Israel Medical Association Journal

Background: Trabecular bone score (TBS) reflects vertebrae microarchitecture and assists in fracture risk assessment. The International Society of Clinical Densitometry postulates that the role of TBS in monitoring antiresorptive therapy is unclear. Whether changes in TBS correlate with bone resorption measured by bone turnover markers is not known.

Objectives: To determine whether longitudinal changes in TBS correlate with C-terminal telopeptide (CTX) of type I collagen.

Methods: Examinees with two bone mineral density (BMD) measurements were detected via the institutional database. Over 5.8% change in TBS was considered least significant and patients were grouped accordingly (increment, decrement, or unchanged). CTX, BMD, co-morbidities, incident fractures, and medication exposure were compared between the groups by Kruskal-Wallis. The correlation between TBS and BMD change and CTX in a continuous model was analyzed by Pearson's correlation coefficient.

Results: In total, 110 patients had detailed medical records. In 74.5%, TBS change was below least significant change. Two other TBS categories, fracture incidence or medication exposure, did not differ by CTX. In the continuous model, BMD and TBS change was positively correlated (r = 0.225, P = 0.018). A negative correlation was observed between BMD change and CTX. The decrease in BMD level was associated with higher CTX (r = -0.335, P = 0.004). No correlation was observed between CTX and TBS.

Conclusions: No correlation between TBS dynamics and bone resorption marker was found. Clinical interpretation and implication of longitudinal TBS changes should be further explored.

Background: Several approaches are used to access the hip joint; most common are the direct lateral and posterior. Little consensus exists on which to use when treating hip fractures.

Objectives: To compare short-term complications, postoperative ambulation, and patient-reported outcome measures (PROMS) of direct lateral vs. posterior approaches in hemiarthroplasty for acute hip fractures.

Methods: We conducted a retrospective clinical trial with 260 patients who underwent bipolar hemiarthroplasty in the direct lateral or posterior approach (166 and 94, respectively) between January 2017 and December 2018. The clinical data included short-term complications: prosthetic dislocation, periprosthetic fractures, and infection. Postoperative ambulation was collected 6 weeks postoperatively; PROMS were collected for 173 patients at 2 years follow-up.

Results: There were six dislocations overall, average time to dislocation was 22 days postoperative (range 4–34). Five dislocations were after the posterior approach (5.3%) and one after direct lateral (0.6%) (P = 0.01). At 6 weeks follow-up, inability to walk was found in 16.9% of the direct lateral group and 6.4% of the posterior approach group (P = 0.02). In the posterior approach group, 76% could walk more than 20 meters; only half of the direct lateral group could (P = 0.0002). At 2 years follow-up, PROMS did not show a statistically significant difference between the groups.

Conclusions: Posterior approach for hemiarthroplasty following femoral neck fractures allows superior ambulation to the direct lateral approach only for the short-term. However, no long-term clinical advantage was found. This short-term benefit does not justify the increased dislocation rate in the posterior approach.

Background: The influence of the coronavirus disease 2019 (COVID-19) pandemic caused countries worldwide to implement lockdowns. Elective surgeries were temporarily suspended, with surgeries being performed only for emergent/urgent medical conditions such as hip fractures where early surgical intervention has shown decreased rates of morbidity/mortality.

Objectives: To assess the indirect influence of the COVID-19 pandemic and associated lockdown on hip fracture patients, considering factors such as time to surgery, early postoperative complications, and ambulation status.

Methods: A comparative retrospective study was conducted on consecutive patients presenting to our emergency department (ED) with hip fractures that were treated surgically (N=29) during a 1-month period during the government lockdown due to the COVID-19 pandemic. The treatments were compared to consecutive patients who presented with hip fractures and were treated surgically (N=44) during the same timeframe in the previous year (control). Comparisons were made using t-test, ANOVA test, Fisher's exact test, and chi-square test.

Results: The COVID-19 group was operated on sooner (20.34 vs. 34.87 hours), had fewer early postoperative complications (10.3% vs. 31.8%), had better ambulatory status at discharge, and experienced a shorter hospital stay (5.93 vs. 8.13 days) with more patients being discharged home (72.4% vs. 22.7%).

Conclusions: Patients presenting with hip fractures to our ED during the COVID-19 pandemic lockdown indirectly benefited from this situation by undergoing earlier surgical treatment, thus experiencing fewer early postoperative complications, faster ambulation, and sooner discharge.

Background: Limited data exist regarding the safety of ultrasound-guided femoral nerve blockade (US-FNB) in patients with hip fractures treated with anti-Xa direct oral anticoagulants (DOAC).

