Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: results at ten years in a randomised study of 450 patients.

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Fracture risk following an osteoporotic fracture.

The aim of this study was to examine the pattern of fracture risk following a prior fracture at the spine, shoulder or hip. We studied 1918 patients with fractures at these sites identified from the Department of Radiology in Malmo who were followed for 5 years. Poisson regression was used to compute fracture rates immediately after the initial fracture and at 5 years thereafter in men and women aged 60 or 80 years. Immediate fracture risk was higher than that of the general population, more markedly so at the age of 60 than at 80 years. At the age of 60 years, the risk of hip, forearm and spine fractures were significantly increased following a prior spine, hip or shoulder fracture in men. A similar pattern was seen in women, except that the increase in risk of forearm fracture following a spine or hip fracture was not statistically significant. The incidence of further fractures at the shoulder, spine or hip fell with time after the first fracture, a fall that was significant for all fractures after a shoulder fracture, hip fracture after a spine fracture, and hip and spine fractures after a hip fracture. We conclude that the risk of a subsequent fracture immediately after an osteoporotic fracture is highest immediately after the event. This provides a rationale for very early intervention immediately after fractures to avoid recurrent fractures.

Mortality after osteoporotic fractures.

The aim of this study was to examine the pattern of mortality following osteoporotic fractures at the spine, shoulder, hip, and forearm. We studied 2,847 patients with fractures at these sites identified from the radiology department in Malmö, Sweden. Poisson regression was used to compute mortality immediately after the fracture and with time. Mortality immediately after fracture was significantly higher in fracture cases than in the general population except for forearm fractures in both men and women. Mortality was higher in men than in women, but not different when adjusted for sex-specific population risks. For spine, shoulder, and hip fracture, mortality fell after the 1st year, an effect that was most marked for patients with spine fractures. The decrease in mortality risk with time was significant for hip, vertebral, and shoulder fracture. We conclude that the risk of death is increased in patients with osteoporotic fractures and that the highest risk is found immediately after the fracture event. The decreasing mortality with time after fracture may be due in part to a decrease in deaths causally related to the fracture. The extent to which early intervention for osteoporosis might avoid some of these deaths is unknown.

Pubertal bone growth in the femoral neck is predominantly characterized by increased bone size and not by increased bone density--a 4-year longitudinal study.

Fragility fractures are correlated to reduced bone size and/or reduced volumetric bone density (vBMD). These region-specific deficits may originate from reduced mineral accrual and/or reduced skeletal growth during the first 2 decades of life. Before pathological development can be defined, normal skeletal growth must be described. To evaluate growth of bone size, accrual of bone mineral content (BMC), areal bone mineral density (aBMD) and vBMD in a population-based cohort, 44 boys and 42 girls were followed by annual measurements from the age of 12 to 16 (attendance rates 90-100%). Segmental bone length, bone width, BMC, aBMD and vBMD were measured by dual-energy X-ray absorptiometry (DXA). Data were compared with predicted adult peak, as determined in 36 men aged 27.7+/-4.6 years and 44 women aged 26.8+/-4.9 years. Growth in width of the femoral neck precedes accrual of BMC in the femoral neck in both genders up to age 15. The girls were at all ages closer to their predicted adult peak in both bone width and BMC compared with the boys except in the femoral neck. As femoral neck vBMD had reached its predicted adult peak already at 12 years in both genders, the increase in femoral neck BMC and femoral neck aBMD from age 12 to 16 was most likely to be explained by the increase in bone size. In boys the peak velocity growth was recorded at ~14 years for BMC, height, width and lean mass. Growth from the age of 12 to 16 seems to build a bigger but not a denser skeleton in the femoral neck.

Physical activity increases bone size in prepubertal boys and bone mass in prepubertal girls: a combined cross-sectional and 3-year longitudinal study.

This study evaluates the effect on the skeleton of physical activity from age 9 to 16. In 42 girls and 44 boys, bone mass and bone size were evaluated longitudinally by dual-energy X-ray absorptiometry (DXA) from ages 13 to 16. Physical activity from ages 9 to 13 was cross-sectionally evaluated at baseline (age 13). Girls with high physical activity from ages 9 to 13 at baseline had higher femoral neck bone mineral content (FN BMC; g) (P = 0.07), higher FN areal bone mineral density (FN aBMD; g/cm2), and higher FN volumetric BMD (FN vBMD; g/cm3) (both P < 0.05) compared with girls of low activity. FN width (cm) and head aBMD (an unloaded region) showed no differences when comparing the two groups. Three years of further high and low activity (from ages 13 to 16) did not yield any increased differences between the two groups. Boys with high physical activity from ages 9 to 13, had at baseline higher FN BMC, FN aBMD, and FN width (all P < 0.05) compared with boys with low activity. FN vBMD and head aBMD showed no differences when comparing the two groups. Three years of further high and low activity did not yield any increased differences between the two groups. We conclude that exercise may yield skeletal benefits before age 13, and that 3 years of continued high or low level activity up to age 16 did not yield any increased differences in bone size or bone mass in either girls or boys.

