Hip fracture in Hong Kong over the last decade--a comparison with the UK.

BACKGROUND: Hip fracture is a major public health problem in Asia and the UK. The objectives of this study were to describe the trends of hip fracture in Hong Kong over the last decade, and to compare the incidence in Hong Kong with that from the Wessex Health Region of the UK in 1995. METHODS: The number of hip fractures was calculated using hospital discharge records for all public hospitals in Hong Kong in 1991 and 1995. Age-specific incidence rates were then calculated using the mid-year census population for the two years. These rates were presented with previously reported age-specific rates for Hong Kong in 1966 and 1985. These age-specific rates for Hong Kong in 1995 were compared with rates for the Wessex Health Region of the UK. The total number of hip fracture expected in 2010 was calculated by applying the age-specific rates of 1995 to the projected population for 2010. RESULTS: In 1995, a total of 1138 men and 2782 women in Hong Kong fractured their hip. The age-specific rates had remained static from 1985 to 1995, after substantial rise from 1966 to 1985. In 1995, the rates of hip fracture rates were 11/1000 in women and 5/1000 in men who were 70 years and older. These rates were almost identical to those observed in the Wessex Health Region of the UK. CONCLUSION: The age-specific incidence rates of hip fracture had not risen in Hong Kong in the last decade. The incidence of hip fracture in Hong Kong was similar to that in the UK in 1995. The total number of patients with hip fracture in Hong Kong will increase substantially in the future, as a result of the ageing of the population.     

Weight cycling and risk of forearm fractures: a 28-year follow-up of men in the Oslo Study

Weight cycling may lead to fractures in non-weight-bearing bone. The authors investigated the association between self-reported episodes of weight loss and forearm fracture in a cohort of elderly Norwegian men (n = 4,601; mean age = 71.6 years). Men initially examined in 1972-1973 as part of the population-based Oslo Study were reexamined in 2000. Weight and height were measured both times; histories of weight cycling (amount and frequency) and fracture and information on covariates were elicited by questionnaire. Irrespective of amount of weight loss, 35-43% of men reporting four or more weight loss episodes at ages 25-50 years had experienced a forearm fracture, as compared with 17-18% of men without weight loss episodes. For weight loss episodes that had occurred after age 50 years, associations were weaker. In an analysis limited to men whose last fracture had occurred after the weight loss episodes, the adjusted odds ratio for forearm fracture was 2.91 (95% confidence interval: 1.10, 7.64) for four or more weight loss episodes versus none. These findings suggest that weight cycling may predict forearm fracture in elderly men and indicate that the potentially harmful effects of weight cycling are related to the number of episodes occurring at ages 25-50 years.     

Fracture risk in the U.S. Medicare population

Using data from the 5% U.S. Medicare sample, we estimated the actuarial (life table) risk that a person aged 65 will fracture the upper or lower limbs or the pelvis, by age 75, 80, 85, and 90, taking into account the chance of dying in the interval. The actuarial risk of a 65-year old white woman sustaining a fracture by age 90 is 16% for the hip, 9% for distal forearm, 5% for proximal humerus, and 4% for ankle. Black women and white men have substantially lower risks, and the risks for black men are very low. Although hip fractures pose the single greatest risk, the risk of all other fractures combined is greater. White women have particularly high risks for all fractures, because of their longevity as well as their high fracture rates. It is important to adjust for the probability of dying when estimating risks in an elderly population.     

北京市城区中老年人髋部骨折的病例对照研究

目的 探索北京市中老年人髋部骨髂发生的危险因素,为今后开展髋部骨折的病因学研究提供线索。方法对北京市城区２０１例５０岁以上髋部骨折病例和４０２名对照进行了１：２配比的病例对照研究。结果 与髋部骨折危险性增另有关的危险因素有低钙饮食、３０年前不上立活动、未服用钙剂、体质指数低目前不经常体育锻炼、未曾在农村居住、工作性质为脑力劳动、髋部骨折阳性家族史和糖尿病。对于女性,绝经提前和哺乳时间和时间短也是髋     

Race and sex differences in mortality following fracture of the hip.

This paper describes the all-cause mortality experience, following a fracture of the hip, of 712,027 persons covered by the Medicare program from 1984 through 1987. White women experienced the lowest mortality rate (17.2 per 1000 person-months), followed by Black women (22.9 per 1000 person-months), Black men (33.5 per 1000 person-months), and White men (33.7 per 1000 person-months). The observed race-sex differences in survival were found at all ages and regardless of the number of comorbid conditions listed with the discharge diagnosis. While these data demonstrate marked race-sex differences in survival following hip fracture, the cause of these differences is not immediately apparent and demands further investigation.     