Objectives: To compare the safety outcomes of US-FNB to conventional analgesia in patients with hip fractures treated with anti-Xa DOAC.

Methods: This observational exploratory prospective study included 69 patients who presented to our emergency department (ED) in 3 years with hip fracture and who were treated with apixaban or rivaroxaban. Patients received either a US-FNB (n=19) or conventional analgesics (n=50) based on their preference and, and the presence of a trained ED physician qualified in performing US-FNB. Patients were observed for major bleeding events during and 30 days after hospitalization. The degree of preoperative pain and opioid use were also observed.

Results: We found no significant difference in the number of major bleeding events between groups (47.4% vs. 54.0%, P = 0.84). Degree of pain measured 3 and 12 hours after presentation was found to be lower in the US-FNB group (median visual analog scale of pain improvement from baseline of -5 vs. -3 (P = 0.002) and -5 vs.-4 (P = 0.023), respectively. Opioid administration pre-surgery was found to be more than three times more common in the conventional analgesia group (26.3% vs.80%, P < 0.0001).

Conclusions: Regarding patients treated with Anti-Xa DOAC, US-FNB was not associated with an increase in major bleeding events compared to conventional analgesia, although it was an effective means of pain alleviation. Larger scale randomized controlled trials are required to determine long-term safety and efficacy.

Background: The coronavirus disease-2019 (COVID-19) pandemic had enormous impact on many aspects of our society, including huge medical, social, and economic challenges.

Objective: To evaluate the impact of the first wave of the COVID-19 pandemic and the related movement restrictions on the incidence of hip fractures in different age groups.

Methods: This single center retrospective observational study included all patients over 60 years old admitted to our hospital with the diagnosis of hip fracture during March and April 2020. Exclusion criteria were periprosthetic or pathologic fractures and multitrauma. We collected the same data on all patients with hip fractures admitted during March and April of 2018 and 2019.

Results: Mean patient age increased from 81.7 to 85.0 years. Only two of 49 patients tested positive for COVID-19. The data show a decrease of 38% in fracture load, but a striking decrease of 85% and 59% among sexagenarians and septuagenarian, respectively. There was no decrease among nonagenarians. Early mortality, both at 30 days and 90 days, was twice as common during the pandemic. However, stratification by age group demonstrated that the risks of early mortality were the same as previous years. Mean waiting time for surgery decreased from 27.5 to 18.9 hours. Patient discharge to home over a rehabilitation facility increased from 9% to 17%.

Conclusions: The COVID-19 pandemic affected the epidemiology of hip fractures in the elderly. The incidence of fractures and age distribution were significantly different from other years. Discharge destinations were also affected. The management of hip fracture patients was not compromised.

Background: Surgery for hip fractures within 48 hours of admission is considered standard. During the lockdown period due to the coronavirus disease-2019 (COVID-19) epidemic, our medical staff was reduced.

Objectives: To compare the demographics, treatment pathways, and outcomes of patients with hip fractures during the COVID-19 epidemic and lockdown with the standard at routine times.

Methods: A retrospective study was conducted of all patients who were treated surgically for hip fracture in a tertiary center during the COVID-19 lockdown period between 01 March and 01 June 2020 and the equivalent period in 2019. Demographic characteristics, time to surgery, surgery type, hospitalization time, discharge destination, postoperative complications, and 30- and 90-day mortality rates were collected for all patients.

Results: During the COVID-19 period, 105 patients were operated due to hip fractures compared to 136 in the equivalent period with no statistical difference in demographics. The rate of surgeries within 48 hours of admission was significantly higher in the COVID-19 period (92% vs. 76%, respectively; P = 0.0006). Mean hospitalization time was significantly shorter (10 vs. 12 days, P = 0.037) with diversion of patient discharge destinations from institutional to home rehabilitation (P < 0.001). There was a significant correlation between the COVID-19 period and lower 90-day mortality rates (P = 0.034). No statistically significant differences in postoperative complications or 30-day mortality rates were noted.

Conclusions: During the COVID-19 epidemic, despite the limited staff and the lack of therapeutic sequence, there was no impairment in the quality of treatment and a decrease in 90-day mortality was noted.

Background: Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world.

Objectives: To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture

Methods: We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6–12 weeks following the fracture to ensure treatment initiation.

Results: From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate.

Conclusions: FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center

Background: Mortality and decrease in function after hip fracture are significantly related to patient factors including age, gender, co-morbidities, and mental status. Several studies demonstrated ethnic disparities in incidence, mortality, and functional outcome after hip fractures in the United States.

