Optimizing fracture prevention: the fracture liaison service,an observational study

Summary

The response rate to the invitation to the fracture liaison service and reasons for non-response were evaluated in 2,207 fragility fracture patients. Fifty-one percent responded; non-responders were most often not interested (38 %) or were hip fracture patients. After 1 year of treatment, 88 % was still persistent and 2 % had a new fracture.

Introduction

To increase the percentage of elderly fracture patients undergoing a dual energy x-ray absorptiometry (DXA) measurement, and to investigate why some patients did not respond to invitation to our fracture liaison service (FLS).

Methods

In four Dutch hospitals, fracture patients ≥50 years were invited through a written or personal invitation at the surgical outpatient department, for a DXA measurement and visit to our FLS. Patients who did not respond were contacted by telephone. In patients diagnosed with osteoporosis, treatment was started. Patients were contacted every 3 months during 1 year to assess drug persistence and the occurrence of subsequent fractures.

Results

Of the 2,207 patients who were invited, 50.6 % responded. Most frequent reasons for not responding included: not interested (38 %), already screened/under treatment for osteoporosis (15.7 %), physically unable to attend the clinic (11.5 %), and death (5.2 %). Hip fracture patients responded less frequently (29 %) while patients with a wrist (60 %) or ankle fracture (65.2 %) were more likely to visit the clinic. In 337 responding patients, osteoporosis was diagnosed and treatment was initiated. After 12 months of follow-up, 88 % of the patients were still persistent with anti-osteoporosis therapy and only 2 % suffered a subsequent clinical fracture.

Conclusion

In elderly fracture patients, the use of a FLS leads to an increased response rate, a high persistence to drug treatment, and a low rate of subsequent clinical fractures. Additional programs for hip fracture patients are required, as these patients have a low response rate.     

Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate

Summary

We assessed the ability of a fracture liaison service (FLS) to directly reduce re-fracture risk. Having a FLS is associated with a ～40 % reduction in the 3-year risk of major bone and ～30 % of any bone re-fracture. The number needed to treat to prevent a re-fracture is 20.

Introduction

FLS have been promoted as the most effective interventions for secondary fracture prevention, and while there is evidence of increased rate of investigation and treatment at institutions with a FLS, only a few studies have considered fracture outcomes directly. We therefore sought to evaluate the ability of our FLS to reduce re-fracture risk.

Methods

Historical cohort study of all patients ≥50 years presenting over a 6-month period with a minimal trauma fracture (MTF) to the emergency departments of a tertiary hospital with a FLS, and one without a FLS. Baseline characteristics, mortality and MTFs over a 3-year follow-up were recorded.

Results

Five hundred fifteen patients at the FLS hospital and 416 patients at the non-FLS hospital were studied. Over 3 years, 63/515 (12 %) patients at the FLS hospital and 70/416 (17 %) at the non-FLS hospital had a MTF. All patients were analysed in an intention-to-treat analysis regardless of whether they were seen in the FLS follow-up clinic. Statistical analysis using Cox proportional hazard models in the presence of a competing risk of death from any cause was used. After adjustment for baseline characteristics, there was a ～30 % reduction in rate of any re-fracture at the FLS hospital (hazard ratio (HR) 0.67, confidence interval (CI) 0.47-0.95, p value 0.025) and a ～40 % reduction in major re-fractures (hip, spine, femur, pelvis or humerus) (HR 0.59, CI 0.39-0.90, p value 0.013).

Conclusions

We found a ～30 % reduction in any re-fractures and a ～40 % reduction in major re-fractures at the FLS hospital compared with a similar non-FLS hospital. The number of patients needed to treat to prevent one new fracture over 3 years is 20.

     

Management of osteoporosis in fracture liaison service associated with long-term adherence to treatment

Summary  

Adherence to osteoporosis treatment is not satisfactory. Our study evaluated persistence and compliance with these treatments prescribed specifically in the context of a fracture liaison service (FLS), an internal health care network, and showed that this type of organization in our institution was associated with high level of adherence.     

Does a fracture liaison service program minimize recurrent fragility fractures in the elderly with osteoporotic vertebral compression fractures

Background

There is a sizable proportion of elderly, both men and women, with fragility fractures, approximately 2 million fractures per year in the United States.

