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Summary A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX. Introduction The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD). Methods We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β -coefficients. Results A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72–2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69–2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63–2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62–2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination. Conclusion A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.

In a trial in patients with pelvic or acetabular fractures or extremity fractures that were treated operatively, aspirin thromboprophylaxis was noninferior to low-molecular-weight heparin in preventing death at 90 days.

Summary The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm. Introduction Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD). Methods The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients. Results Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33–1.51) and men (HR 1.53, 95% CI 1.41–1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27–1.84) in men vs. HR 1.32 (95% CI 1.20–1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men. Conclusions A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction.

SummaryTreatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively.IntroductionTreatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC).MethodsThis is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality.ResultsPatients in the OGC (OR 2.62; CI 95% 1.40–4.91) but not those in the GCS (OR 0.74; CI 95% 0.38–1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (β, − 1.08; SE, 0.54, p = 0.045) but not the GCS (β, − 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10–0.96) but not those in the GCS (OR 0.37; CI 95% 0.10–1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders.ConclusionsOlder adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.

Disturbance of the sleep–wake cycle is a characteristic of delirium. In addition, changes in melatonin rhythm influence the circadian rhythm and are associated with delirium. We compared the effect of melatonin and placebo on the incidence and duration of delirium. We performed this multicentre, double-blind, randomized controlled trial between November 2008 and May 2012 in 1 academic and 2 nonacademic hospitals. Patients aged 65 years or older who were scheduled for acute hip surgery were eligible for inclusion. Patients received melatonin 3 mg or placebo in the evening for 5 consecutive days, starting within 24 hours after admission. The primary outcome was incidence of delirium within 8 days of admission. We also monitored the duration of delirium. A total of 452 patients were randomly assigned to the 2 study groups. We subsequently excluded 74 patients for whom the primary end point could not be measured or who had delirium before the second day of the study. After these postrandomization exclusions, data for 378 patients were included in the main analysis. The overall mean age was 84 years, 238 (63.0%) of the patients lived at home before admission, and 210 (55.6%) had cognitive impairment. We observed no effect of melatonin on the incidence of delirium: 55/186 (29.6%) in the melatonin group v. 49/192 (25.5%) in the placebo group; difference 4.1 (95% confidence interval −0.05 to 13.1) percentage points. There were no between-group differences in mortality or in cognitive or functional outcomes at 3-month follow-up. In this older population with hip fracture, treatment with melatonin did not reduce the incidence of delirium. Trial registration: Netherlands Trial Registry, NTR1576: MAPLE (Melatonin Against PLacebo in Elderly patients) study; www.trialregister.nl/trialreg/admin/rctview.asp?TC=1576

Background The poor outcome after a hip fracture is not fully understood. The aim of the study was to describe the prevalence of co-morbidities, complications and causes of death and to investigate factors that are able to predict mortality in old people with femoral neck fracture. Methods Data was obtained from a randomized, controlled trial with a 3-year follow-up at Umeå University Hospital, Sweden, which included 199 consecutive patients with femoral neck fracture, aged ≥70 years. The participants were assessed during hospitalization and in their homes 4, 12 and 36 months after surgery. Medical records and death certificates were analysed. Results Multivariate analysis revealed that cancer, dependence in P-ADL (Personal Activities of Daily Living), cardiovascular disease, dementia at baseline or pulmonary emboli or cardiac failure during hospitalization were all independent predictors of 3-year mortality. Seventy-nine out of 199 participants (40 %) died within 3 years. Cardiovascular events (24 %), dementia (23 %), hip-fracture (19 %) and cancer (13 %) were the most common primary causes of death. In total, 136 participants suffered at least one urinary tract infection; 114 suffered 542 falls and 37 sustained 56 new fractures, including 13 hip fractures, during follow-up. Conclusion Old people with femoral neck fracture have multiple co-morbidities and suffer numerous complications. Thus randomized intervention studies should focus on prevention of complications that might be avoidable such as infections, heart diseases, falls and fractures.

Hip fracture surgery in elderly patients is associated with a poor postoperative outcome and a high mortality. Malnutrition is a frequent problem in elderly patients and may be associated with mortality after hip fracture surgery. The Mini Nutritional Assessment (MNA) is a valuable tool to identify malnourished patients and those at risk for malnutrition. To evaluate the association between the preoperative MNA score and mortality after surgery for hip fractures in elderly patients. Patients with a hip fracture and an indication for surgery were included in our study. This study was part of a randomized trial on the effect of taurine on postoperative outcome in elderly hip fracture patients. The MNA was assessed on admission before surgery. Length of stay, postoperative complications and mortality were documented. The association of the MNA score on postoperative outcome and mortality was analyzed using Cox regression analysis. The one-year survival rate in 226 elderly hip fracture patients was 79%. In-hospital mortality rates and 1-year mortality were 27% and 46% in malnourished patients, 12% and 26% in patients at risk for malnutrition and 7% and 17% in well-nourished patients as assessed by MNA. Preoperative malnutrition measured by the MNA is associated with mortality in elderly hip fracture patients.