Development and internal validation of the male osteoporosis risk estimation score

PURPOSE We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA).METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture.RESULTS The MORES included 3 variables—age, weight, and history of chronic obstructive pulmonary disease—and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85–0.97), a specificity of 0.59 (95% CI, 0.56–0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807–0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population.CONCLUSIONS Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.     

Cost effectiveness of screen-and-treat strategies for low bone mineral density

Bone densitometry is currently widely recommended for, and considered central to, identifying post-menopausal women and older men at high risk of fracture and establishing an indication for pharmacological fracture-prevention therapy. The purpose of this article is to comprehensively review cost-effectiveness modelling studies published to date of bone mass measurement technologies (primarily dual energy x-ray absorptiometry [DXA]) designed to identify those individuals at sufficiently high risk of fracture to warrant pharmacological fracture-prevention therapy.Based on older paradigms of the pharmacological treatment of those with a bone density value below a specific threshold, bone densitometry appears to be cost effective for post-menopausal women aged > or =65 years, regardless of the presence or absence of other clinical risk factors. For younger post-menopausal women, bone densitometry is likely to be cost effective only for those with specific clinical risk factors, such as prior fracture or low bodyweight. For older men, bone densitometry may be cost effective for those who have had a prior fracture and/or are aged > or =80 years, but the subset of men for whom bone densitometry is likely to be cost effective may vary from country to country depending on societal willingness to pay for health benefits, fracture rates in the population and the costs of bone densitometry and drug treatment. The cost effectiveness of other technologies such as heel ultrasound, peripheral DXA and quantitative CT remains uncertain.However, in the context of the new WHO paradigm of directing treatment based on absolute fracture risk rather than bone density, a new generation of cost-effectiveness modelling studies will be required to define the most cost-effective way bone densitometry can be used to identify those who are likely to benefit sufficiently from pharmacological fracture-prevention therapies.     

The seasonality of hip fracture and its relationship with weather conditions in New South Wales

Abstract: The seasonal pattern in hip fracture rates and its relationship to weather variables was studied using hospital admission data for New South Wales. There was a consistent seasonal pattern for hip fracture, with a trough in the summer and a peak in the winter, for the six years for which data were available: 1981, 1983, 1986, 1988, 1989 and 1990. The seasonal trends for all years were statistically significant (P<0.01) in men and in women, and in people who were 75 years and over. The relationship between the monthly admission rates for hip fracture in Sydney and such weather variables as mean daily minimum temperature, mean cloud cover, number of days with strong wind, number of days of fog, number of days of mist and number of days with 0.1 mm or more rainfall in a month were studied by Poisson regression. The mean daily minimum temperature for each month was the single weather variable independently and consistently associated with the monthly rates of hip fracture in both younger and older people. For the first time, a seasonal pattern for hip fracture and its close association with monthly temperature in Australia has been demonstrated.     

Association between plasma 25-hydroxyvitamin D levels and fracture risk: the EPIC-Oxford study

The importance of vitamin D for bone health is well established, but few data exist on the relation between plasma levels of 25-hydroxyvitamin D and risk of fracture. The authors examined this association within the EPIC-Oxford (European Prospective Investigation into Cancer and Nutrition-Oxford cohort) study of men and women in the United Kingdom (1993-1999). Five years after recruitment, participants completed a follow-up questionnaire where fracture incidence was self-reported. Plasma 25-hydroxyvitamin D concentration was measured in 730 incident fracture cases and 1,445 matched controls. There was a clear association between plasma 25-hydroxyvitamin D concentration and month of blood draw, the highest values being during the summer months. Among women, there were significant relations between 25-hydroxyvitamin D levels and age, body mass index, marital status, use of hormone therapy, physical activity, diet group, dietary intake of vitamin D, and alcohol. Similar relations were seen among men, although often they were nonsignificant because of smaller numbers. There was no evidence of an association between plasma 25-hydroxyvitamin D and fracture risk for men or women; the relative risks associated with a doubling of plasma 25-hydroxyvitamin D were 1.15 (95% confidence interval: 0.82, 1.61) and 0.95 (95% confidence interval: 0.80, 1.13), respectively. These results were not affected by adjustment for potential confounders and were consistent across a number of subgroups.     