A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years.

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age.

Targeting of hormone replacement therapy immediately after menopause.

The aim of this study was to model the effect of short (3-year) treatments with hormone replacement therapy (HRT) at the time of menopause on the risk of osteoporotic fracture, and to assess the impact of strategies to target high-risk individuals. From the relationship between bone mineral density (BMD) and fracture risk, treatment that increased bone mineral density at the hip by 6% over untreated women would save 35 vertebral, 62 hip, 13 proximal humeral, and 16 forearm fractures per 1000 women. The number needed to treat (NNT) to prevent one of these fractures was 8. The NNT fell modestly by targeting HRT to women with low bone mass or osteoporosis (NNT 6 and 5, respectively). The gains in fractures saved from targeting women with low bone mass or osteoporosis were offset by the requirement for assessment by BMD. Changes in the assumptions about the efficacy of HRT had a modest impact on fractures saved compared with the effect of changing assumptions concerning the offset of effect when treatment was stopped. We conclude that comparatively short courses of HRT might be effectively offered to all suitable women at menopause provided that the effects on bone persist when treatment is stopped.

Peripubertal moderate exercise increases bone mass in boys but not in girls: a population-based intervention study.

On the basis of cross-sectional studies in elite athletes and longitudinal studies, physical activity in growing children has been suggested to enhance bone mineral acquisition and prevent osteoporosis later in life. The level of exercise in most of these studies is not applicable in a population on a day-to-day basis. The aim of this study was to determine whether moderate increased exercise within the school curriculum from age 12 to 16 years would have anabolic bone effects. In a population-based setting of 40 boys and 40 girls the school curriculum was enhanced to physical education 4 times per week for 3-4 years. Controls were 82 boys and 66 girls who had had physical education twice a week over a corresponding period. Both cases and controls were measured at age 16 years. Bone mineral content (BMC), areal bone mineral density (aBMD), bone size (femoral neck width) and volumetric BMD (vBMD) were measured in total body, spine and femoral neck (FN) by dual-energy X-ray absorptiometry. Data are presented as mean +/- SD. BMC (8 +/- 15%, p = 0.04), aBMD (9 +/- 13%, p = 0.002) and vBMD (9 +/- 15%, p = 0.001) were all higher in FN in the male intervention group compared with controls. FN bone size was no higher in the intervention group than in the controls. In girls, no differences were found when comparing the intervention group with controls. The results remained after adjusting for confounding factors such as weight, height, milk intake and activity after school. In summary, we report that increased bone mass can be achieved in a population-based cohort of boys (but not in girls) by moderate increased physical activity within the school curriculum from age 12 to 16 years. We speculate that the same results can be seen in girls if intervention starts at an earlier age. We conclude that increasing the physical education content of the Swedish school curriculum may improve bone mass in at least peripubertal boys.

Incidence of hip fractures in Malmö, Sweden, 1992-1995. A trend-break.

The incidence of hip fractures in Malmö, Sweden, has been studied since 1924. Predictions based on material from the 1950s to the 1980s have shown an almost exponential increase in incidence. During 1992-1995, 2,268 patients aged 50 and older, with hip fractures, were admitted to Malmö University Hospital, the only hospital in the city treating hip fractures. 76% were women with a mean age of 81 (SD 8) years, and the mean age of men was 78 (SD 9) years. 47% of the fractures were cervical. The annual incidences per 10,000 inhabitants were 36 in men and 85 in women. The corresponding numbers of subjects over 80 years were 170 men and 297 women. These findings show that the incidence is no longer increasing. The causes of such a trend-break could be successful osteoporosis prevention, an increasing proportion of non-Scandinavian immigrants with a lower genetic risk of osteoporotic fractures, or a healthier elderly population. Increasing number of the population at risk already have two operated hips, due to previous fractures or arthrosis. Other causes may be fewer prescriptions of sedatives and higher winter temperatures.

Comparison of quantitative ultrasound measurements in calcaneus with DXA and SXA at other skeletal sites: a population-based study on 280 children aged 11-16 years.

