Significant changes in the surgical methods and length of hospital stay of hip fracture patients occurring over 10 years in Central Finland

BACKGROUND AND AIMS: The objective of this study is to determine the changes occurring in the treatment chain and mortality of hip fracture patients in Central Finland over a ten-year period. In order to cope with an aging population and increasing cutbacks in the health care system, health-center hospitals run by general practitioners have taken a more active role in the rehabilitation of elderly patients. MATERIAL AND METHODS: Patients with acute hip fracture admitted to Jyv?skyl? Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were collected from the hospital discharge register and the medical records of these patients were studied retrospectively. RESULTS: The median length of central hospital stay diminished from 18 days to 5 days and the percentage of hip fracture patients discharged to cope on their own diminished from 22 % to only 7 %. The percentage of trochanteric fractures treated by osteosynthesis increased from 83 % to 96 % and the percentage of cervical fractures treated by hemiprosthesis increased from 35 % to 76 %. First-year mortality has remained almost unchanged. CONCLUSIONS: There has been a dramatic change in surgical methods, in the length of hospital stay on the traumatology ward, and in discharge patterns and no change in mortality during the last 10 years in Central Finland.     

The changing picture of hip fractures: dramatic change in age distribution and no change in age-adjusted incidence within 10 years in Central Finland

The objective of this study was to find out if the age-standardized incidence of hip fractures has changed in 10 years in Central Finland. Patients with acute hip fracture admitted to Jyv?skyl? Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were selected from the hospital discharge register and from contemporaneous records of the Department of Anesthesiology and the ward of traumatology. Earlier studies in Finland have indicated that there has been an increase in incidence rates. The results of this study show no change in the age-standardized incidence of hip fractures of men and women during the last 10 years. However, because of the change in the age distribution of the population, the number of hip fractures has increased by 11%. The mean age of the hip fracture patients increased from 75.4 years in 1982-1983 to 78.4 years in 1992-1993. In 1982-1983, 18.0% of the patients were > or =85 years. The corresponding figure in 1992-1993 was 30.2%. Therefore, we summarize that there has been a dramatic change in age distribution and no change in age-adjusted incidence within the last 10 years in central Finland.     

Bone mass in women with hip fracture

The bone mineral density was determined by dual-photon absorptiometry on the proximal femur in 32 women with femoral neck fractures, 30 with trochanteric fractures, 39 with a fracture elsewhere than the hip, and 16 premenopausal healthy women. Single-photon absorptiometry was performed at two sites on the radius. The bone mineral density in the neck and intertrochanteric area was greater in the women with femoral neck fractures than in those with trochanteric fractures. The bone mineral distribution in the proximal femur was essentially the same for the femoral neck fracture group as for the reference group of healthy women. Neither the Singh index, determined in radiographs, nor the measurements on the radius by single photon absorptiometry provided a reliable estimate of the bone mineral density in the proximal femur     

Bone mass in women with hip fracture

The bone mineral density was determined by dual-photon absorptiometry on the proximal femur in 32 women with femoral neck fractures, 30 with trochanteric fractures, 39 with a fracture elsewhere than the hip, and 16 premenopausal healthy women. Single-photon absorptiometry was performed at two sites on the radius. The bone mineral density in the neck and intertrochanteric area was greater in the women with femoral neck fractures than in those with trochanteric fractures. The bone mineral distribution in the proximal femur was essentially the same for the femoral neck fracture group as for the reference group of healthy women. Neither the Singh index, determined in radiographs, nor the measurements on the radius by single photon absorptiometry provided a reliable estimate of the bone mineral density in the proximal femur.     

Spatial Differences in the Distribution of Bone Between Femoral Neck and Trochanteric Fractures

