The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss.The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS.ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire.The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not.The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.
Objectives To investigate whether medication reviews increase treatment with fracture‐preventing drugs and decrease treatment with fall‐risk‐increasing drugs. Design Randomized controlled trial (1:1). Setting Departments of orthopedics, geriatrics, and medicine at Sahlgrenska University Hospital, Gothenburg, Sweden. Participants One hundred ninety‐nine consecutive individuals with hip fracture aged 65 and older. Intervention Medication reviews, based on assessments of risks of falls and fractures, regarding fracture‐preventing and fall‐risk‐increasing drugs, performed by a physician, conveyed orally and in written form to hospital physicians during the hospital stay, and to general practitioners after discharge. Measurements Primary outcomes were changes in treatment with fracture‐preventing and fall‐risk‐increasing drugs 12 months after discharge. Secondary outcomes were falls, fractures, deaths, and physicians' attitudes toward the intervention. Results At admission, 26% of intervention and 29% of control participants were taking fracture‐preventing drugs, and 12% and 11%, respectively, were taking bone‐active drugs, predominantly bisphosphonates. After 12 months, 77% of intervention and 58% of control participants were taking fracture‐preventing drugs (P = .01), and 29% and 15%, respectively, were taking bone‐active drugs (P = .04). Mean number of fall‐risk‐increasing drugs per participants was 3.1 (intervention) and 3.1 (control) at admission and 2.9 (intervention) and 3.1 (control) at 12 months (P = .62). No significant differences in hard endpoints were found. The responding physicians (n = 65) appreciated the intervention; on a scale from 1 (very bad) to 6 (very good), the median rating was 5 (interquartile range (IQR) 4–6) for the oral part and 5 (IQR 4–5.5) for the text part. Conclusion Medication reviews performed and conveyed by a physician increased treatment with fracture‐preventing drugs but did not significantly decrease treatment with fall‐risk‐increasing drugs in older adults with hip fracture. Prescribing physicians appreciated this intervention.
Abstract Due to the increasing life expectancy, orthopaedic surgeons are more and more often confronted with fragility fractures of the pelvis (FFPs). These kinds of fractures are the result of a low-energy impact or they may even occur spontaneously in patients with severe osteoporosis. Due to some distinct differences, the established classifications for pelvic ring lesions in younger adults do not fully reflect the clinical and morphological criteria of FFPs. Most FFPs are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to increasing displacement, nonunion and persisting instability. Therefore, new concepts for surgical treatment have to be developed to address the functional needs of the elderly patients. Based on an analysis of 245 consecutive patients with FFPs, we propose a novel classification system for this condition. This classification is based on morphological criteria and it corresponds with the degree of instability. Also in the elderly, these criteria are the most important for the decision on the type of treatment as well as type and extent of surgery. The estimation of the degree of instability is based on radiological and clinical findings. The classification gives also hints for treatment strategies, which may vary between minimally invasive techniques and complex surgical reconstructions.
The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena.We questioned whether progression and reoperation occur with enough frequency to justify additional risks of longer intramedullary devices.A retrospective chart review was done for 96 patients with metastases, myeloma, or lymphoma who had undergone stabilization or arthroplasty of impending or actual femoral or humeral pathologic fractures using an approach favoring intramedullary fixation devices and long-stem arthroplasty. Incidence of progressive bone disease, reoperation, and complications associated with fixation and arthroplasty devices in instrumented femurs or humeri was determined.At minimum 0 months followup (mean, 11 months; range, 0–72 months), 80% of patients had died. Eleven of 96 patients (12%) experienced local bony disease progression; eight had local progression at the original site, two had progression at originally recognized discretely separate lesions, and one had a new lesion develop in the bone that originally was surgically treated. Six subjects (6.3%) required repeat operative intervention for symptomatic failure. Twelve (12.5%) patients experienced physiologic nonfatal complications potentially attributable to embolic phenomena from long intramedullary implants.Because most patients in this series were treated with the intent to protect the bone with long intramedullary implants when possible, the reoperation rate may be lower than if the entire bone had not been protected. However, the low incidence of disease progression apart from originally identified lesions (one of 96) was considerably lower than the physiologic complication rate (12 of 96) potentially attributable to long intramedullary implants.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Abstract Introduction Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. Patients and methods A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. Results 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI > 30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors ( P < 0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. Discussion Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.
The purpose of the study was to estimate the cost-effectiveness of balloon kyphoplasty compared to nonsurgical management and vertebroplasty for the treatment of hospitalised osteoporotic vertebral compression fractures in the UK. A cost-effectiveness model was constructed and used for analysis. Balloon kyphoplasty may be cost-effective compared to relevant alternatives.The objective of this study was to estimate the cost-effectiveness of balloon kyphoplasty (BKP) for the treatment of patients hospitalised with acute osteoporotic vertebral compression fracture (OVCF) compared to percutaneous vertebroplasty (PVP) and nonsurgical management (NSM) in the UK.A Markov simulation model was developed to evaluate treatment with BKP, NSM and PVP in patients with symptomatic OVCF. Data on health-related quality of life (HRQoL) with acute OVCF were derived from the FREE and VERTOS II randomised clinical trials (RCTs) and normalised to the NSM arm in the FREE trial. Estimated differences in mortality among the treatments and costs for NSM were obtained from the literature whereas procedure costs for BKP and PVP were obtained from three National Health Service hospitals. It was assumed that BKP and PVP reduced hospital length of stay by 6 days compared to NSM.The incremental cost-effectiveness ratio was estimated at Great Britain Pound Sterling (GBP) 2,706 per quality-adjusted life year (QALY) and GBP 15,982 per QALY compared to NSM and PVP, respectively. Sensitivity analysis showed that the cost-effectiveness of BKP vs. NSM was robust when mortality and HRQoL benefits with BKP were varied. The cost-effectiveness of BKP compared to PVP was particularly sensitive to changes in the mortality benefit.BKP may be a cost-effective strategy for the treatment of patients hospitalised with acute OVCF in the UK compared to NSM and PVP. Additional RCT data on the benefits of BKP and PVP compared to simulated sham surgery and further data on the mortality benefits with BKP compared to NSM and PVP would reduce uncertainty.
