Peter R. G. Brink

Risk of new clinical fractures within 2 years following a fracture

Introduction:Clinical fractures are associated with an increased relative risk of future fractures, but the absolute risk and timing of new clinical fractures immediately after a clinical fracture have not been reported extensively. The study objective was to determine the absolute risk of subsequent clinical fractures within 2xa0years after a clinical fracture. Methods:We analyzed clinical fracture data from a university hospital recruiting all fractures in the area between January 1999 and December 2001. Subjects were 2,419 male and female patients aged 50xa0years and older, with a total of 2,575 fractures. There were 139 patients with more than one simultaneous fracture. Mean age was 66xa0years for males and 72 for females. Results:The cumulative incidence of patients with new clinical fractures over 2xa0years was 10.8% (262/2,419). In the 262 patients with subsequent fractures, we observed a higher mean age, more females and more often multiple baseline fractures compared with the 2,157 patients without subsequent fractures. Kaplan-Meier analysis indicated that age, gender and having multiple baseline fractures contributed significantly to cumulative new fracture incidence. Cox regression showed that these variables independently contributed to a higher subsequent fracture incidence. New fracture incidence was higher with increasing age ( p <0.001; hazard ratio [HR] 1.2 per decade; confidence interval [CI] 1.1–1.3). Females had a new fracture incidence of 12.2% compared with 7.4% in males ( p =0.015; HR 1.5; CI 1.1–2.0). Patients with multiple baseline fractures had a new fracture incidence of 17.3% compared with 10.4% for subjects with one baseline fracture ( p =0.006; HR 1.8; CI 1.2–2.7). Of all clinical fractures occurring within 2xa0years after a clinical fracture, 60% occurred during the first year and 40% during the second year ( p =0.005). The absolute risk to develop an incident clinical fracture within 2xa0years after any clinical fracture was 10.8%. Increased age, female gender and the presence of multiple simultaneous fractures at baseline each independently increased the risk of incident fracture. Significantly more fractures occurred in the first year following the index fracture than in the second year. Conclusion: Altogether, these data support the need for early prevention of future fracture among individuals with a fracture after age 50, using interventions which have been shown to have a rapid anti-fracture benefit.

Bone and Fall-Related Fracture Risks in Women and Men with a Recent Clinical Fracture

BACKGROUNDnWorldwide fracture rates are increasing as a result of the aging population, and prevention, both primary and secondary, is an important public health goal. Therefore, we systematically analyzed risk factors in subjects with a recent clinical fracture.nnnMETHODSnAll men and women over fifty years of age who had been treated in the emergency department of, or hospitalized at, our institution because of a recent fracture during a one-year period were offered the opportunity to undergo an evidence-based bone and fall-related risk-factor assessment and bone densitometry. The women included in this study were also compared with a group of postmenopausal women without a fracture history who had been included in another cohort study.nnnRESULTSnOf the 940 consecutive patients, 797 (85%) were eligible for this study and 568 (60%) agreed to participate. The prevalence of fall-related risk factors (75% [95% confidence interval = 71% to 78%]; n = 425) and the prevalence of bone-related risk factors (53% [95% confidence interval = 49% to 57%]; n = 299) at the time of fracture were higher than the prevalence of osteoporosis (35% [95% confidence interval = 31% to 39%]; n = 201) as defined by a dual x-ray absorptiometry T score of <or=-2.5 in the spine and/or hip. The fall and bone-related risk factors were present irrespective of the fracture location, patient age, or gender. An overlap between bone and fall-related risk factors was found in 50% of the patients. After adjusting for age, weight, and height, we found that women with a fracture more frequently had a diagnosis of osteoporosis (odds ratio = 2.9; 95% confidence interval = 2.0 to 4.1) and had a more extensive history of falls (odds ratio = 4.0; 95% confidence interval = 2.7 to 5.9) than did the postmenopausal women without a fracture history.nnnCONCLUSIONSnMen and women over fifty years of age who had recently sustained a clinical fracture had, at the time of that fracture, bone and fall-related risk factors that were greater than the risk predicted by the presence of osteoporosis. Risk factors were overlapping, heterogeneous, and found in multiple combinations. This was the case regardless of the patients age, fracture location, or gender. These findings suggest that an integrated bone and fall-related risk-factor assessment is a preferable means for identifying elderly subjects at risk for fracture. Integrated bone and fall-related risk assessment and treatment studies are needed to document this proposal.