There is little knowledge about the spatial distribution differences in volumetric bone mineral density and cortical bone structure at the proximal femur between femoral neck fractures and trochanteric fractures. In this case‐control study, a total of 93 women with fragility hip fractures, 72 with femoral neck fractures (mean ± SD age: 70.6 ± 12.7 years) and 21 with trochanteric fractures (75.6 ± 9.3 years), and 50 control subjects (63.7 ± 7.0 years) were included for the comparisons. Differences in the spatial distributions of volumetric bone mineral density, cortical bone thickness, cortical volumetric bone mineral density, and volumetric bone mineral density in a layer adjacent to the endosteal surface were investigated using voxel‐based morphometry (VBM) and surface‐based statistical parametric mapping (SPM). We compared these spatial distributions between controls and both types of fracture, and between the two types of fracture. Using VBM, we found spatially heterogeneous volumetric bone mineral density differences between control subjects and subjects with hip fracture that varied by fracture type. Interestingly, femoral neck fracture subjects, but not subjects with trochanteric fracture, showed significantly lower volumetric bone mineral density in the superior aspect of the femoral neck compared with controls. Using surface‐based SPM, we found that compared with controls, both fracture types showed thinner cortices in regions in agreement with the type of fracture. Most outcomes of cortical and endocortical volumetric bone mineral density comparisons were consistent with VBM results. Our results suggest: 1) that the spatial distribution of trabecular volumetric bone mineral density might play a significant role in hip fracture; 2) that focal cortical bone thinning might be more relevant in femoral neck fractures; and 3) that areas of reduced cortical and endocortical volumetric bone mineral density might be more relevant for trochanteric fractures in Chinese women. © 2017 American Society for Bone and Mineral Research.     

Femoral Neck and Intertrochanteric Fractures Have Different Risk Factors: A Prospective Study

The aim of this study was to determine whether both types of hip fracture, femoral neck and intertrochanteric, have similar risk factors. A prospective cohort study was carried out on community-dwelling elderly women in four areas of the United States: Baltimore, MD; Pittsburgh, PA; Minneapolis, MN and Portland, OR. The participants were 9704 Caucasian women, 65 years and older, of whom 279 had fractured their femoral neck and 222 had fractured their trochanteric region of the proximal femur. The predictors used were the bone mass of the calcaneus and proximal femur, anthropometry, history of fracture (family and personal), medication use, functional status, physical activity and visual function. The main outcome measures were femoral neck and intertrochanteric fractures occurring during an average of 8 years of follow-up. In multivariate proportional hazards models, several risk factors increased the risk of both types of hip fracture; including femoral neck bone density and increased functional difficulty. In hazard regression models that directly compared risk factors for the two types of hip fracture, calcaneal bone mineral density (BMD) predicted femoral neck fractures more strongly than intertrochanteric fractures (OR = 1.16; 95% CI = 1.02–1.31). Steroid use and impaired functional status also predicted femoral neck fractures instead of intertrochanteric fractures. Poor health status (OR = 0.74; 95% CI = 0.55–1.00) predicted intertrochanteric fractures more strongly than femoral neck fractures. We conclude that femoral neck fractures are largely predicted by BMD and poor functional ability while aging and poor health status predispose to intertrochanteric fractures. Received: 8 February 2000 / Accepted: 10 June 2000     

Quantitative ultrasound parameters as well as bone mineral density are better predictors of trochanteric than cervical hip fractures in elderly women. Results from the EPIDOS study

RATIONALE: Hip fractures can be separated into cervical and trochanteric fractures. Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. There is also evidence suggesting that the mechanisms are different. Evidence from the literature remains limited on the predictive power of bone mineral density (BMD) and quantitative ultrasounds (QUS) for both types of hip fractures. METHODS: 5703 elderly women aged 75 years or more, who were recruited from the voting lists in the EPIDOS study, and had baseline calcaneal ultrasounds (QUS) and DXA measurements at the hip and the whole body, were analyzed in this paper. Among those, 192 hip fractures occurred during an average follow-up of 4 years, 108 cervical and 84 trochanteric fractures. RESULTS: Femoral neck, trochanteric and whole body BMD were able to predict trochanteric hip fracture (RR's and 95% CI were, respectively, 3.2 (2.4-4.2); 4.8 (3.5-6.6); and 2.8 (2.2-3.6)) more accurately than cervical fractures (respectively, 2.1 (1.7-2.7); 2.3 (1.8-3.0); 1.2 (1.0-1.6)). All ultrasound parameters, SOS, BUA, and stiffness index (SI) were significant predictors of trochanteric (RR's respectively 3.0 (2.2-4.1), 2.5(2.0-3.1), and 3.5(2.6-4.7)) but not cervical fractures. After adjustment for femoral neck or trochanteric BMD ultrasound parameters were still significant predictors of trochanteric fracture, and stiffness tended to be a better predictor of trochanteric fractures than either BUA or SOS with a relative risk of 2.25 (1.6-3.1). CONCLUSIONS: A significant decrease of all bone measurements, BMD and QUS, was highly predictive of trochanteric fractures, whereas a decrease of femoral neck and trochanteric BMD were only associated with a slight increase in cervical fracture risk and a low total body BMD or QUS parameters were not significant predictors of cervical fractures. In women who sustained a hip fracture, the decrease of BMD and QUS values increases the risk of trochanteric fracture as compared to cervical fracture. Trochanteric fractures were mostly a consequence of a generalized low BMD and QUS, whereas other parameters might be involved in cervical fractures.     