Hip fractures frequently cause severe pain and functional decline in adults presenting to emergency departments (EDs). Although intravenous (IV) opioids are widely used for pain control, their use may be limited by adverse effects, especially in patients with comorbidities or cognitive impairment. Ultrasound-guided femoral nerve block (FNB) offers a regional analgesic technique that may provide effective pain relief while reducing opioid-related complications. However, comparative randomized trials in the ED setting remain limited. In this single-center, randomized, double-blind clinical trial, adult patients with radiologically confirmed hip fractures were assigned to receive either ultrasound-guided FNB (20 mL 0.5 % bupivacaine) or IV fentanyl (1 μg/kg). To preserve blinding, patients in each group received a placebo injection mimicking the alternative treatment. Pain severity was measured at baseline and 20 min post-intervention using the Numeric Pain Rating Scale or the Pain Assessment in Advanced Dementia Scale (PAINAD), based on cognitive status. The primary outcome was change in pain score at 20 min. Secondary outcomes included rescue analgesia requirement within four hours and adverse events. A total of 104 patients were enrolled and randomized. The FNB group experienced greater median pain reduction compared to the fentanyl group (4 [IQR 3–5] vs. 2 [IQR 2–3]; median difference: 2, 95 % CI: 1–2). Rescue analgesia was required in 21.1 % of FNB patients versus 61.5 % in the fentanyl group. Adverse events were observed only in the fentanyl group, including nausea (23 %), dizziness (15 %), headache (9.6 %), and hypotension (5.7 %). No FNB-related complications were reported. Subgroup analysis showed consistent efficacy among cognitively impaired patients. FNB resulted in superior analgesia, fewer side effects, and lower need for rescue opioids compared to IV fentanyl. Additionally, FNB has shown an effective and safe pain control in patients with cognitive impairment compared to patients without cognitive impairment. Trial registration:ClinicalTrials.gov Identifier: NCT06862154. •Femoral nerve block (FNB) reduced pain more than IV fentanyl in ED patients with hip fractures.•Rescue opioid use was significantly lower in the FNB group (21.1 %) than in the fentanyl group (61.5 %).•Adverse events occurred only in the fentanyl group, including nausea (23 %) and hypotension (5.7 %).•FNB was safe, with no complications observed in any of the patients who received the block.

Background The incidence of early postoperative complications of displaced intracapsular hip fractures is high. The purpose of this study was to compare the early postoperative complications and assess the incidence of femoral neck shortening on using a newly designed proximal femoral cannulated screw locking plate (CSLP) versus multiple cancellous screws (MCS) in the treatment of displaced intracapsular hip fractures in young adults. Methods Sixty-eight young adult patients with displaced intracapsular hip fractures were randomly assigned to either the CSLP group or the MCS group and treated routinely by internal fixation with either the CSLP or the MCS. Harris Hip Score, nonunion, failure of fixation, overall complications, and femoral neck shortening were recorded and compared. Results Two patients (5.88%) in the CSLP group and eight (23.53%) in the MCS group had postoperative nonunion ( P  < 0.05). There was one case (2.94%) of fixation failure in the CSLP group and three cases (8.82%) in the MCS group ( P  > 0.05). Three patients (8.82%) in the CSLP group and 11 (32.35%) in the MCS group had overall complications ( P  < 0.05). Mean femoral neck shortening was 5.10 mm in the vertical plane and 5.11 mm in the horizontal plane in the CSLP group and 11.14 mm in the vertical plane and 10.51 mm in the horizontal plane in the MCS group. Severe femoral neck shortening (≥ 10 mm) did not occur in either the vertical or the horizontal plane in any patient of the CSLP group but occurred in 10 patients (28.57%) in the vertical plane and in 8 (22.86%) patients in the horizontal plane in the MCS group. Conclusions Compared with MCS, the use of CSLP in the treatment of displaced intracapsular hip fractures in young adults can reduce the rates of postoperative nonunion and overall complications and minimize femoral neck shortening. Trial registration ChiCTR1800016032 . Registered 8 May 2018. Retrospectively registered.

Background Hip fractures are common in elderly patients. The surgery is usually delayed due to underlying conditions, and pain control is crucial while the patient is cleared for surgery. In this randomized controlled trial (RCT) study, we hypothesized that the application of skin traction in patients with intertrochanteric fracture does not significantly change the Visual Analogue Score (VAS) of pain. Methods This is a prospective, single institution, parallel randomized controlled trial. Two hundred and twenty-nine patients with isolated intertrochanteric fractures were enrolled in the study. Patients with neurologic issues, drug addiction, scars or swelling, or vascular issues at the site of skin traction application were excluded from the study. Patients were divided into two groups: group A included 97 patients, and group B included 95 patients. Skin traction was applied for group A, while only a soft pillow was put beneath the patients’ knees in the other group. The VAS score was measured after the diagnosis, two hours before the operation, and 24 h after the surgery. The morphine dosage administered per day was documented for both groups. Results After excluding patients with postoperative delirium, 154 patients (55 males and 99 females) with isolated intertrochanteric fractures (69 right-sided and 85 left-sided), and a mean age of 70 ± 10 remained in the study. There were no significant differences between the two groups regarding age, gender, and mean time from injury to admission ( P  > .05). The mean VAS score measures and morphine dosage administered per day were not significantly different between the two groups ( P  > .05). Both groups experienced significant pain relief 24 h postoperatively ( P  < .001). Conclusion Pre-operative skin traction application affected neither the patients' VAS scores nor the mean morphine dosage per day in patients with isolated intertrochanteric fractures. Our data does not support the routine application of pre-operative skin traction in patients with intertrochanteric fractures. Trial registration The project was registered in the Iranian Registry of Clinical Trials (registration reference: IRCT20180729040636N3, registration date: 01/07/2020). Level of evidence 1.