Effectiveness of screening for osteoporosis by bone density measurement for the prevention of fractures: a review of the evidence

To review evidence on the benefits of screening women and men for osteoporosis, a Pub Med search was performed in English papers published between 1990 and 2002. We used data from a cohort study to estimate risk of fracture from bone mineral density. Bone mineral density measured by dual X-ray absorptiometry (DXA) can predict bone fracture among elderly women, peri- and early post-menopausal women, and elderly men. It is recommended that all white women older than 65 years be screened routinely for osteoporosis. We suggest that Japanese elderly women should receive BMD measurements as a screening, but we have still issues to be solved including age from when the screening should be started, methods, and how to treat the women found to have osteoporosis at the screening. For peri- and postmenopausal women and elderly men, it might be beneficial to measure BMD as a screening and start treatment for those patients found to have osteoporosis. However, incidence of fractures for these people is lower than that for elderly women. One bone mass measurement can predict bone fracture risk for as long as over 10 years or more, but predictive ability of BMD decreases with time. Therefore, cost effectiveness needs to be reviewed to determine the benefits of screening among peri-menopausal women and men. Although bone assessment by quantitative ultra sound (QUS) method by ultrasound can also predict future fractures, only a relatively small number of longitudinal studies have been conducted in the Western countries, and there is no established evidence by means of longitudinal studies among Japanese. It is necessary in Japan to seek such evidence, however, since this method is widely used for an osteoporosis examinations.     

Time trends in incidence rates of first hip fracture in the Uppsala Health Care Region, Sweden, 1965-1983

Time trends from 1965 through 1983 for age-specific and age-standardized rates of first hospital admission for a proximal femur fracture were studied in the Uppsala Health Care Region, Sweden, using a centralized register for inpatient care. During the 19-year study period, 29,277 hospital admissions for a first hip fracture were recorded in this population of about 1.5 million persons. The total number of first hip fracture admissions per year increased for both sexes. Age-standardized admission rates for both cervical and trochanteric fractures increased in men (average change per year of 1.8% and 2.6%, respectively) in contrast to the decreased admission rate for cervical fractures (-1.6% per year) and a stable rate for trochanteric fractures (0.4% per year) in women. The cumulative rate of cervical or trochanteric fracture at ages 30-79 years increased 46% in men (from 42/1,000 population in 1965 to 61.5/1,000 population in 1983) in contrast to a 24% decrease in women (from 134/1,000 population in 1965 to 101.5/1,000 population in 1983). The female:male ratio of age-standardized incidence rates decreased for both types of fracture during the study period. This finding of stable or decreasing rates of hip fracture in women contrasts with the findings of most previous studies.     

Who is at risk of osteoporosis?

This contribution assesses who is at risk of osteoporosis, by delineating the key risk factors involved in the condition. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Some risk factors for fragility fracture act through bone mineral density (BMD), for example female gender, asian or Caucasian race, premature menopause, primary or secondary amenorrhoea, primary and secondary hypogonadism in men, prolongued immobilisation, low dietary calcium intake, vitamin D deficiency. However, a number of others contribute significantly to fracture risk over and above their association with BMD (age, high bone turnover, poor visual acuity, neuromuscular disorders, previous fragility fracture, glucocorticoid therapy, family history of hip fracture, low body weight, cigarette smoking, excess alcohol consumption).     

Proximal femur fractures in the elderly in The Netherlands during the period 1991-2004: incidence, mortality, length of hospital stay and an estimate of the care capacity needed in the future

OBJECTIVE: To assess the incidence of operations for neck and pertrochanteric femur fractures during the last 15 years and to estimate the future demand for such operations in The Netherlands. DESIGN: Retrospective. METHOD: For the years 1991, 1995, 2000 and 2004, the following anonymised data were collected in the National Medical Registry of Prismant for all patients admitted to Dutch hospitals for a hip fracture: age-group, gender, length of pre- and postoperative hospital stay, destination after discharge and hospital mortality. These data were related to demographic data for the Dutch population from Statistics Netherlands (CBCS) and to estimates for the Dutch population in the future from Primos Prognostic Data. RESULTS: The average absolute increase in the period 1991-2004 was linear, with 230 fractures per year. Women were operated for a hip fracture 1.5-2 times as often as men in the same age range. The age-specific incidence remained constant over the years but the absolute number of elderly persons per age group increased. The average length of pre- and postoperative hospital stay was reduced by half during the period under investigation. The postoperative hospital mortality decreased from 8.1% in 1991 to 5.6% in 2004, and was 1.5 times as high for men aged 70 years or over as for women of the same age group. In 2004 as compared to 1991, 2.5 times as many patients were discharged to a nursing home. In view of the increasing age of the population, the total number of operated hip fractures can be expected to be 20,200 in the year 2010 and 23,900 in the year 2020. CONCLUSION: In the period 1991-2004 there was an annual increase of 230 operations for proximal femur fractures that was closely related to the ageing of the Dutch population. During the years under investigation, the incidence in the same age range was higher in women, but men had a higher hospital mortality. It is estimated that the decreasing hospital mortality and the decrease in the length of hospital stay will increase the need for nursing-home care for this category of patients.     

Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham Study

OBJECTIVES: This study examined the effect of birth cohort on incidence rates of hip fracture among women and men in the Framingham Study. METHODS: Age-specific incidence rates of first hip fracture were presented according to tertile of year of birth for 5209 participants of the Framingham Study, a population-based cohort followed since 1948. Sex-specific incidence rate ratios were calculated by Cox regression to assess the relation between birth cohort and hip fracture incidence. RESULTS: An increasing trend in hip fracture incidence rates was observed with year of birth for women (trend, P =.05) and men (trend, P =.03). Relative to those born from 1887 to 1900 (incidence rate ratio [IRR] = 1.0), age-specific incidence rates were greatest in the most recent birth cohort, born from 1911 to 1921 (IRR = 1.4 for women, IRR = 2.0 for men), and intermediate in those born from 1901 to 1910 (IRR = 1.2 for women, IRR = 1.5 for men). CONCLUSIONS: Results suggest risk of hip fracture is increasing for successive birth cohorts. Projections that fail to account for the increase in rates associated with birth cohort underestimate the future public health impact of hip fracture in the United States.     

Consequences of a Hip Fracture in Activity Performance and Life Satisfaction in an Elderly Swedish Clientele

The purpose of the study was to explore whether activity performance in elderly people changed following a hip fracture and whether the change influenced life satisfaction. The sample consisted of 29 patients, 23 women and 6 men aged between 65 and 100. In an initial interview at the hospital a questionnaire about daily living activities before the fracture and an ADL taxonomy were used. In a second interview three to four months later at their homes the same questionnaires was used and the subjects were asked about satisfaction with life as a whole. After the fracture many had difficulties in conducting hobby activities and in making social contacts outside the home. Grooming and washing were other activities that few could manage. A large number wanted to perform most of the activities that they did not have the ability to do. A hip fracture is a hazardous event in the life of an elderly person, and may lead to a permanently more restricted life. It is apparent also that this influenced how satisfied these people were with their life in general.     

Tobacco smoking and risk of hip fracture in men and women

BACKGROUND: Previous findings suggest that tobacco smoking increases the risk of hip fracture in women. A similar adverse effect of smoking is suspected to be present in men, but bone mineral density studies have raised the concern that men may be more sensitive to the deleterious effect of smoking on bone than women. In this study we prospectively determined the influence of current, previous, and cumulative smoking history on risk of hip fracture in men and women and addressed the issue of possible gender difference in the susceptibility to tobacco smoking. METHODS: Pooled data from three population studies conducted in Copenhagen with detailed information on smoking habit. A total of 13,393 women and 17,379 men, initially examined between 1964 and 1992, were followed until 1997 for first admission due to hip fracture. The relative risks (RR) of hip fracture associated with smoking were estimated by means of multiplicative Poisson regression models. RESULTS: During follow-up, 722 hip fractures were identified in women, and 447 in men. After adjustment for potential confounders, including body mass index, female current smokers had an RR of hip fracture of 1.36 (95% CI: 1.12-1.65) and male smokers 1.59 (95% CI: 1.04-2.43) relative to never smokers. In both sexes, the RR of hip fracture gradually increased by current and accumulated tobacco consumption. The RR were consistently higher in men than in women, but the test for interaction between sex and tobacco smoking was insignificant. After 5 years, male ex-smokers had an adjusted RR of 0.73 (95% CI: 0.55-0.98) relative to current smokers, while no significant decrease in risk was observed in female ex-smokers (RR = 0.91; 95% CI: 0.72-1.17)). Approximately 19% of all hip fractures in the present study population were attributable to tobacco smoking. CONCLUSION: Tobacco smoking is an independent risk factor for hip fracture in men and women, and there appears to be no gender differences in smoking related risk. Smoking cessation reduces the risk of hip fracture in men after 5 years, while the deleterious effect of smoking seems to be more long-lasting in female ex-smokers.     