Fracture Liaison Service: Impact on Subsequent Nonvertebral Fracture Incidence and Mortality

BACKGROUNDnA fracture liaison service model of care is widely recommended and applied, but data on its effectiveness are scarce. Therefore, the risk of subsequent nonvertebral fractures and mortality within two years after a nonvertebral fracture was analyzed in patients who presented to a hospital with a fracture liaison service and a hospital without a fracture liaison service.nnnMETHODSnIn 2005 to 2006, all consecutive patients with an age of fifty years or older presenting with a nonvertebral fracture were included. In the group that presented to a hospital without a fracture liaison service (the no-FLS group), only standard fracture care procedures were followed to address proper fracture-healing. In the group that presented to a hospital with a fracture liaison service (the FLS group), dual x-ray absorptiometry scans and laboratory testing were performed, and if applicable, patients were treated according to the Dutch guideline for osteoporosis. The risk for subsequent nonvertebral fracture and mortality were analyzed using multivariable Cox regression models with adjustments for age, sex, and baseline fracture location.nnnRESULTSnIn total, 1412 patients presented to the fracture liaison service (73.2% were women, and the mean age was 71.1 years), and 1910 underwent standard fracture care (69.8% were women, and the mean age was 69.5 years). After adjustment for age, sex, and baseline fracture location, patients who attended the fracture liaison service had a significantly lower mortality risk (hazard ratio: 0.65; 95% confidence interval [CI]: 0.53 to 0.79) over two years of follow-up. The subsequent nonvertebral fracture risk was also significantly lower in the patients in the FLS group, but this effect was time-dependent, with a hazard ratio of 0.84 (95% CI: 0.64 to 1.10) at twelve months and 0.44 (95% CI: 0.25 to 0.79) at twenty-four months.nnnCONCLUSIONSnPatients seen at the fracture liaison service had a significantly lower mortality and subsequently a lower risk of nonvertebral fracture than those not seen at the fracture liaison service, with a reduction of 35% and 56%, respectively, over two years of follow-up. A fracture liaison service appears to be a successful approach to reduce the number of subsequent fractures and premature mortality in this cohort of patients.

Risk of subsequent fracture and mortality within 5 years after a non-vertebral fracture.

SummaryThe absolute 5-year risk of subsequent non-vertebral fractures (NVFs) in 1,921 patients presenting with a NVF was 17.6% and of mortality was 32.3%. These risks were highest within the first year, indicating the need to study which reversible factors can be targeted to immediately minimise subsequent fracture risk and mortality.IntroductionNVFs are the most frequent clinical fractures in patients presenting at the emergency unit because of a clinical fracture. The aim of the study was to determine the 5-year absolute risk (AR) of subsequent NVF and mortality in patients at the time they present with a NVF.MethodsBetween 1999 and 2001, 1,921 consecutive patients 50+u2009years from a level 1 trauma centre were included. All NVFs were confirmed on radiograph reports, and mortality was checked in the national obituary database. Available potential risk factors for a subsequent NVF and mortality (age, sex and baseline fracture location: major—hip, pelvis, multiple ribs, proximal tibia/humerus and distal femur; minor—all others) were expressed as hazard ratios (HR) with 95% confidence intervals (CI) using multivariable Cox regression analysis.ResultsThe AR for a subsequent NVF was 17.6% and was related to age (HR per decade, 1.44; 95%CI, 1.29–1.60). The AR for mortality was 32.3% and was related to age (HR per decade, 2.59; 95%CI, 2.37–2.84), male sex (HR, 1.74; 95%CI, 1.44–2.10), major fracture at baseline (HR, 5.56; 95%CI, 3.48–8.88; not constant over time) and subsequent fracture (HR, 1.65; 95%CI, 1.33–2.05). The highest risks were found within the first year (NVFs, 6.4%; mortality, 12.2%) and were related to age and, in addition, to baseline fracture location for mortality.ConclusionsWithin 5xa0years after an initial NVF, nearly one in five patients sustained a subsequent NVF and one in three died. One third of subsequent NVFs and mortality occurred within 1xa0year, indicating the need to study which reversible factors can be targeted to immediately prevent subsequent fractures and mortality.

The Relationship Between the Outcome of Operatively Treated Calcaneal Fractures and Institutional Fracture Load: A Systematic Review of the Literature

