老年髋部骨折患者髂骨松质骨中微量元素分析

目的了解老年髋部骨折患者骨中微量元素与髋部骨折及骨质疏松症的关系.方法自髂前上棘后方2cm之髂嵴处以髂骨活检器钻取骨组织.16例患者的髂骨标本用于无机元素分析.其中8例为老年髋部骨折患者,包括男性2例,女性6例,平均年龄74.83±9.43岁.8例为成年暴力性骨折患者,包括男性2例,女性6例,平均年龄41.38±3.42岁.以原子吸收法进行测定.结果老年髋部骨折患者髂骨活检标本的钙、镁和锰含量低于对照组(分别为P<0.01,P<0.01和P<0.05).老年女性髋部骨折患者的铜含量也较成年女性对照组低(P＜0.05).     

老年人髋部骨折156例临床治疗分析

目的 报告老年人髋部骨折的临床治疗方法，分析老年髋部骨折特点及诊治注意事项。方法 自1997年1月－1999年12月共治疗60岁以上（60－93岁）髋部骨折156例。男性55例，平均年龄71．8岁；女性101例，平均年龄73．1岁。骨折类型：股骨颈骨折94例，男性20例，女性74例；股骨粗隆间骨折62例，男性35例，女性27例。本组接受非手术治疗41例；手术治疗115例，其中行各种内固定手术45例，人工股骨头置换68例，股骨头颈切除2例。部分病例同时给予骨质疏松药物治疗。结果 获得随访110例。随访时间0．5－3．5年。术后下肢静脉栓塞2例，股骨头缺血坏死2例，内固定物松动，滑脱2例，断裂1例，人工股骨头下沉致疼痛4例，术后近期死亡2例（死于心肌梗塞及呼吸道感染），97例（88．2％）恢复行走功能。结论 （1）老年人髋部骨折以女性多见，占64．7％；男性少见，占35．3％。这与女性绝经后骨折疏松症的发生密切相关。而老年股骨颈骨折多见于女性，股骨粗隆间骨折则多见于男性。70岁以后，老年髋部骨折发生率明显上升。这与老年性骨质疏松症的发生明显相关。说明随着年龄的增加，骨折的发生率明显增高，骨折危险性增加。（2）老年人髋部骨折属于骨质疏松性骨折，股骨粗隆间骨折一般都有明确外伤史；而股骨颈骨折常由轻微外力（扭转）所致，因此在诊断时须防止漏诊或误诊，影响治疗效果。（3）老年人多伴有心血管系统或呼吸系统疾病，骨折后长期卧床具致使的威胁，因此在治疗上如无禁忌应争取早期手术，早期下床活动。（4）在治疗骨折的同时，应注意对骨质疏松症的治疗，这对减轻全身骨痛，促进骨折愈合，防止再骨折均有重要意义。     

Femoral neck geometry and hip fracture risk: the Geelong osteoporosis study

To determine the relationship between femoral neck geometry and the risk of hip fracture in post-menopausal Caucasian women, we conducted a retrospective study comparing the femoral neck dimensions of 62 hip fracture cases to those of 608 randomly selected controls. Measurements were made from dual-energy X-ray absorptiometry scans (Lunar DPX-L), using the manufacturers ruler function, and included: hip axis length (HAL), femoral neck axis length (FNAL), femoral neck width (FNW), femoral shaft width (FSW), medial femoral shaft cortical thickness (FSCT_med), and lateral femoral shaft cortical thickness (FSCT_lat). The fracture group was older (median age 78.3 years vs 73.8 years), lighter (median weight 59.9 kg vs 64.5 kg), and, after adjustment for age, taller (mean height 158.7±0.8 cm vs 156.7±0.2 cm) than the controls. Furthermore, bone mineral density was lower in this group (0.682±0.016 g/cm² vs 0.791±0.006 g/cm²). After adjustment for age, bone mineral content (BMC) or height, hip fracture patients had greater FNW (up to 6.6%) and FSW (up to 6.3%) than did the controls. Each standard deviation increase in FNW and FSW was associated with a 1.7-fold (95% CI 1.3–2.3) and a 2.4-fold (95% CI 1.8–3.2) increase in the fracture risk, respectively. BMC-adjusted FNAL was greater in the fracture group (+2.1%) than in the controls, while the age-adjusted FSCT_med was reduced (–7.2%). There was a trend towards longer HAL (up to 2.1%) after adjustment for age or BMC, and thinner age-adjusted FSCT_lat (–1.7%) in fracture patients that did not reach statistical significance. In multivariate analysis, the risk of hip fracture was predicted by the combination of age, FNW, FSW, BMC and FSCT_med. HAL was not analyzed because of the small number of HAL measurements among fracture cases. We conclude that post-menopausal women with hip fractures have wider femoral necks and shafts, thinner femoral cortices and longer femoral neck axis lengths than do women with no fractures. Alteration in hip geometry is associated with the risk of hip fracture.The authors declare no conflicts of interest with regard to this article     

