Jes Bruun Lauritzen

Effect of external hip protectors on hip fractures

Most hip fractures seem to be related to trauma near the hip, so a controlled trial was conducted to investigate the effect of external hip protectors on the prevention of such fractures in residents of a nursing home. 10 of the 28 wards in the nursing home were randomised to receive external hip protectors; thus 167 women and 80 men were given protectors and 277 and 141 men no protectors. A fall register was set up for 2 treatment wards (45 residents) and 2 control wards (76 residents). There were 8 hip and 15 non-hip fractures in the hip-protector group and 31 hip and 27 non-hip fractures in the control group. The relative risk of hip fractures among women and men in the intervention group was 0.44 (95% CI 0.21-0.94). None of the 8 residents in the intervention group who had a hip fracture was wearing the device at the time of the fracture. 154 falls were registered and 20% of these falls produced a direct impact to the hip. In 25 falls direct impact to the hip was sustained at a time when hip protectors were not being worn, and 6 fractures were produced. The study indicates that external hip protectors can prevent hip fractures in nursing-home residents.

Hip fractures: incidence, risk factors, energy absorption, and prevention

The present review summarizes the pathogenic mechanisms leading to hip fracture based on epidemiological, experimental, and controlled clinical studies. The estimated lifetime risk of hip fracture is about 14% in postmenopausal women and 6% in men. The incidence of hip fractures increases exponentially with aging, but the time trend in increasing age-specific incidence may finally reach a plateau. Postmenopausal women suffering earlier non-hip fractures have an increased risk of later hip fracture. The relative risk is highest within the first years following the fracture. Nursing home residents have a high risk of hip fracture (annual rate of 5-6%), and their incidence of falls is about 1.5 falls/person per year. Most hip fractures are a result of a direct trauma against the hip. The incidence of falls on the hip among nursing home residents is about 0.29 falls/person per year and about 20% of these traumas lead to hip fracture. Women with hip fractures have a lower body weight compared with controls, and they may also have less soft tissue covering the hip, even when adjusted for body mass index, indicating a more android body habitus. Experimental studies show that the passive energy absorption in soft tissue covering the hip may influence the risk of hip fracture and be an important determinant for the development of hip fracture, perhaps even more important than bone strength. External hip protectors were developed and tested in an open randomized nursing home study. The rate of hip fracture was reduced by 50%, corresponding to 9 of 247 residents saved from sustaining a hip fracture. This review points to the essentials in the development of hip fracture: risk of fall; type of fall; type of impact; energy absorption; and last, bone strength, which is the final permissive factor leading to hip fracture. Risk estimation and prevention of hip fracture may prove realistic when these issues are taken into consideration.

A Comprehensive Hip Fracture Program Reduces Complication Rates and Mortality

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1‐year mortality before and after introduction of a comprehensive multidisciplinary fast‐track treatment and care program for hip fracture patients (the optimized program).

Serum osteoprotegerin (OPG) and the A163G polymorphism in the OPG promoter region are related to peripheral measures of bone mass and fracture odds ratios.

The purpose of this study is to investigate the association of serum osteoprotegerin (OPG) and the A163G polymorphism in the OPG promoter with peripheral measures of bone mass and with odds ratios for wrist and hip fracture in a case-control study of postmenopausal Danish women. The study included 66 women with lower forearm fracture, 41 women with hip fracture, and 206 age-matched controls. All had broadband ultrasound attenuation (BUA) and speed of sound (SOS) measured at the heel as well as bone mineral density (BMD) measured by DXA at the distal forearm. S-OPG was measured by ELISA. The A163G genotypes were determined by PCR-RFLP analysis. S-OPG levels correlated positively with age (r = 0.45; P ≪ 0.0001) and negatively with distal forearm BMD (r = −0.31; P ≪ 0.0001), heel BUA (r = −0.23; P ≪ 0.0001), and heel SOS (r = −0.22; P ≪ 0.0001). Comparing the highest quartile of S-OPG to the lowest, the odds ratio for osteoporotic fracture was 2.5 (95% CI, 1.3–4.7; P = 0.006). The G allele of the A163G was associated with significantly lower t-scores of both lower forearm BMD, heel BUA, and heel SOS as well as being significantly more frequent in the fracture patients compared to the controls. Patients with a combination of the highest quartile of S-OPG and presence of the G allele (n = 23) had a significantly elevated fracture odds ratio, 4.0 (95% CI, 1.7–9.9). A significant negative association between S-OPG with peripheral measures of bone mass and with increased fracture odds ratios was found. Furthermore, the A163G mutation in the OPG promoter had a significant influence on bone mass and fracture status independently of S-OPG level.

Femoral fractures in postmenopausal breast cancer patients treated with adjuvant tamoxifen.

SummaryThe anti-estrogen tamoxifen is the prevalent endocrine treatment in postmenopausal breast cancer patients. However, nothing is known about the long-term effects of the drug on the skeleton as assessed by the occurrence of fractures.We investigated the occurrence of fractures of the femur in patients from a Danish Breast Cancer Cooperative Group (DBCG) trial initiated in 1977 by a linkage of data from the Danish National Registry of Patients with data from the DBCG registry. 1716 postmenopausal women with high-risk breast cancer were randomized to local radiotherapy with or without tamoxifen, 30 mg daily for 1 year.Fifty-one patients in the control group had one femoral fracture and 64 tamoxifen treated patients had one femoral fracture. Eleven patients in the control group had one trochanteric fracture compared to 27 patients in the tamoxifen group (logrank = 5.28, P = 0.022; hazard ratio = 2.12, 95% CL 1.12, 4.01).The results could not be explained by a longer survival in the tamoxifen group nor by bone metastases with pathological fractures.In conclusion, our study suggests that tamoxifen does not seem to offer protection against fractures in old age and may even increase the risk of fractures at particular sites. This hypothesis needs to be disproved or confirmed in other trials.