BACKGROUNDnIt has been assumed that outcome after open reduction and internal fixation of displaced intra-articular calcaneal fractures may be affected by the presence of institutional trauma care and the institutions fracture volume. The purpose of this systematic review was to investigate whether a relationship exists between institutional fracture load and the rates of serious infection and subtalar arthrodesis following the treatment of these fractures.nnnMETHODSnWith use of a systematic method, all studies published between 2000 and 2006 describing adult patients undergoing open reduction and internal fixation of a displaced intra-articular fracture of the calcaneus were included. Patients with open fractures and patients undergoing percutaneous procedures were excluded. Institutional fracture load was calculated by dividing the number of calcaneal fractures that were treated operatively by the number of months that were included in the reported studies. A serious deep infection was defined as an infection requiring surgical débridement and hardware removal, reconstruction with a flap, and/or the presence of osteomyelitis. Traumatic subtalar arthritis was considered to be severe when subtalar arthrodesis was required. Numerous confounding factors were also analyzed, and a systematic methodological quality assessment was performed.nnnRESULTSnOf a total of 236 studies, twenty-one were included in the analysis. The total number of fractures included was 1656. The median institutional fracture load was 0.8 fracture per month (95% confidence interval, 0.2 to 4.6 fractures per month). The median infection rate in the studies combined was 5.1% (95% confidence interval, 0.0% to 19.9%). The infection rate increased exponentially with a decreasing fracture load (r(2) = -0.5; p = 0.03). The median rate of subtalar arthrodesis was 2.5% (95% confidence interval, 0.0% to 15.4%). A significant inverse correlation was present between the fracture volume and the subtalar arthrodesis rate (r(2) = -0.7; p = 0.008). These factors were unrelated to the methodological quality. Multivariate analysis identified fracture volume as an independent determinant of the infection rate.nnnCONCLUSIONSnA significant relationship between the deep infection rate, traumatic subtalar arthritis, and the fracture load may indicate a need for specialized institutional trauma care to improve outcomes associated with the operative treatment of calcaneal fractures.

The effects of low-intensity pulsed ultrasound and pulsed electromagnetic fields bone growth stimulation in acute fractures: a systematic review and meta-analysis of randomized controlled trials.

IntroductionThe aim of this systematic review and meta-analysis was to evaluate the best currently available evidence from randomized controlled trials comparing pulsed electromagnetic fields (PEMF) or low-intensity pulsed ultrasound (LIPUS) bone growth stimulation with placebo for acute fractures.Materials and methodsWe performed a systematic literature search of the medical literature from 1980 to 2013 for randomized clinical trials concerning acute fractures in adults treated with PEMF or LIPUS. Two reviewers independently determined the strength of the included studies by assessing the risk of bias according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.ResultsSeven hundred and thirty-seven patients from 13 trials were included. Pooled results from 13 trials reporting proportion of nonunion showed no significant difference between PEMF or LIPUS and control. With regard to time to radiological union, we found heterogeneous results that significantly favoured PEMF or LIPUS bone growth stimulation only in non-operatively treated fractures or fractures of the upper limb. Furthermore, we found significant results that suggest that the use of PEMF or LIPUS in acute diaphyseal fractures may accelerate the time to clinical union.ConclusionsCurrent evidence from randomized trials is insufficient to conclude a benefit of PEMF or LIPUS bone growth stimulation in reducing the incidence of nonunions when used for treatment in acute fractures. However, our systematic review and meta-analysis suggest that PEMF or LIPUS can be beneficial in the treatment of acute fractures regarding time to radiological and clinical union. PEMF and LIPUS significantly shorten time to radiological union for acute fractures undergoing non-operative treatment and acute fractures of the upper limb. Furthermore, PEMF or LIPUS bone growth stimulation accelerates the time to clinical union for acute diaphyseal fractures.

Risk of falling in patients with a recent fracture

BackgroundPatients with a history of a fracture have an increased risk for future fractures, even in short term. The aim of this study was to assess the number of patients with falls and to identify fall risk factors that predict the risk of falling in the first three months after a clinical fracture.MethodsProspective observational study with 3 months of follow-up in a large European academic and regional hospital. In 277 consenting women and men aged ≥ 50 years and with no dementia and not receiving treatment for osteoporosis who presented to hospital with a clinical fracture, fall risk factors were assessed according to the guidelines on fall prevention in the Netherlands. Follow-up information on falls and fractures was collected by monthly telephone interview. Incidence of falls and odds ratios (OR, with 95% confidence intervals) were calculated.Results512 consecutive patients with a fracture were regarded for analysis, 87 were not eligible for inclusion and 137 patients were excluded. No follow-up data were available for 11 patients. Therefore full analysis was possible in 277 patients.A new fall incident was reported by 42 patients (15%), of whom five had a fracture. Of the 42 fallers, 32 had one new fall and 10 had two or more.Multivariate analysis in the total group with sex, age, ADL difficulties, urine incontinence and polypharmacy showed that sex and ADL were significant fall risk factors. Women had an OR of 3.02 (95% CI 1.13–8.06) and patients with ADL-difficulties had an OR of 2.50 (95% CI 1.27–4.93).Multivariate analysis in the female group with age, ADL difficulties, polypharmacy and presence of orthostatic hypotension indicated that polypharmacy was the predominant risk factor (OR 2.51; 95% CI: 1.19 – 5.28). The incidence of falls was 35% in women with low ADL score and polypharmacy compared to 15% in women without these risk factors (OR 3.56: CI 1.47 – 8.67).Conclusion15% of patients reported a new fall and 5 patients suffered a new fracture within 3 months. Female sex and low ADL score were the major risk factors and, in addition, polypharmacy in women.

