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Hip fracture

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More than 329,000 hip fractures per year in adults greater than 65 years of age.

Globally, hip fractures are among the top 10 causes of adult disability.

It is a severe injury associated with increased mobility and mortality.

A hip fracture refers to a break that occurs in the upper part of the femur.

The most devastating complication of osteoporosis, especially in the elderly.

Consequences of hip fractures include: functional decline, institutionalization, destitution, and mortality.

The incidence of fractures due to osteoporosis increases exponentially throughout life.

1.6 million older adults sustain hip fractures annually worldwide.

The highest incidence of hip fractures occurs in nursing home residents, where 50% of the residents fall each year 

Decline in incidence of hip fractures over the last decade in North America.

25-30% of hip fractures occur in men.

By the ninth decade of life 1 of every 3 women and 1 of every 6 men wii have sustained a hip fracture (Birge SJ et al).

44% of individuals with a hip fracture or readmitted it to the hospital, a 21% will die in the first year following the fracture.

The hospital readmission rate is nearly twofold greater than the readmission rate following elective joint replacement, and one year mortality is 2-4 fold greater than mortality observed in community dwellers of the same age and sex without fracture.

Risk increases as people age, people aged 85 years and older are more than 10 times more likely to sustain hip fracture than individuals age 65-69 years.

Bone mineral density is used to estimate fracture risk because T-scores are a strong predictor of future fracture.

The FRAX tool is commonly used to predict fractures and individuals with an estimated risk of major osteoporotic fracture between 10 and 20% are a moderate fracture risk, whereas individuals with an estimated risk of 20% have a high risk for fracture.

Among hip fracture survivors and other fractures, pain, depression, infections, functional decline, and recurrent fractures are all common complications leading to a higher rate of institutionalization.

The differential diagnosis of pathologic and insufficiency fractures include neoplastic disease is such as myeloma, and metastases from solid tumors, metabolic causes, including osteomalacia, osteoporosis, Paget’s disease of bone and osteitis fibrosa cystica from hyperparathyroidism.

A history of medial femoral condyle fracture without antecedent trauma arouses concern for a skeletal insufficiency or pathologic fracture, both which occur with normal stressors on weakened bone: the former occurs in the context of the few skills in disease and the latter resulting from focal disease.

Osteoporosis, falls are major risk factors, and polypharmacy, use of assistive devices , and cognitive impairment.

Approximately 20% of American women and 10% of American men will sustain a hip fracture, almost always related to a fall.

While rationale for high lifelong milk consumption is to meet calcium requirements for bone health, countries with the highest intakes of milk and calcium tend to have the highest rates of hip fractures.

Increased risk of fractures associated with benzodiazepines and nonbenzodiazepine sleep medications.

Globally among the top 10 causes of loss disability-adjusted life years for people older than 50 years.

In a meta-analysis of 39 studies associated with a five-eightfold increase risk of death during the three months after hip fracture, and a twofold increase after six months (Leblanc ES et al).

After sustaining hip fracture the odds ratio for a subsequent hospitalization is 3.31.

In the first 3months after a hip fracture, the mortality relative hazard is 5.75 for women and 7.95 for men.

Hip fracture associated with a one-year mortality risk of approximately 17% for women and up to 30% for men, although rates are improving in recent studies.

Among Medicare population sustaining a hip fracture, 13% die within three months,and 24% die within 12 months (Lu-Yao GL et al).

Of the patients in the Medicare age group who survive six months after fracture, only 50% recover prefracture ability to perform activities of daily living.

 

Only 25% of hip fracture patients return to their previous level of function.

Nursing home residents are much more likely than community dwelling older adults to sustain hip fractures and have poorer functional outcomes.

Associated with pain, impaired mobility, fear of falling and loss of independence.

Most hip fractures occur in women who are not osteoporotic based on BMD testing.

Strokes are a well documented risk factor.

Uric acid levels ≥7 mg/dL in men are associated with higher risk of hip fractures compared with uric acid levels of <7 mg/dL.

BMD measurements are the best predictor.

Approximately 25% of older patients with hip fracture survive less than 1 year.

10% of patients with hip fractures will fracture the other hip within 12 months, 30% will be readmitted to acute care facility, 50% have permanent functional disabilities 25% require long-term care and 10-25% die.