Leisure time physical activity and risk of non-vertebral fracture in men and women aged 55?years and older: the Troms? Study

Our aim was to examine associations between leisure time physical activity and risk of non-vertebral fractures in men and women aged ≥55 years, with focus on the anatomical fracture location. Self-reported physical activity was registered in 3,450 men and 4,072 women aged 55-97 years at baseline in the Troms? Study, Norway, in 1994-1995. Non-vertebral fractures were registered through December 31, 2009. During 75,546 person-years at risk, 1,693 non-vertebral fractures were identified. Risk of any non-vertebral fracture decreased with increasing physical activity level in men (P (trend) = 0.006) and non-significantly in women (P (trend) = 0.15), after adjustment for age, body mass index, height, smoking, and previous fracture. The reduced fracture risk was due to a reduced risk in the weight-bearing skeleton, particular at the hip, whereas risk of fracture in the non-weight-bearing skeleton was not related to physical activity. At weight-bearing sites, an inverse relationship between physical activity and fracture risk was present in both sexes (P (trend) ≤ 0.013). Compared with sedentary subjects, the most active men and women had respectively 37% (HR = 0.63, 95% CI: 0.45, 0.88) and 23% (HR = 0.77, 95% CI: 0.62, 0.95) reduced fracture risk in the weight-bearing skeleton. Physical activity is associated with reduced fracture risk at weight-bearing sites, with no associations at non-weight-bearing sites, in both sexes. Habitual physical activity is an important amendable approach to prevent hip fracture.     

Activities of daily living decrease similarly in hospital-treated patients with a hip fracture or a vertebral fracture: a one-year prospective study in 151 patients

AIMS: A hip fracture is commonly regarded as the most devastating fragility fracture, as regards both morbidity and mortality, while a vertebral fracture is usually regarded as having lower general morbidity. The purpose of this study was to investigate whether hospitalized patients with a hip or a vertebral fracture experience similar functional deterioration following the fracture as regards activity of daily living (ADL) and experienced quality of life (QOL). METHODS: Eighty-seven women and 22 men, mean age 81 (range 66-96), with a hip fracture and 34 women and 8 men, mean age 81 (range 68-92), with a vertebral fracture were followed up for 12 months. ADL before fracture and at 4 and 12 months after the fracture were evaluated as well as QOL at 4 and 12 months after the fracture, by questionnaires. RESULTS: A hip and a vertebral fracture in community dwellers within the same age range confers a similar decrease in ADL during the four months following the fracture. No restoration was seen in ADL or total QOL during the year following the fracture. Patients with a vertebral fracture had a lower QOL than patients with a hip fracture 4 and 12 months after the fracture. CONCLUSION: The need for external community assistance for patients with a vertebral fracture that forces them to have hospital treatment may be similar to the need following a hip fracture.     

Long-term impact of smoking cessation on the incidence of coronary heart disease.

Using a simulation model of the US male population, we estimated the long-term impact that future smoking cessation programs would have on the distribution and occurrence of coronary heart disease in males ages 35-84. For interventions that reduce the number of smokers by 25 percent in 1990, the number of men free of coronary heart disease is projected to increase by 416,787 (0.7 percent) in 2015, and the age-standardized absolute incidence to decline by 2.3 percent. Incidence rates and absolute incidences are projected to fall in men under age 65, but absolute incidence would rise in men over age 65, in large part because of the increased number of men who were at risk for coronary heart disease because of a reduction in non-coronary smoking-related mortality. These trends were more marked for greater smoking reductions and were generally unaffected in a variety of analyses using alternative assumptions, which considered smoking as a risk factor in the elderly, a lag-time before benefits from smoking cessation were realized and secular declines in smoking prevalence. Subject to the assumptions of our model, we conclude that smoking reductions will markedly reduce coronary heart disease, especially in younger age groups, and that this benefit will be slightly offset by a small increase in absolute incidence in elderly men.     

Fracture prevalence in an Australian population

Abstract: There is little published information on the epidemiology of fracture in Australia. We have therefore carried out a population-based retrospective study of fracture in an Australian population covering 1 073 subjects, 60 per cent of the eligible population over the age of 65 resident in Busselton in the southwest of Western Australia. They completed a questionnaire on the number of fractures, the skeletal site and the degree of trauma that caused the fracture. In this population, 39 per cent had sustained a total of 620 fractures, and 22 per cent of women and 6 per cent of men had sustained osteoporotic fractures. Hip and spine fractures accounted for only 9 per cent of osteoporotic fractures in females whereas wrist fractures accounted for 27 per cent, other upper limb fractures for 19 per cent and other lower limb fractures for 11 per cent. These results suggest that emphasis on spinal and hip fractures as the only manifestations of osteoporosis is inappropriate.