A Year of Fractures: a snapshot analysis of the logistics, problems and outcomes of a hospital-based fracture liaison service

Summary

Our fracture liaison service identifies patients with low trauma fractures, determines the need for osteoporosis therapy and instigates therapy if necessary. We describe the tracking and outcome of 768 patients attending our emergency department over 1 year and discuss the problems we encountered and potential solutions.

Introduction

Osteoporotic fractures result in substantial morbidity, mortality and economic cost, and patients sustaining a first fracture are known to be at higher risk of sustaining future fracture. Treatment of at-risk patients has been shown to assist in prevention of future fracture including hip fracture. We established a “First Fracture Project” to identify and treat these patients in 2003.

Methods

We assessed “A Year of Fractures”: the logistics, outcome and problems in tracking patients presenting to our emergency department with a low trauma fracture by our fracture liaison service, over 1 year from July 2008 to June 2009. Patients were tracked by our osteoporosis nurse and offered assessment, and treatment where necessary.

Results

In 1 year, 768 patients aged 50 or over were identified from emergency department records as attending with a low trauma fracture. About 84 % of patients eventually received assessment. Of the162 patients progressing through the entire process, 74 % had osteoporosis treatment planned and/or commenced.

Conclusions

Our fracture liaison service was effective at identifying most low trauma fracture patients at risk of further fracture and providing access to osteoporosis assessment. There were many difficulties: we outline logistic and practical issues in delivering our service and suggest potential improvements.     

老年股骨脆性骨折患者基于骨折联络服务模式的出院计划干预研究

目的 了解ICU机械通气患者呼吸机集束化策略的临床依从性及对患者呼吸机相关性肺炎(VAP)发生率的影响,为有效预防VAP提供参考.方法 对104例ICU机械通气患者实施呼吸机集束化策略,统计患者VAP发生率、机械通气时间、ICU住院日、预后及呼吸机集束化策略临床依从性.结果 实施呼吸机集束化策略后,22例(21.15%)发生VAP.患者ICU住院日为2～44(12.22±6.04)d,好转69例,恶化11例,死亡24例.80例完全落实呼吸机集束化策略者VAP发生率15.00%,24例不完全依从者VAP发生率41.67%,呼吸机集束化策略完全依从者VAP发生率显著低于不完全依从者(P＜0.01);预防消化性溃疡及预防深静脉血栓两项措施的临床依从性对VAP发生无影响(均P＞0.05).结论 呼吸机集束化策略能有效预防VAP并改善患者预后,但临床依从性是影响其预防效果的显著因素,预防消化性溃疡及预防深静脉血栓这两项措施的有效性需进一步研究论证.     

Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands

Summary  

Implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at a Fracture Liaison Service (FLS) was evaluated. Despite one guideline, all FLSs differed in the performance of patient selection and prevalence of clinical risk factors (CRFs) indicating the need for more concrete and standardised guidelines.     

Effectiveness of a multidisciplinary team approach to hip fracture management

The purpose of the current study was to evaluate the effectiveness of a multidisciplinary Hip Fracture Service in the treatment of hip fractures in elderly patients. Baseline information and hospital outcomes were compared for 510 patients over the age of 65 with hip fracture treated before and after the institution of the Hip Fracture Service. Data included basic demographic data, admission laboratory results, surgical information, number of comorbidities, mortality, medical complications, discharge information, time to surgery, and length of stay in hospital. The demographics of the two groups of patients were similar. Patients treated as part of the Hip Fracture Service had fewer medical complications (36% vs. 51%), more often had surgery within 24 hours (63% vs. 35%), and had shorter hospital stays (mean, 5.7 days vs. 8.1 days) than patients treated before the Hip Fracture Service. These findings provide the rationale for a prospective, randomized trial of the service.     