Contributes to increased mortality with more than 50% of individuals with a hip fracture die within 5 years.

Initiation of antihypertensive drugs in hypertensive community dwelling elderly patients is associated with an immediate increased hip fracture risk (ButtDA et al).

There is a 66 percent increased risk for hip fracture within 30 days of non-benzodiazepine hypnotic drug use (Berry SD et al).

The risk of for hip fracture is greatest in the first 15 days among new users of non- benzodiazepines.

The risk of hip fracture is greatest among new users of non- benzodiazepines, and individuals with cognitive impairment or who require assistance in transferring.

One year after surviving a hip fracture approximately 50% have impaired walking ability and only 40% can perform independent activities of daily living.

Among older adults with hip fractures approximately 13.5% die within six months and 24% within one year.

The mortality rate following a hip fracture persists beyond 10 years, and there is excess mortality risk among men than women.

For patients who survive six months, only 50% recover pre-fracture ability to perform activities of daily living, and only 25% recover their ability to perform instrumental ADLs.

Older adults are five times more likely than age matched controls without hip fracture to be institutionalized at one year.

Approximately 50% of hip fractures are intertrochanteric, and a large percentage of those are unstable.

12-20% die within 6 months after a hip fracture and a third of survivors never regain normal activity.

58% of patients need placement in a skilled nursing facility at time of dismissal from hospitalizations for a hip fracture.

Risk of death after hip fracture differs by age and health status: women aged 65-69 years have a 5 fold increased mortality risk in the first year after hip fracture after hip fracture, while women 80 years or older have no increased risk (LeBlanc ES et al.

In the above study lookng only at women over the age of eighty with good or excellent health mortallity risk increased 3 fold in the first year after hip fracture, and stayed up 5-10 years. (LeBlanc ES et al).

22-75% of patients do not reach prefracture ambulatory or functional status between 6 and 12 months after the fracture.

Because it is the goal of hip fracture surgery to return patients to preinjury level of functioning the functional status concerning comorbid illnesses need to be determined.

Surgical risks must be considered to determine whether non-operative management is more appropriate.

Patients with significant systemic disease, ASA classification 3-4 have a one-year mortality rate nine times higher than rates in patients classified as ASA 1-2.

Surgery should proceed when clinical status is optimized, and coagulopathy, respiratory problems, electrolyte abnormalities, and CHF are addressed.

Early surgery associated with decreased pain, length of hospital stay, and fewer postoperative complications.

Delay of surgery for hip fracture of more than 2 days from admission approximately doubles the 1year mortality: however after controlling for comorbid conditions the delay no longer exists, meaning excess mortality risk is associated with medical reasons for the delays rather than the delay alone.

Prompt surgical treatment of acute hip fractures in patients taking clopidogrel does not compromise perioperative outcomes (Feely MA et al).

In the above study it was no difference in perioperative bleeding complications or mortality in patients who undergoing prompt operative treatment of hip fracture while taking clopidogrel compared with patients not taking such a drug.

Principal causes of in-hospital deaths are cardiac failure and myocardial infarction, which occur early after fracture, peaking at 2 dajys.

Pulmonary embolism deaths peak in the second week after fracture.

In-hospital mortality rates range from 1.4% to 12%.

Mortality after hip fracture is five times higher in women and eight times higher in men compared with controls (Haentjens P).

Timely surgery associated with improved outcomes.

Bronchopneumonia accounts for the majority of late deaths.

Most cases caused by sideways fall with direct impact on the greater trochanter of the proximal femur.

Tc 99m polyphosphate bone scanning has a sensitivity up to 98% in confirming the presence of a fracture when radiographs are inconclusive or negative.

For all hip fractures, an AP pelvis, internal rotation AP and cross-table lateral of the affected hip should be obtained.

MRI up to 100% efficacy in diagnosing hip fractures.

Usually classified as intracapsular (femoral neck), or extracapsular (intertrochanteric or subtrochanteric).

For nondisplaced a minimally displaced fractures of the femoral neck, surgical management most commonly consists of placement of a screw alone or plate and screw fixation.

A nondisplaced a minimally displaced fracture of the femur femoral neck, if not treated with fixation, there is a 12-33% of fracture displacement prior to healing.