The effect of taping versus semi-rigid bracing on patient outcome and satisfaction in ankle sprains: a prospective, randomized controlled trial

BackgroundFunctional treatment is a widely used and generally accepted treatment for ankle sprain. A meta-analysis comparing the different functional treatment options could not make definitive conclusions regarding the effectiveness, and until now, little was known about patient satisfaction in relation to the outcome.MethodsPatients with acute ankle sprain received rest, ice, compression and elevation with an compressive bandage at the emergency department. After 5-7u2009days, 100 patients with grade II and III sprains were randomized into two groups: one group was treated with tape and the other with a semi-rigid ankle brace, both for 4u2009weeks. Post-injury physical and proprioceptive training was standardized. As primary outcome parameter patient satisfaction and skin complications were evaluated using a predefined questionnaire and numeric rating scale. As secondary outcome parameter the ankle joint function was assessed using the Karlsson scoring scale and range of motion.ResultsPatient-reported comfort and satisfaction during treatment with a semi-rigid brace was significantly increased. The rate of skin complication in this group was significantly lower compared to the tape group (14.6% versus 59.1%, Pu2009<u20090.0001). Functional outcome of the ankle joint was similar between the two treatment groups, as well as reported pain.ConclusionTreatment of acute ankle sprain with semi-rigid brace leads to significantly higher patient comfort and satisfaction, both with similar good outcome.

Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands

SummaryImplementation of case findings according to guidelines for osteoporosis in fracture patients presenting at a Fracture Liaison Service (FLS) was evaluated. Despite one guideline, all FLSs differed in the performance of patient selection and prevalence of clinical risk factors (CRFs) indicating the need for more concrete and standardised guidelines.IntroductionThe aim of the study was to evaluate the implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at FLSs in the Netherlands.MethodsFive FLSs were contacted to participate in this prospective study. Patients older than 50xa0years with a recent clinical fracture who were able and were willing to participate in fracture risk evaluation were included. Performance was evaluated by criteria for patient recruitment, patient characteristics, nurse time, evaluated clinical risk factors (CRFs), bone mineral density (BMD) and laboratory testing and results of CRFs and BMD are presented. Differences between FLSs were analysed for performance (by chi-square and Student’s t test) and for prevalence of CRFs (by relative risks (RR)).ResultsAll FLSs had a dedicated nurse spending 0.9 to 1.7xa0h per patient. During 39 to 58xa0months follow-up, 7,199 patients were evaluated (15 to 47 patients/centre/month; mean age, 67xa0years; 77% women). Major differences were found between FLSs in the performance of patient recruitment, evaluation of CRFs, BMD and laboratory testing, varying between 0% and 100%. The prevalence of CRFs and osteoporosis varied significantly between FLSs (RR between 1.7 and 37.0, depending on the risk factor).ConclusionAll five participating FLSs with a dedicated fracture nurse differed in the performance of patient selection, CRFs and in the prevalence of CRFs, indicating the need for more concrete and standardised guidelines to organise evaluation of patients at the time of fracture in daily practice.

Tension band wiring of the olecranon: is it really a dynamic principle of osteosynthesis?

The tension band principle as applied to transverse olecranon fractures fixed by tension band wiring is based on the premise that distraction forces on the outer cortex of the ulna during elbow flexion are converted to compression forces on the articular surface of the olecranon at the fracture site. In view of some clinical outcomes, where hardware failure and secondary dislocations occur, the question arises if the dynamic compression theory is correct. Compressive forces during active flexion and extension after tension band wiring of a transverse osteotomy of the olecranon were measured in 6 fresh frozen human cadaveric models using a pressure-sensor in the osteotomy gap. We could collect 30 measurements during active flexion and 30 during active extension. Active flexion did not cause any compressive forces in the osteotomy gap. Extension with the humerus in an upright position and the elbow actively extended causes some compression (0.37-0.51 MPa) at the articular surface comparing with active flexion (0.2 MPa) due to gravity forces. Posterior, there was no significant pressure difference observed (0.41-0.45 versus 0.36-0.32 MPa) between active flexion and extension. The tension band wiring principle only exists during active extension in a range of 30-120° of flexion of the elbow. Postoperative exercise programs should be modified in order to prevent loss of compression at the fracture site of transverse olecranon fractures, treated with tension band wiring when the elbow is mobilised.