骨密度结合股骨近端几何参数预测老年髋部骨折

目的研究老年人骨密度(Bone mineral density,BMD)值结合股骨近端几何参数是否能提高骨质疏松性髋部骨折危险性的预测。方法将85例绝经后妇女髋部骨折患者按骨折类型分组, 其中52例股骨颈骨折,33例转子间骨折。对照组100例老年女性。在骨盆片上测量股骨近端几何参数,在股骨颈、Ward’s三角和转子处测量BMD值,对结果进行统计学处理分析。结果骨折组的BMD值均低于对照组(P<0．01);股骨干皮质厚度与股骨颈BMD值有相关性(r=0．45,P< 0．01);逐步线性回归分析结果显示股骨距内侧皮质厚度、转子处BMD值、颈干角和Ward’s三角 BMD值相结合是预测髋部骨折最好方法(r=0．74,r2=0．53,P<0．01)。结论骨密度值结合放射学测量股骨近端几何参数能提高对骨质疏松性髋部骨折及骨折类型的预测。     

Changes in the morphology of hip fractures within a 10-year period

The objective of this study was to find out whether the morphology of various types of hip fractures and the mean ages of the patients had changed in a recent 10-year period. All patients aged 65 years or more with acute hip fracture admitted to Miguel Servet University Hospital in 1989-1990 (n = 457) and in 1999-2000 (n = 518) were studied. The results showed a significant increase in the incidence of displaced cervical fractures (P < 0.001) and a decrease in the incidence of nondisplaced cervical fractures (P < 0.001) in women. The incidence of different types of trochanteric fractures did not vary. No change was observed in the mean age of patients with cervical fractures, but the mean age of women with A12 trochanteric fractures was significantly higher in 1999-2000 than in 1989-1990 (P < 0.05).     

Rising incidence of hip fracture in Uppsala, 1965-1980

The frequency and incidence of hip fracture in persons aged 55 years and older in the county of Uppsala during the years 1965,1970,1975 and 1980 are reported. For every 5-year interval, the number of hip fractures increased by 21-25 per cent. The ratio of women to men changed from 3.8 in 1965 to 3.1 in 1980. Trochanteric fractures were more common during the later years. The ratio of femoral neck fractures to trochanteric fractures decreased from 1.8 to 1.1 between 1965 and 1980. The incidence of hip fracture in the investigated part of the population increased from 43 per 10 000 in 1965 to 65 in 1980. The age-specific incidence increased especially in the group aged 85 years and older, in which fractures of the femoral neck were three times and trochanteric fractures four times more common in 1980 than in 1965. This investigation shows that the incidence of hip fracture has increased, particularly in the higher age groups. If the age-specific incidences continue to rise in the higher age groups, the frequency of hip fractures will be doubled within a 20-year period.     

Rising incidence of hip fracture in Uppsala, 1965-1980

The frequency and incidence of hip fracture in persons aged 55 years and older in the county of Uppsala during the years 1965, 1970, 1975 and 1980 are reported. For every 5-year interval, the number of hip fractures increased by 21-25 per cent. The ratio of women to men changed from 3.8 in 1965 to 3.1 in 1980. Trochanteric fractures were more common during the later years. The ratio of femoral neck fractures to trochanteric fractures decreased from 1.8 to 1.1 between 1965 and 1980. The incidence of hip fracture in the investigated part of the population increased from 43 per 10 000 in 1965 to 65 in 1980. The age-specific incidence increased especially in the group aged 85 years and older, in which fractures of the femoral neck were three times and trochanteric fractures four times more common in 1980 than in 1965. This investigation shows that the incidence of hip fracture has increased, particularly in the higher age groups. If the age-specific incidences continue to rise in the higher age groups, the frequency of hip fractures will be doubled within a 20-year period.     