We performed ultrasound measurements (QUS) of the calcaneus in a population-based setting on 280 healthy children, aged 11-16 years, from a small urban area in southern Sweden. The results are compared with dual-energy X-ray absorptiometry (DXA) measurements in the total body, the lumbar spine and the hip, as well as single-energy X-ray absorptiometry (SXA) of the forearm. Normative data and correlations between the three different techniques were determined. We found significant correlations between QUS and age (r = 0.34-0.54), height (r = 0.13-0.56) and weight (r = 0.30-0.60), and between QUS and bone mineral density (BMD) measurements (r = 0.44-0.70). Boys increased all their bone mineral variables with age, whereas girls showed a decreasing trend from age 15 years. QUS had a significantly higher increase in standardized value with age than Ward's triangle BMD, but a significantly lower increase in standardized value with age than distal radius (cortical site) BMD. At other BMD sites we did not find any significant differences compared with QUS regarding changes with age. The measurements obtained by QUS, DXA and SXA, respectively, were divided into, quartiles. Of all subjects in the lowest quartile for QUS measurements, only 34-50% were also in the lowest quartiles for DXA and SXA measurements. In conclusion, QUS measurements of the calcaneus in children show similar results as for adult regarding the correlation with DXA and SXA; they also have a significant correlation with anthropometric data. QUS did not identify the same individuals with low bone mass as the X-ray techniques.

Assessment of sex hormones and bone mineral density in relation to occurrence of fracture in men: a prospective population-based study.

Patients with fragility fractures have low bone mineral density (BMD)--this statement is supported mainly by data on women. In this study, including only men, the objectives were to determine whether a decline in BMD alone or in combination with data on male sex hormones and skinfold thickness could be of value in predicting forthcoming fractures. We also wanted to find out whether high consumers of alcohol can be identified by measuring BMDs and male sex hormones. A prospective, population-based study was performed in the city of Malmö, Sweden. 242 men were randomly selected; all were of Scandinavian ethnic background, and were aged 50, 60, 70, and 80 years. Forearm BMD, testosterone, sex-hormone-binding globulin (SHBG), and skinfold thickness were analyzed. In addition, alcohol consumption and carbohydrate-deficient transferrin (CDT)--a marker of alcohol abuse--were analyzed. The study group was followed prospectively for 7 years and all fractures sustained were recorded. Prospectively, for a 1 SD decrease in forearm BMD, the Cox proportional hazard model gave a relative risk (RR) of 1.75 with a 95% confidence interval of 1.08-2.83 for a forthcoming fracture and 3.88 (1.30-11.57) for a hip fracture. For a 1 SD change in skinfold thickness, measured on the dorsum of the hand, a RR of 1.69 (0.99-2.87) for a forthcoming fracture was found and the corresponding value for hip fracture was 2.34 (1.10-5.00). Testosterone and SHBG did not enhance fracture prediction. Abusers of alcohol had, retrospectively, significantly more fractures. Individuals with alcohol consumption rates in the highest quartile had significantly higher CDT levels, but we were unable to identify high consumers of alcohol by analyzing BMD or sex hormones. In this study we found that forearm BMD and skinfold thickness could be used in predicting forthcoming fractures in men.

Balance and gait performance in an urban and a rural population.

OBJECTIVE: To compare the differences in standing balance and gait performance between two populations, correlated with age and physical activities of daily living. DESIGN: A cross-sectional study. SETTINGS: Malmö, the third largest city in Sweden, and Sjöbo, a typical agricultural community 60 km east of Malmö. PARTICIPANTS: Participants were 570 men and women from the urban community (urban) and 391 from the rural community (rural), born in 1938, 1928, 1918, and 1908, and women born in 1948. The two cohorts were subdivided into true urbans, who had lived only in the city (n = 269), and true rurals, who had never lived in a city (n = 354). MEASUREMENTS: Information about workload, housing, spare time activities, medication, and illness during different decades of life was gathered using two questionnaires. The first questionnaire was sent to the home after agreement to participate, and the second was presented at the test session. The clinical measurements were standing balance, gait speed, and step length. RESULTS: The urban subjects had significantly (P < .001) impaired balance compared with rural subjects. This difference increased with increasing age. The urban subjects walked faster than the rural subjects (P < .001), and the urban subjects used fewer steps than their rural counterparts (P < .001). Spare time activities had a significant influence on the above tests, but, except for gait velocity (P = .011), workload was of minor importance according to analysis of covariance. CONCLUSION: Background factors such as usual daily activities of living and lifestyle seem to be of importance when evaluating and comparing different populations with respect to their balance and gait performance.

