Objective: With an increasing number of old people in populations an understanding of the determinants of mobility and strength is of paramount importance. The effect/consequens of vertebral fractures and cognitive decline on these parameters is not known. The aim of the study was to investigate possible confounding or interaction of cognitive decline with clinical vertebral fractures (VF) with respect to crucial functions, morbidity and hospitalization.

Material and Methods: Data from the population-based Age, Gene/Environment Susceptibility Reykjavik Study (AGES Reykjavik Study) (n=5371) were used. Three groups were used, not fractured (nFR), other fracture than vertebra (oFR), and vertebral fracture (VF). The effect of VF and cognition on function was measured by Timed Up and Go (TUG), 6 meter walk (6mw), grip- and knee-extension strength. VF status was examined from a verified fracture registry for the study group since midlife. Cognition status was evaluated by a consensus panel using detailed cognitive tests and clinical information.

Results: The prevalence of VF increased with age in both sexes and was higher among women (p< 0.0001). Women had overall worse function than men. The effect of VF on function was similar for both men and women. There was a consistent gradient between the fracture groups in performance for all the function tests, NFR performing best and VF worst. For the 6mw, TUG and knee-extension strength, women with VF did worse than those without VF.

Individuals with previous history of VF required more often hospitalization (OR 2.8.(1.8–4.4)). After median follow up time of 30 months from entry into the study those with fractures were significantly more often hospitalized compared to NFR, oFR HR 1.2(1.1–1.3) p< 0.0001 and VF (HR 1.4 (1.2–1.6), p< 0.0001) and men more so than women. These results were not confounded by prevalent hip fractures. Individuals in the NFR group had the shortest hospital stay and those in the VF group stayed the longest and men significantly longer than women (p< 0.0001).

VF had significantly more back pain, used more analgetics and had more gastrointestinal complaints. This explaines only a small proportion of the excess hospitalization.

Cognitive impairment had an effect on performance but interaction with fractures was not seen.

Conclusion: Individuals with VF are at increased risk of beiing hospitalized and in a need of extended hospital stay. They have bad mobility and strength and need analgetics. Those who were cognitively impaired had even worse function which was independent of the VF.

QCT permits a direct measure of bone and muscle size and assessment of bone/muscle relationship. We have studied cross-sectional QCT variables in mid-thigh as predictors of incidental limb fractures in the AGES-Reykjavik Study, a cohort of 66–96-year-old men (n=2160) and women (n=2385) drawn from an established population based cohort and not taking medications affecting bone metabolism. We used 4-detector Siemens CT system, a single axial section through the right mid-thigh (10 mm slice thickness). The variables included in the Cox’s proportional hazard model were; total cross-sectional cortical area (CSA), derived cortical thickness, shaft BMD, shaft bending strength index (BSI), medullary area and buckling ratio, total cross-sectional muscle and quadriceps area and bone/muscle area ratio. All low trauma limb fractures (including proximal end of femur but excluding toes, foot, hand and finger fractures) during mean 3.5 years of follow-up were validated by medical and radiological records, altogether 170 in women and 61 in men, including 87 hip fractures.

Results: with sex as a confounding variable the most significant risk factor was the buckling ratio (ratio of bone radius to cortical thickness) with more than twofold greater risk in the top compared to the lowest tertile. This variable was mostly independent of muscle area which was however a significant protective factor independent of bone variables. Bone/muscle area ratio and BSI were not significant in multivariate analysis. The area under the ROC curve, using these QCT predictors and age, was 0.70 (CI 0.66–0.73).

We conclude that cortical instability associated with decreasing cortical thickness due to medullary expansion is a significant risk factor for limb fractures including hip fractures in old age. Further knowledge on factors affecting buckling ratio might be of importance in the prevention of these fractures in the elderly.

Introduction: Increasing costs for health care has forced its providers to economize with current resources. This paper reports on cost analysis from a randomized study where the study group (SG) was subjected to pre-operative education and postoperative home-based rehabilitation after total hip replacement (THR). The comparison group (CG ) comprised patients treated according to routine pathway at the time.

Methods: Between 1997 and 2000 a total of 50 patients were operated on in two hospitals, 29 at the Landspíta-linn University Hospital in Reykjavík and 21 in a nearby rural hospital. They were randomized into a study group (SG) of 27 patients and control group of 23. All contacts with the health care during a six month period after the operations were registered. The effectiveness of the treatments was measured with the Oxford Hip Score (OHS).

Results: The average hospital costs totalled $5,848 in the SG and $7,291 in the CG. Total health care costs was $6,402 on average in the SG and $9,248 in the CG. By including average patient related costs the total rose to $9,570 in the SG and $13,377 in the CG (all costs in 1999 USD). The difference was statistically significant (p=0.0001) for the total costs. The group variable was statistically significant – regression analysis adjusted for age gender etc., not excluding significant factors according to the Ramsey RESET test. The recovery according to the OHS was from 33.1 preoperatively down to 14.2 after six months follow up for the study group. For the CG it was 36.6 and 20.5 respectively. Thus the cost difference (ΔC) was $3,807 and an effectiveness difference (ΔE) of 6.3. No significant difference was found in cost between hospitals, although indications favoured the rural hospital

Conclusions: Our method of shortening hospital stay and transferring parts of the postoperative treatment to the patient’s homes appears to be an effective way of reducing the unit price of THR in Iceland.

In a prospective, consecutive study 93 patients who had had previous lumbar spinal surgery underwent repeat decompression for persistent or recurrent back and leg pain. The previous operations had been discectomies in 65 patients and decompression for spinal stenosis in 28; two of the latter group had also had posterolateral fusion. At the repeat operation, disc herniation was found in 19 patients, lateral spinal stenosis in 19, central spinal stenosis in 20 and periradicular fibrosis in 35. Ninety-one patients were followed up for two years after surgery; the effect of the operation was recorded using a four-scale grading system. The results were significantly related to the diagnosis. Nerve-root compression due to recurrent disc herniation or to bony compression responded well to repeat decompression. In patients with a single nerve-root compression the results were similar to those obtained in primary operations. Sciatica due to nerve-root scarring was seldom improved by the repeat operation.

In a prospective, consecutive study we determined the frequency of common symptoms and signs in 300 patients with lumbar nerve-root compression syndromes. We compared 100 patients with disc herniation (mean age 43 years), 100 with lataral spinal stenosis (41 years) and 100 with central spinal stenosis (65 years), using a standard protocol of common signs and symptoms. The diagnoses were established by one or more of myelography, CT, MRI and nerve-root block, and all were confirmed at operation. The preoperative duration of symptoms was significantly shorter in patients with disc herniation. Pain at rest, at night, and on coughing was as common in lateral stenosis as in disc herniation, but regular consumption of analgesics was more common in patients with disc herniation. Positive straight-leg-raising tests were more common in disc herniation than in lateral stenosis and were uncommon in central stenosis. Motor disturbances were seen most often in central spinal stenosis, especially patellar reflex changes. Sensory disturbances were most common in patients with complete disc herniation.

We have investigated the level of physical activity of 49 women between the ages of 15 and 45 years who sustained a fracture of the neck of the femur at between 60 and 70 years of age, and compared this with the level of activity reported by 49 control subjects without fracture, who were matched for age and social status. We found that the patients had been significantly less physically active than the controls, especially as regards household duties and professional working conditions.