In vivo discrimination of hip fracture with quantitative computed tomography: Results from the prospective European Femur Fracture Study (EFFECT)

In assessing osteoporotic fractures of the proximal femur, the main objective of this in vivo case‐control study was to evaluate the performance of quantitative computed tomography (QCT) and a dedicated 3D image analysis tool [Medical Image Analysis Framework—Femur option (MIAF‐Femur)] in differentiating hip fracture and non–hip fracture subjects. One‐hundred and seven women were recruited in the study, 47 women (mean age 81.6 years) with low‐energy hip fractures and 60 female non–hip fracture control subjects (mean age 73.4 years). Bone mineral density (BMD) and geometric variables of cortical and trabecular bone in the femoral head and neck, trochanteric, and intertrochanteric regions and proximal shaft were assessed using QCT and MIAF‐Femur. Areal BMD (aBMD) was assessed using dual‐energy X‐ray absorptiometry (DXA) in 96 (37 hip fracture and 59 non–hip fracture subjects) of the 107 patients. Logistic regressions were computed to extract the best discriminates of hip fracture, and area under the receiver characteristic operating curve (AUC) was calculated. Three logistic models that discriminated the occurrence of hip fracture with QCT variables were obtained (AUC = 0.84). All three models combined one densitometric variable—a trabecular BMD (measured in the femoral head or in the trochanteric region)—and one geometric variable—a cortical thickness value (measured in the femoral neck or proximal shaft). The best discriminant using DXA variables was obtained with total femur aBMD (AUC = 0.80, p = .003). Results highlight a synergistic contribution of trabecular and cortical components in hip fracture risk and the utility of assessing QCT BMD of the femoral head for improved understanding and possible insights into prevention of hip fractures. © 2011 American Society for Bone and Mineral Research.     

Ultrasound and dual X-ray absorptiometry densitometry in women with hip fracture

To assess the usefulness of the measurement of the os calcis by ultrasound, a method that probably reflects bone quality as well as density, we have studied 54 women with hip fracture of the proximal femur and a control group. Ultrasound evaluation of the os calcis [broadband ultrasound attenuation (BUA), speed of the sound (SOS), and a combined index (stiffness)], and bone mineral density (BMD) determination over the proximal femur by dual X-ray absorptiometry (DXA) were performed. Weight, BMD, and ultrasound values in the hip fracture patients were significantly lower than controls (P<0.001). The Z-scores for BUA and stiffness were not different than that for femoral neck. Ward's triangle or trochanteric BMD (between-1.7 and -1.5). The odds ratios determined by receiver-operating characteristics (ROC) analysis were greater at the femoral neck (25.1) and BUA (24.4). Intermediate values were found at stiffness (16.9), Ward's triangle (12.8), and trochanter (11.1), and lower values were obtained at SOS (4.2). In turn, patients with trochanteric hip fractures had a significantly lower femoral neck and Ward's triangle BMD, stiffness, and BUA than patients with cervical hip fractures. Comparing a subgroup of 30 women with hip fractures without vertebral fractures with an age-matched group of 87 women with osteoporotic vertebral fractures, both groups were of similar weight and BMD but all ultrasound values were significantly lower in the hip fractures compared with vertebral fracture patients (P<0.05-P<0.01). Our findings suggest that in women with hip fractures, ultrasound evaluation of the os calcis has diagnostic sensitivity comparable to DXA of the femur and could be useful to predict hip fracture risk. Ultrasound values are lower in hip fractures compared with vertebral fracture, age-matched women and in older compared with younger hip fracture patients.     

Rising incidence of hip fracture in Uppsala, 1965–1980

The frequency and incidence of hip fracture in persons aged 55 years and older in the county of Uppsala during the years 1965,1970,1975 and 1980 are reported. For every 5-year interval, the number of hip fractures increased by 21–25 per cent. The ratio of women to men changed from 3.8 in 1965 to 3.1 in 1980. Trochanteric fractures were more common during the later years. The ratio of femoral neck fractures to trochanteric fractures decreased from 1.8 to 1.1 between 1965 and 1980. The incidence of hip fracture in the investigated part of the population increased from 43 per 10 000 in 1965 to 65 in 1980. The age-specific incidence increased especially in the group aged 85 years and older, in which fractures of the femoral neck were three times and trochanteric fractures four times more common in 1980 than in 1965. This investigation shows that the incidence of hip fracture has increased, particularly in the higher age groups. If the age-specific incidences continue to rise in the higher age groups, the frequency of hip fractures will be doubled within a 20-year period.     