Olecranon fractures are common injuries of the upper extremity; majority are treated surgically. A variety of fixation techniques are available to surgeons in modern practice, but there is little comparative clinical research to guide one's decision. Nonetheless, good results over all are to be expected after surgical management. This article presents a review of the current understanding and available evidence in the treatment of olecranon fractures, their relevant anatomy, fracture patterns, fixation options, and outcomes.
Abstract Non-vertebral non-hip (NVNH) fractures account for 90% of all fractures in patients up to 80 years of age and for 59% thereafter. There is a significant relationship between reductions in peripheral bone mineral density and the risk of fractures at various NVNH sites except for the face. Fractures of the clavicle, upper arm, forearm, spine, ribs, hip, pelvis, upper leg and lower leg elevate the risk of future fractures. Among NVNH fractures in women aged 80 years or over, forearm fractures have the highest incidence, and proximal humerus fractures have the second highest incidence. There is a large variation in incidence across geographical regions, with incidence higher in Northern Europe and lower in Asia and Africa. NVNH fractures are associated with higher mortality and significantly higher health-care costs than controls with osteoporosis. Reductions in health-related quality of life (HRQOL) for women with major NVNH fractures are of a similar magnitude as reductions for women with incident hip fractures; however, forearm fractures do not significantly affect HRQOL. Therapeutic options for NVNH fractures differ by fracture location. The recent development of implants for internal fixation made it a more popular choice for treating distal radius and proximal humerus fractures; however, treatment decisions should take into account patient age, activity levels, co-morbidities and injury characteristics. The recent increase in the number of patients with osteoporotic pelvic fractures is drastic, although they can generally be treated non-surgically with pain management and mobilisation.
Prevention of fractures is a considerable public health challenge. In a population-based cohort of French elderly people, a diet closer to a Mediterranean type had a borderline significant deleterious effect on the risk of fractures, in part linked to a low consumption of dairy products and a high consumption of fruits.Higher adherence to the Mediterranean diet (MeDi) is linked to a lower risk of several chronic diseases, but its association with the risk of fractures is unclear. Our aim was to investigate the association between MeDi adherence and the risk of fractures in older persons.The sample consisted of 1,482 individuals aged 67 years or older, from Bordeaux, France, included in the Three-City Study in 2001–2002. Occurrences of hip, vertebral and wrist fractures were self-reported every 2 years over 8 years, and 155 incident fractures were recorded. Adherence to the MeDi was evaluated at baseline by a MeDi score, on a 10-point scale based on a food frequency questionnaire and a 24-h recall. Multivariate Cox regression tests were performed to estimate the risk of fractures according to MeDi adherence.Higher MeDi adherence was associated with a non-significant increased risk of fractures at any site (hazard ratio [HR] per 1-point increase of MeDi score = 1.10, P = 0.08) in fully adjusted model. Among MeDi components, higher fruits consumption (>2 servings/day) was significantly associated with an increased risk of hip fractures (HR = 1.95, P = 0.04), while low intake of dairy products was associated with a doubled risk of wrist fractures (HR = 2.03, P = 0.007). An inverse U-shaped association between alcohol intake and risk of total fracture was observed (HR high vs. moderate = 0.61, P for trend = 0.03).Greater MeDi adherence was not associated with a decreased risk of fractures in French older persons. The widely recognized beneficial effects of the MeDi do not seem to apply to bone health in these people.
In Cambrian Mesón Group, NW Argentina, small faults and three opening-mode fracture sets defined by orientation and cement texture (Sets 1–3) formed sequentially in sandstone that most likely had constant mechanical properties throughout deformation. Yet the opening-mode sets display contrasting fracture-aperture-size distributions, spacing patterns, and tendency to be bed bounded. Set 1 fractures are quartz-filled or -lined opening-mode fractures with crack-seal texture, having a wide range of opening-displacement (kinematic aperture) sizes; they are irregularly spaced and non-strata-bounded fractures. Set 1 macro and microfracture-opening-displacement sizes are well described by a power law with slope −0.8. Set 2 fractures are microscopic, mostly quartz filled and have characteristic aperture sizes, are probably not bed bounded and have either a near-random or clustered spatial distribution. Set 3 fractures are quartz-lined, opening-mode fractures with extensive open pore space, having a narrow (characteristic) opening-displacement size distribution; they are regularly spaced and stratabounded. Differences between Sets 1 and 3 can be accounted for by quartz deposition resisting fracture reopening to a greater extent for Set 1 during repeated, episodic growth, where crack-seal texture is present in fracture-spanning quartz. In contrast Set 3 fractures are nearly barren with only trace-cement deposits that did not resist opening. Power-law opening-displacement size distributions may be favored in cases where fracture growth is unequally partitioned amongst variably cemented fractures, whereas a characteristic size is favored where growth is unaffected by cementation. Results imply that thermal history and diagenesis are important for fracture-size-distribution patterning.