Changes in bone mineral density of the distal femur following uncemented total knee arthroplasty

The aim of the study was to quantitate changes in bone mineral density (BMD) in the distal femur following uncemented porous-coated total knee arthroplasty. Eight patients with total knee arthroplasties (PCA Primary, Howmedica, Rutherford, NJ) (female:male ratio, 6:2; mean age, 70 years; range, 51-77 years) were scanned by dual-photon absorptiometry within 3 months after surgery and at 2 years. An average decrease of 36% (P = .01) was found in BMD behind the anterior flange of the femoral prosthesis. Proximal to the fixation pegs, BMD increased by 22% (P = .12), but behind the posterior flange of the femoral component, BMD remained unchanged (P = .53). Stress shielding anteriorly in the distal femur occurred in all patients examined 2 years after surgery, and the increase in BMD proximal to the fixation pegs was probably a result of increased and altered mechanical loading.

Risk of hip fracture after osteoporosis fractures: 451 women with fracture of lumbar spine, olecranon, knee or ankle

In a follow-up study during 1976-1984, the risk of a subsequent hip fracture was investigated in women aged 60-99 years, hospitalized for the following fractures: lumbar spine (n 70), olecranon (n 52), knee (n 129) and ankle (n 200). Follow-up ranged from 0 to 9 years. Observation time of the 4 different fractures were 241, 180, 469, and 779, person-years, respectively. In women aged 60-79 years with one of the following fractures the relative risk of a subsequent hip fracture was increased by 4.8 (lumbar spine), 4.1 (olecranon), 3.5 (knee) and 1.5 (ankle). The relative risk of hip fracture showed a tendency to level off 3 years after the primary fracture.

Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays?: A retrospective study of 38,020 patients

Background and purpose Hip fractures are associated with high mortality, but the cause of this is still not entirely clear. We investigated the effect of surgical delay, weekends, holidays, and time of day admission on mortality in hip fracture patients. Patients and methods Using data from the Danish National Indicator Project, we identified 38,020 patients admitted from 2003 to 2010. Logistic regression analysis was used to study the association between sex, age, weekend or holiday admission, night-time admission, time to surgery, and ASA score on the one hand and mortality on the other. Results The risk of death in hospital increased with surgical delay (odds ratio (OR) = 1.3 per 24 h of delay), ASA score (OR (per point added) = 2.3), sex (OR for men 2.2), and age (OR (per 5 years) = 1.4). The mortality rate for patients admitted during weekends or public holidays, or at night, was similar to that found for those admitted during working days. Interpretation Minimizing surgical delay is the most important factor in reducing mortality in hip fracture patients.

Association of a Common Allelic Polymorphism (C677T) in the Methylene Tetrahydrofolate Reductase Gene with a Reduced Risk of Osteoporotic Fractures. A Case Control Study in Danish Postmenopausal Women

Twin studies indicate a substantial genetic component in the development of osteoporosis. One of the latest studied candidate genes is the one coding for methylene tetrahydrofolate reductase (MTHFR) (C677T) in which a point mutation gives rise to a thermolabile variant of MTHFR. The aim of this study was to investigate the influence of this mutation on peripheral measures of bone density and on the odds ratios (OR) for hip and lower forearm fracture in a case control study of Danish postmenopausal women. A total of 74 women with lower forearm fracture, 41 women with hip fracture, and 207 age-matched controls were included. All had broadband ultrasound attenuation (BUA) and speed of sound (SOS) measured at the heel as well as bone mineral density (BMD) measured by dual X-ray absorptiometry at the distal forearm. The MTHFR (C677T) genotypes were determined using polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP). Only 2 of 21 individuals with the TT genotype had sustained a fracture as opposed to 46 of 142 with the CT genotype and 67 of 159 with the CC genotype (P = 0.007). Using logistic regression, the following odds ratios were found when comparing the individuals homozygotic for the C-allele with those homozygotic for the T-allele: lower forearm fracture OR = 3.93 (1.25; 12.40, P = 0.02), hip fracture OR = 6.99 (l.35; 36.92, P = 0.02) and the fractures combined OR = 4.33 (1.73; 10.81, P = 0.002). In this study, the MTHFR (C677T) genotypes were not significantly associated with BMD at the lower forearm or with ultrasound parameters measured at the calcaneus. However, a significant increase in the odds ratio of fracture was found for the wild-type C-allele.

Changes in bone mineral density of the proximal tibia after uncemented total knee arthroplasty A 3-year follow-up of 25 knees

We measured bone remodeling of the proximal tibia prospectively for 3 years after uncemented total knee arthroplasty (TKA) in 25 knees with primary arthrosis. In the trabecular bone below the tibial component, bone mineral density (BMD) was measured in 6 different regions of interest (ROI), using dual photon absorptiometry (DPA). In the tibial condyles, where the change in knee alignment indicated that the load was reduced postoperatively, a fast bone loss of 7-20% was seen during the first 6 months after surgery. A small, but significant increase in BMD of 2-7% was seen in the tibial condyles, where the load was increased. On average, the density for all ROI below the tibial component showed a significant and progressive decrease in BMD, reaching 22% at 3 years follow-up.