Structural determinants of hip fracture in elderly women: re-analysis of the data from the EPIDOS study

Hip fracture is the most disastrous osteoporotic fracture, characterized by high mortality, morbidity and institutionalization for the patient and by high economic costs for the health care system. The morphology of the upper part of the femur can influence the risk of hip fracture, e.g., a longer femoral neck is associated with a higher risk of cervical fractures, but not trochanteric ones. In this study, we evaluated the prediction of hip fracture risk by morphological parameters estimated from DXA measurements, and we compared their predictive value for cervical and trochanteric fractures in elderly women by reanalyzing previously published data (Duboeuf et al. J Bone Miner Res 1997 12 1895). This nested case-control study was performed in 232 elderly community-dwelling women from the EPIDOS cohort, including 65 women who sustained a hip fracture. After adjustment for confounding variables, women who sustained a cervical fracture had lower areal bone mineral density (aBMD), lower cortical thickness and a higher average buckling ratio ( P <0.005 for all) as well as longer femoral neck ( P <0.01) than controls. Women who sustained a trochanteric fracture had lower aBMD, lower cortical thickness and higher buckling ratio than controls ( P <0.0001) and than women who sustained a cervical fracture ( P <0.05). Their bending resistance (cross-sectional moment of inertia—CSMI, section modulus) was significantly lower in comparison with controls ( P <0.05–0.001). A decrease in aBMD, cortical thickness, CSMI and section modulus as well as an increase in buckling ratio were predictive of all hip fractures (OR –1.42–2.46 per 1 SD, P <0.05–0.0001), but the ORs for all structural parameters were markedly higher for trochanteric than for cervical fractures. CSMI and section modulus were predictive of trochanteric, but not cervical fractures. However, aBMD was strongly correlated with the CSA, cortical thickness and buckling ratio ( r ²>0.74), which suggests that they convey the same information. CSMI and section modulus correlated with aBMD more weakly, but their OR lost statistical significance after adjustment for aBMD. In conclusion, low femoral neck aBMD, CSA and cortical thickness as well as a high buckling ratio are associated with the higher risk of hip fracture, especially trochanteric ones. These indices are highly correlated with aBMD and convey the same message. The calculated CSMI and section modulus predict trochanteric fractures, but not cervical fractures, and their statistical significance is lost after adjustment for aBMD, indicating that they reflect mainly aBMD, not mechanical properties. Thus, the independent contribution of the external diameter of the femoral neck to the risk of hip fracture cannot be reliably estimated by this technique.     

Proximal femoral nail for treatment of trochanteric femoral fractures

PURPOSE: To report outcomes of 87 consecutive patients treated with a proximal femoral nail (PFN) for trochanteric femoral fractures. METHODS: 17 men and 70 women aged 58 to 95 (mean, 85) years with trochanteric femoral fractures underwent PFN fixation using an intramedullary nail, a lag screw, and a hip pin. Fractures were classified according to the AO system; the most common fracture type was A2 (n=45), followed by A1 (n=36) and A3 (n=6). The position of the lag screw within the femoral head was measured. The lateral slide of the lag screw after fracture consolidation was measured by comparing the immediate postoperative and final anteroposterior radiographs. RESULTS: 90% of lag screws were placed in an optimal position. The length of lateral slide of the lag screw in stable A1 fractures was significantly less than that in unstable A2 fractures; it was over 10 mm in 7 of 45 patients with A2 fractures. Cut-out of lag screw did not occur, suggesting that free sliding of the lag screw facilitates direct impaction between fragments. CONCLUSION: A PFN is useful for the treatment of trochanteric femoral fractures.     