Bone mineral density in adolescents. Higher values in a rural area--a population-based study of 246 subjects in southern Sweden.

We performed, in a cross-sectional study, dual energy X-ray absorptiometry (DXA) among 15-16-year-old boys (n 58) and girls (n 44) living in an urban area and among boys (n 82) and girls (n 66) of the same age from a rural area. We measured bone mineral density (BMD) of the total body, the lumbar spine and the hip. In the rural population, we found significantly higher BMD levels in the lumbar spine (14% for the boys and 12% for the girls) and the total body (6.9% for the boys and 3.4% for the girls). We detected no significant differences in the hip BMD. Adolescents in rural areas seem to develop a higher peak bone mass and thereby presumably have a lower risk of developing fragility fractures.

Social function after cervical hip fracture. A comparison of hook-pins and total hip replacement in 47 patients.

47 patients with a cervical hip fracture Garden 3 or 4 and fully ambulatory before the fracture, were randomized to either fixation with Hansson hook-pins (24 patients, median age 79 years) or to a Charnley hip replacement (23 patients, median age 80 years). The patients were followed for 2 years. Social function was evaluated using a standard questionnaire. There were no postoperative deaths and no significant differences in hospital stay. 9/24 patients treated with hook-pins developed healing complications and 2 dislocations occurred in the THR group. After 1 and 2 years, fewer patients treated with hip replacement used outdoor walking aids; they were also more likely to do their own shopping. Hip replacement is a good choice when treating healthy older people with displaced cervical hip fractures, when primary mortality is expected to be low and the risk of healing complications after nailing is high.

Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan Multicentre Trial Group.

OBJECTIVE: To assess the effects of intra-articular injections of hyaluronan on symptoms of knee osteoarthritis (OA). METHODS: Two hundred and forty patients with symptomatic, radiological knee OA were randomly assigned to treatment with weekly injections for five weeks with either 25 mg of high molecular weight hyaluronan or vehicle. Results were evaluated at weeks 1, 2, 3, 4, 5, 13, and 20 by visual analogue scales (pain, function, motion, activity), algofunctional index, and global evaluation by patient and investigator. Analysis was by "intention to treat', "per protocol', and area under the curve principles on unstratified patient groups and for patients stratified into four groups of equal size by age and baseline algofunctional index. RESULTS: No serious side effects were reported. At 20 weeks both treatment groups were improved compared with baseline, with no difference between unstratified groups treated with placebo or hyaluronan. Comparison of treatment groups stratified by age and baseline algofunctional index revealed a significant difference in favour of hyaluronan over placebo (pain, activity, algofunctional index, global evaluations by patient and investigator) for patients older than 60 years and with a baseline algofunctional index greater than 10. There was no clinically relevant difference between the two treatments for the other three stratified subgroups of younger age or fewer symptoms. Similar results were obtained by area under the curve, intention to treat, and per protocol analysis. CONCLUSIONS: Patients older than 60 years with knee osteoarthritis and with significant symptoms corresponding to an index of severity of knee disease of 10 or more, comprise the group most likely to benefit from treatment with intra-articular hyaluronan injections.

Femoral neck geometry and radiographic signs of osteoporosis as predictors of hip fracture.

A total of 125 consecutive hip fracture patients were investigated regarding hip geometry. There were 33 men of mean age 76 +/- 10 years, and 92 women of mean age 78 +/- 9 years. Patients with previous hip surgery were excluded. Hip geometry (hip-axis length, width of collum femoris, and femoral shaft and neck-shaft angle) were registered on both plain radiographs and DEXA scans performed within 2 weeks after fracture. On the radiographs, the calcar femorale, the Singh index, and the femoral neck index (FNI) were also calculated and compared with earlier published values of bone mineral density hip in the hip fracture patients. The fracture cases were compared with controls, 192 DEXA scans and 163 radiographs, in patients without hip surgery or known hip disease. As measured on the DEXA scans we found a wider collum femoris and a wider femoral shaft in both the male and female fracture cases, compared to controls. Also, the fracture cases showed signs of osteoporosis as measured by the calcar femorale, the Singh index, and the femoral neck index. These measurements showed good correlation with bone mineral density of the hip as measured by the DEXA scans.

Changes of bone mineral mass and soft tissue composition after hip fracture.