Effectiveness of an acute pain service inception in a general hospital

STUDY OBJECTIVES: To assess the effects of an Acute Pain Service (APS) inception on postoperative pain management in a general teaching hospital using pain indicators as performance measures. DESIGN: Open, prospective, nonrandomized, observational study. SETTING: Postanesthesia Care Unit, surgical wards of University Hospital Center of Charleroi. PATIENTS: 1304 patients in the pre-APS inception phase and 671 patients after its implemention who have undergone various types of surgery (orthopedics, gynecology, urology, neurosurgery, stomatology, ear, nose, and throat, ophthalmic, abdominal, vascular-thoracic, plastic, and maxillofacial). INTERVENTIONS: An APS, nurse-based, anesthesiologist-supervised model was devised, based on the concept that postoperative pain relief can be greatly improved by providing in-service training for surgical nursing staff and optimal use of systemic analgesics. MEASUREMENTS AND MAIN RESULTS: Postoperative pain was assessed using a visual analog scale (VAS) every 4 hours for 72 hours in the two phases. Analgesic consumption was registered at the same time. Time-related VAS scores were summarized using several pain indicators. There was an overall improvement in the pain scores after APS inception. The differences were most pronounced, around 50%, in patients undergoing vascular, maxillofacial, gynecologic, and urologic surgeries, and stomatology. Regular administration of paracetamol and nonsteroidal antiinflammatory drugs decreased morphine consumption in the second phase. CONCLUSION: This study validates the benefits of a formal APS, using continuous monitoring of rest pain intensity and analgesic consumption in the postoperative period. Results not only support previous research findings but also offer outcome-based tools to evaluate current practices as compared with desired outcomes.     

Factors associated with receiving anti-osteoporosis treatment among older persons with minimal trauma hip fracture presenting to an acute orthogeriatric service

Background/AimThe aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period.DesignObservational study using prospectively collected data.MethodsDemographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment.Results91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23–1.70, p < 0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30–5.49, p = 0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08–0.54, p = 0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25–0.98, p = 0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment.ConclusionA significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden.     

Effectiveness of sonography assisted minimal invasive plate osteosynthesis (MIPO) compare with fluoroscope assisted in femoral shaft fracture: A cadaveric study

IntroductionA minimal invasive plate osteosynthesis (MIPO) has an advantage of biological soft tissue preservation that consists of preserving bony blood supply, fracture hematoma and less soft tissue damage which leads to decreasing of infection rate and rapid bone healing. However, the radiation exposure is still a disadvantage of this technique. A sonography that provides dynamic real time imaging may be used as an alternative technique for assisting MIPO. The aim of this study was to compare the effectiveness of MIPO in femoral shaft fracture between the sonography assisted and the fluoroscopy assisted.MethodsTwenty-eight cadaveric limbs were subjected to create femoral shaft fracture. Then, sonography assisted reduction with temporary external fixation and MIPO were performed. Images of the sonography and the fluoroscopy were recorded including before reduction, after reduction and after MIPO in order to identify fracture displacements in anteroposterior and mediolateral directions. Moreover, the anterior and posterior distances from edge of the bone to the plate were measured to confirm plate position. The effectiveness of this technique was defined as the proper plate position and acceptable alignment after fixation. All distances from the sonography and the fluoroscopy were also analyzed and compared using Pearson correlation and Bland-Altman method to assess the agreements between two tests.ResultAll of the subjects were met the criteria for acceptable alignment. We found only three femoral shaft fracture (11%) operated with MIPO by sonography assisted that showed slipped plate off femoral bones. According to Pearson correlation, there were good to excellent agreements in term of measuring fracture displacement before (Pearson Correlation >0.7) and after reduction (Pearson Correlation >0.7) between these two tests. There was moderate agreement regarding to evaluation of plate position (Pearson Correlation 03.–0.7). When we compared two methods of measurement using Bland-Altman plot, there were no statistical significant difference (P < 0.05).ConclusionImages from the sonography could provide visualization of the fracture during reduction and MIPO as accurately as the radiography. Thus, the sonography assisted MIPO in femoral shaft fracture can be done effectively comparing with radiographic assisted.     

Effectiveness of foot orthoses: a survey of one year of a podiatric orthotics service

This study presents an audit of one year of patients who received foot orthoses in a small UK NHS Health Authority. Fifty-eight of 81 subjects responded (72%) to a postal survey. Ninety-one percent of respondents described some improvement and 17% some deterioration (some subjects reported both, either at different times or different sites). Eighty percent continued to wear the orthoses at least some of the time after a time period ranging from 4–15 months (mean 10 months). Approximately half of those no longer wearing orthoses reported complete relief from symptoms and half had problems with fit, comfort or secondary symptoms related to wearing the orthoses.     

伊利扎罗夫技术治疗Pilon骨折的临床效果观察

目的 探索伊利扎罗夫(Ilizarov)技术治疗Pilon骨折的临床效果.方法 选取2016年4月至2018年4月就诊的Pilon骨折患者80例,按照随机数字法分为对照组和试验组,各40例.对照组给予钢板内固定治疗,试验组给予Ilizarov外固定架固定治疗.统计两组患者的美国骨科足与踝关节协会(American Or...