). The diagnostic accuracy of the predictor model had a sensitivity of 0.54 and a specificity of 0.90. Positive likelihood ratio was moderate with 5.3, negative likelihood ratio 0.5. Overall predictive accuracy of the model was 81%. The area under the curve in receiver operating characteristic (ROC) analysis of the index was 0.78 (CI95% 0.65–0.92), demonstrating a satisfactory quality of discrimination. Psychological factors in patients with acute LBP in a primary care setting correlated with a progression to persistent LBP up to six months. The benefit of including factors such as ‘depression and maladaptive cognition’ in screening tools is that these factors can be addressed in primary and secondary prevention

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Clopidogrel, an anti-platelet agent is used in the secondary prevention of ischaemic events in high risk patients. Recent studies suggest that there are no National guidelines on when to stop clopidogrel in patients with hip fracture. It is suggested that stopping clopidogrel and waiting up to 1 week or more before surgery may have adverse effects on the patient. This study is aimed at identifying factors predicting outcome in these patients. All patients admitted to our unit in 2006 with proximal femoral fracture were included. Patients on clopidogrel were identified for further investigation. Demographic, perioperative and postoperative data including complications and death were documented. Thirty one of 586 patients with proximal femoral fracture were on clopidogrel on admission. Mean delay to surgery was 8.4 days (range 2–16 days SD 2.5). The mean age was 81 years (64–97) with a male to female ratio of 1:2.4. Of the 31 patients, 8 (25.8%) had died at 1 year. The standardised mortality ratio was higher in patients less than 65 years old and lower in all patients over 65 years. Significant predictors of death on univariate analysis at one year were spinal anaesthesia (p = 0.04), postoperative blood transfusion (p = 0.03), postoperative complication (p = 0.03) and delay to surgery (p = 0.03). There was a positive correlation between delay to surgery and developing a postoperative complication (Pearson’s correlation 0.33 p = 0.04). Multivariate analysis revealed that delay to surgery was the only independent factor predicting death at one year. No evidence exists to suggest that clopidogrel should be stopped 1 week prior to surgery for proximal femoral fracture. Waiting for 1 week or more prior to surgery is directly correlated to developing postoperative complications and subsequent death at one year