Objectives: To assess the relationship between ethnicity and hip fracture incidence and outcomes of mortality, functional change, and perioperative complications in the Israeli population.

Methods: We reviewed our institutional hip fracture registry for all patients from 2014–2015. Patients with incomplete data, < 60 years of age, or pathologic and periprosthetic fractures were excluded. Our study comprised 693 patients. Ethnicity was based on country of birth. Specifically, for those born in Israel, the nationality of either Jewish or Arab was further dichotomized. Perioperative complications, mortality, and mobility status at 1 year follow-up were recorded. The ethnicities of 27,130 patients admitted to the medicine and surgical wards during the same time interval served as a control group for the hip fracture cohort.

Results: Immigrants from Europe and America had the highest incidence of hip fractures. Fracture types varied in incidence in groups with 70% of extracapsular hip fractures occurring in Arabs and immigrants from Eastern countries, compared to 60% in immigrants from Western countries and the former Soviet Union. Mortality, perioperative complications, and mobility at 1 year were similar in all ethnic groups.

Conclusion: Our study demonstrated significant differences in incidence and fracture characteristic among ethnicities, but no difference in patient outcome. These findings differed from the available North American studies.

Background: The surgical treatment of hip fractures remains controversial especially when considering age. 

Objectives: To investigate the long-term functional outcomes of displaced subcapital hip fractures that were reduced and surgically fixed using parallel cannulated screws in patients aged 60 years and younger. 

Methods: During the period 1996–2005, 27 patients under age 60 with displaced subcapital hip fractures classified as Garden III or IV were treated with fracture reduction and surgical internal fixation using cannulated screws. Patient outcomes were assessed using the Harris Hip Score (HHS) and physical examination.

Results: During a follow-up period of 8–17 years 4 of the 27 patients (14.8%) developed non-union/femoral head avascular necrosis and had undergone hip arthroplasty. All reoperations were performed within the first year after fracture fixation, all in the 50–60 year old age group. The revision rate among patients 50–60 years old was significantly higher than that of patients 50 years and younger (40% vs. 0%, P = 0.037). Mean HHS was higher for patients not requiring revision surgery (85.4) than for patients with revision surgery (75.5), but this difference was not significant.

Conclusions: Internal fixation using fracture reduction and cannulated screw fixation is a successful treatment modality for displaced subcapital hip fractures in patients younger than 50 years old. Patients aged 50–60 years may have a higher risk of avascular necrosis or non-union and require arthroplasty, often within the first year after fracture fixation. The long-term outcome following these fractures is good when excluding patients who had early complications.

 

Objectives: To evaluate trends in the incidence of hip fractures in this population.

Methods: The study was based on two surveys done approximately 20 years apart. It included women and men 50 years and older with radiographic evidence of a new hip fracture caused by low impact trauma. Only fractures that resulted from low or moderate trauma were considered for the current study. Incidence rates were calculated based on population data obtained from the official Central Bureau of Statistics.

Results: There was an overall twofold increase in the incidence rate of hip fractures. However, this increase occurred almost exclusively in the over-75 year old age groups (2.5-fold increase, both in women and men). The mean (and median) age of patients with hip fractures increased significantly over the study period, corresponding with the increase in longevity between the two periods.

Conclusions: There was a marked secular increase in the incidence of proximal hip fractures in both genders, primarily because of an increase in the fracture rate in the very old. The increase in median age of fracture patients suggests that the observed increase in fracture rate can be attributed mainly to aging of the population rather than to deterioration in bone quality over the generations.

Background: The progressive increase in the number of elderly patients with hip fractures and the particular multidisciplinary needs of this population call for the investigation of other models of orthogeriatric care.

Objectives: To describe the nature and assess the feasibility of a comprehensive orthogeriatric unit attending to patients' surgical, medical and rehabilitation needs in a single setting.

Methods: This retrospective chart review describes consecutive older patients with hip fractures admitted directly from the emergency ward to an orthogeriatric ward.

Results: The mean age of the 116 patients evaluated was 82.4 years. Delay to surgery was 3.6±3.1 days and total length of stay 23.9±11.0 days. No patient was transferred to other acute medical wards of the hospital and 66.4% were able to return to their previous living place. Rates of major complications and mortality were extremely low.

Conclusion: The present model of a comprehensive orthogeriatric ward is a practical, applicable and feasible service for elderly hip fracture patients and can cover the various needs of these patients. The deployment arrangements needed to establish and operate the ward were minimal and there were only a few management and organizational problems. The cost-effectiveness and other comparative benefits of this type of service have yet to be clarified.