Fractures of the proximal femur in Finland in 1980

In 1980 2449 patients with femoral neck and 1096 with trochanteric fractures were treated in Finland. The female--male ratio was 3:1 for femoral neck and 2:1 for trochanteric fractures. The age-specific incidence was higher for women than for men in both fracture types. About 3/4 of the patients were over 70 years old. The mean hospitalization time was 37 days for the patients with a femoral neck and 34 days for those with a trochanteric fracture. These patients accounted for 9% of all surgical hospitalization days in Finland during the year 1980. The injuries occurred evenly during every month. The number of femoral neck fractures will double during the period 1968 to 1985.     

The impact of proximal femur geometry on fracture type - a comparison between cervical and trochanteric fractures with two parameters

Introduction: only a few studies have tested the ability of proximal femur geometry parameters to discriminate between cervical hip fractures and those of the trochanter. The main objective of this study was to evaluate the geometrical differences between these two fracture types by measuring the neck shaft angle (nsa) and the femoral neck axis length (fnal). we also compared the distributions of these parameters and the distributions of fracture type by gender. Material and Methods: a retrospective analysis was made in a population-based material of 428 hip fractures collected during a two-year period from 1999 to 2000 (323 women and 105 men aged 65 years or older). nsa and fnal were manually measured from pelvic radiographs. Results: no significant differences in nsa or fnal were found between cervical and trochanteric hip fractures in women or in men. men had significantly higher nsa and fnal than women. age was not related to these geometrical parameters. The distributions by fracture type were similar in both genders. Conclusions: The different pathogenesis of cervical and trochanteric hip fractures cannot be explained by nsa or fnal. a standardized measurement setup is needed when evaluating the role of hip geometry in fracture patients.     

Use of DXA‐Based Structural Engineering Models of the Proximal Femur to Discriminate Hip Fracture

Several DXA‐based structural engineering models (SEMs) of the proximal femur have been developed to estimate stress caused by sideway falls. Their usefulness in discriminating hip fracture has not yet been established and we therefore evaluated these models. The hip DXA scans of 51 postmenopausal women with hip fracture (30 femoral neck, 17 trochanteric, and 4 unspecified) and 153 age‐, height‐, and weight‐matched controls were reanalyzed using a special version of Hologic's software that produced a pixel‐by‐pixel BMD map. For each map, a curved‐beam, a curved composite‐beam, and a finite element model were generated to calculate stress within the bone when falling sideways. An index of fracture risk (IFR) was defined over the femoral neck, trochanter, and total hip as the stress divided by the yield stress at each pixel and averaged over the regions of interest. Hip structure analysis (HSA) was also performed using Hologic APEX analysis software. Hip BMD and almost all parameters derived from HSA and SEM were discriminators of hip fracture on their own because their ORs were significantly >1. Because of the high correlation of total hip BMD to HSA and SEM‐derived parameters, only the bone width discriminated hip fracture independently from total hip BMD. Judged by the area under the receiver operating characteristics curve, the trochanteric IFR derived from the finite element model was significant better than total hip BMD alone and similar to the total hip BMD plus bone width in discriminating all hip fracture and femoral neck fracture. No index was better than total hip BMD for discriminating trochanteric fractures. In conclusion, the finite element model has the potential to replace hip BMD in discriminating hip fractures.     

Changes in bone mass and fracture type in patients with hip fractures. A comparison between the 1950s and the 1980s in Malm?, Sweden

A consecutive series of 970 hip fractures from 1950 to 1958 were reevaluated and compared with roentgenograms of 1359 hip fractures from 1983 to 1985. The femoral neck index (FNI) was measured and the Singh index (SI) determined. The number of trochanteric fractures has increased more than the number of cervical fractures during the past 30 years. There has been a shift during the last 30 years toward more dislocated cervical fractures. There has been no change in the distribution between stable and unstable trochanteric fractures. The FNI was significantly lower in the 1980s compared with the 1950s, both in men and women. In the 1980s, men and women with cervical fractures had a lower FNI compared with men and women with trochanteric fractures, even after age correction. The SI was significantly lower in the 1980s than in the 1950s, both in men and women, but the difference was significant in trochanteric fractures only. In the 1980s, trochanteric fractures had a lower SI compared with cervical fractures; this relationship was significant both in men and women. Our findings indicate that the bone mass, both cortical and trabecular, measured on roentgenograms of the hip, has diminished in the urban population during the past three decades. This could be one of many reasons for the increased incidence of hip fractures.