Historically the majority of the femoral neck fractures have been treated with reduction and internal fixation, most current guidelines advocate arthroplasty for displaced fractures of the femoral neck in elderly patients.

In patients with intertrochanteric fractures fixation using a sliding hip screw or intramedullary screw, dependent on the stability of the fracture, is performed, and there is little evidence to recommend replacement arthroplasty over internal fixation.

Intracapsular fractures subject to disruption of its vascular supply leading to avascular necrosis and provide a poor anchorage for a fixation device increasing the possibility of non or malunion.

With displaced femoral neck fractures in the elderly, management remains uncertain.

Options were displaced femoral neck fractures include hemiarthroplasty, which involves replacing the femoral head with prosthesis, or a total hip arthroplasty, which involves replacement of both the femoral head and the acetabulum with prostheses.

Advocates of total hip arthroplasty believe patients have better functioning and quality of life as compared with hemiarthroplasty.

Total hip arthroplasty have a greater surgical morbidity than hemiarthroplasty and may increase the risk of dislocation, which leads often to a secondary procedure to reduce or revise the prosthesis.

In a randomized trial of total hip arthroplasty or hemiarthroplasty among elderly patients with displaced femoral neck fractures the incidence of secondary procedures did not differ between the two groups, and total hip arthroplasty provided clinically unimportant improvement over hemiarthroplasty in functioning quality of life over 24 months (HEALTH investigators).

Femoral fracture can be treated with internal fixation, hemiarthroplasty or total hip replacement.

Extracapsular intertrochanteric fractures usually repaired with surgical reduction and internal fixation.

With displaced femoral neck fractures treatment includes either a partial hip replacement or total hip arthroplasty.

Hemiarthroplasty has a expected 9 survivalship before it requires revision.

Hemiarthroplasty is reserved for lesser active patients and those with a shorter life expectancy.

In comparison of regional anesthesia to include spinal or epidural anesthesia, versus general anesthesia there is no significant differences in mortality or functional outcomes after hip fracture repair.

Regional anesthesia compared to general,anesthesia is associated with 50% reduction in postoperative confusion.

Regional anesthesia surgery via spinal epidural blockade plus sedation may reduce postoperative complications.

Spinal anesthesia for hip fracture surgery in older adults is not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days.: The incidence of postoperative delirium was similar for the two types of anesthesia (Newman M).

Among adults undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30 day mortality but is associated with the modestly shorter length of stay, these findings do not support the mortality benefit for regional anesthesia (Neumann MD et al).

Some studies suggest improved outcome for patients with a displaced femoral neck fracture with total hip arthroplasty compared to hemiarthroplasty.

 

Treatment of displaced femoral neck fractures, the standard approach is hip arthroplasty with prosthetic joint replacement rather than fracture fixation.

 

Fracture fixation is associated with high rates of non-unions-5-28%, and avascular necrosis-5-18% because of the tenuous blood supply of the proximal femur.

 

During hip arthroplasty the femoral stem fixation can be accomplished with cement, or with bony growth into a porous coated implant.

 

Most hemiarthroplasties  in the United States are not done with cement, as using cement increases the procedure time, and risks bone cement implantation syndrome.

 

In patients with hip fracture treated  with hemiarthroplasty  uncemented fixation compared with cemented fixational is associated with a significantly higher risk of aseptic revision (Okie K).

6 months of extended outpatient rehabilitation with resistance training improves physical function, quality of life and decreases disability in frail elderly community-dwelling individuals compared to low-intensity home exercise program.

After hip fracture extended physical therapy reduces falls by 25%, but not hospital readmissions (Bischoff-Ferrari HA et al).

Cholecalciferol 2000IU/d after hip fracture reduces hospital readmissions by 39%, but not falls (Bischoff-Ferrari HA et al).

Pharmacological therapy is recommended for individuals with hip or vertebral fractures, bone mineral density T score is less than or equal to -2.5, or bone marrow density T score between -1 and -2.5 and a 10 year probability of hip fracture of at least 3% or 10 year probability of major osteoporotic fracture of at least 20%.

Oral bisphosphonates are considered a first line therapy for individuals with osteoporosis, and the number of older adults needed to prevent one hip fracture is approximately 200.

 

 

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