The aim of this prospective longitudinal study was to measure prospectively the bone mineral density (BMD) and anthropometric variables after a hip fracture. In particular, we studied changes in the BMD in both the injured and uninjured hips, and examined if the postoperative mortality rate and complications, including pseudarthrosis of the fracture and late segmental collapse of the head of the femur, could be predicted by early bone mass measurements. The bone mineral density and the body composition were measured with dual energy X-ray absorptiometry in 102 consecutive hip fracture patients, 31 men and 71 women, with a mean age of 74 and 79 years, respectively. All cases were operated on within 3 days. The measurements were undertaken within 10 days after the fracture, after 4 and after 12 months. The BMD of the hip fracture cases decreased, especially in the lower extremities where the patients lost 7%, during the first year after the fracture. The patients also lost lean body mass (5%) but gained fat (11%) during the same period. They lost significantly more bone mass in the fractured hip than in the uninjured hip (p < 0.05). No difference was found between those patients who survived and those who died within 2 years after their hip fracture in neither the initial measurement nor in the follow-up measurements. Also, we found no difference between those patients whose hip fracture healed and those who developed late segmental collapse or pseudarthrosis. In conclusion, osteoporotic hip fracture cases lose bone mass at an increased rate, especially in the fractured hip. Also, their soft tissue composition changes, gaining fat while losing muscle mass. Furthermore, it seems that early bone mineral measurements cannot predict postoperative failures or postoperative mortality.

Rehabilitation of hip fracture patients with Parkinson's Disease.

The incidence of hip fractures has increased over the past decades, and for patients with hip fractures, medical and social conditions have deteriorated during the same time. In this study the results of orthopaedic rehabilitation of patients with Parkinson's disease and a hip fracture are compared with those in all other hip fracture patients. A total of 74 patients with Parkinson's disease and hip fracture were compared with 1,361 patients without the disease. Prior to fracture, patients with Parkinson's disease were less likely to be living an independent life in their own homes. Postoperatively women with Parkinson's disease were hospitalized for a significantly longer period. Postoperative rehabilitation was significantly slower and less successful than among patients without the disease. Patients with Parkinson's disease comprise a subgroup of hip fracture patients who need more rehabilitation resources than can easily be provided at an ordinary orthopaedic ward. A team-work between an orthopaedic surgeon, a neurologist and a rehabilitation unit seems to be mandatory in order to achieve shorter hospitalization and earlier return to the pre-fracture environment.

Assessment of biochemical markers of bone metabolism in relation to the occurrence of fracture: a retrospective and prospective population-based study of women.

We have in a population-based setting evaluated biochemical markers of bone metabolism in 328 women, aged 40-80 years, and related it to contents of bone mineral measurements and the retrospective and prospective presence of fracture. The participants were recruited from the city population files. Serum samples for analysis of osteocalcin (Oc), procollagen I carboxy-terminal extension peptide (PICP), and carboxy-terminal telopeptide of type I collagen (ICTP) were taken, and forearm bone mineral content (BMC) was measured by single photon absorptiometry (SPA). Fracture history was recorded, and the information was verified and supplemented from both radiologic and orthopedic files. Five years later the registration of fractures was repeated. At the initial investigation, Oc was 23% lower in women who had sustained a fracture (n = 37) within 6 years before measurement (6.3 +/- 3.6 microgram/l vs 8.2 +/- 4.2 microgram/l (p = 0.006)), after adjusting for age and BMC difference. PICP and ICTP were not different from values in the women without fracture. However, in women aged 70-80 years with a fracture sustained during the previous 6 years, PICP was lower (128 +/- 32 microgram/l vs 144 +/- 34 microgram/l, p = 0.046). Oc and ICTP were significantly correlated to age and BMC (Oc-age r = 0.36, Oc-BMC r = -0.31, ICTP-age r = 0.44, ICTP-BMC r = -0.24). The correlations of PICP were weaker. Prospectively, logistic regression gave an odds ratio (OR) of 1.8 (p = 0.015) for a low PICP and fracture susceptibility, at a change of 1 SD, independent of age and BMC. In the age bracket 70-80, the odds ratio was 2.4 (p = 0.036). The odds ratio for ICTP, independent of age and BMC, was 1.9 (P = 0.043) for 1 SD decrease and subsequent fracture risk. We concluded that women who had sustained at least one recent fracture had an altered bone turnover with decreased bone formation but an unaltered resorption. Women with retrospectively registered fractures also sustained subsequent fractures. A decrease from the mean of the collagen markers PICP and ICTP was associated with an increased risk for future fracture. Utilizing these biochemical markers of bone metabolism in a female population, PICP and ICTP had a similar influence on the risk of future fracture as forearm BMC (OR = 1.6, p = 0.03).