Antiresorptive treatment,when initiated after a first hip fracture,may not protect of a second contralateral episode in elderly population: A study with 685 patients

IntroductionOsteoporosis predisposes for a higher risk of hip fracture and its treatment is frequently underprescribed. Our purpose was to assess the relation between having a second hip fracture and receiving osteoporosis treatment. Also to assess the relation between this second fracture and using central nervous system drugs or being institutionalised.Patients and methodsWe reviewed all the patients that were admitted to our hospital with an osteoporotic proximal femoral fracture between September 2009 and February 2011. We identified 685 patients, 74 of which presented a contralateral fracture. We evaluated if they were receiving osteoporosis treatment or taking any medication that could affect the central nervous system and if they were institutionalised.ResultsA 10.8% of patients had a second fracture and the mean time between the two of them was 20 months (1–122). There was a clear female predominance (76.35%). The mean age at occurrence of the primary fracture was 83.02 years and 85 for the second. A 90.8% did not follow any type of osteoporosis medication before the first fracture. A 50.9% did not receive central nervous system drugs and 79.1% lived at home at the time of the first fracture. 12.8% of the patients that did not follow the osteoporosis treatment, had a contralateral fracture, 3% more than those that did follow some kind of treatment, but this difference was not significant (p = 0.2).DiscussionWe identified a similar number of patients undergoing osteoporotic treatment as registered in literature. There was no significant difference between suffering a second hip fracture and following osteoporosis treatment, using psychotropic drugs or being institutionalised.     

Direct costs of osteoporosis and hip fracture: an analysis for the Mexican healthcare system

Summary This study reports the direct costs related to osteoporosis and hip fractures paid for governmental and private institutions in the Mexican health system and estimates the impact of these entities on Mexico. We conclude that the economic burden due to the direct costs of hip fracture justifies wide-scale prevention programs for osteoporosis (OP). Methods To estimate the total direct costs of OP and hip fractures in the Mexican Health care system, a sample of governmental and private institutions were studied. Information was gathered through direct questionnaires in 275 OP patients and 218 hip fracture cases. Additionally, a chart review was conducted and experts’ opinions obtained to get accurate protocol scenarios for diagnoses and treatment of OP with no fracture. Microcosting and activity-based costing techniques were used to yield unit costs. Results The total direct costs for OP and hip fracture were estimated for 2006 based on the projected annual incidence of hip fractures in Mexico. A total of 22,233 hip fracture cases were estimated for 2006 with a total cost to the healthcare system of US$ 97,058,159 for the acute treatment alone ($4,365.50 per case). We found considerable differences in costs and the way the patients were treated across the different health sectors within the country. Conclusion Costs of the acute treatment of hip fractures in Mexico are high and are expected to increase with the predicted increment of life expectancy and the number of elderly in our population.     

Young patients with hip fracture: a population-based study of bone mass and risk factors for osteoporosis

Introduction Hip fracture in young patients is rare. The present study was aimed to clarify the comorbidity pattern and reveal relevant risk factors for osteoporosis and fracture in this patient group.Materials and methods Using electronic diagnosis registers and lists of the operating theatres for the Oslo hospitals, patients with new hip fracture during two 1-year periods from May 1994 through April 1995 and from May 1996 through April 1997 were identified. All patients age 20–49 years at the time of fracture were included (n=49), and a detailed medical history was recorded. Thirty-two of the patients volunteered for examination and completed a questionnaire and interview to reveal risk factors for osteoporosis. Data from the Oslo Health Study served as reference material. Bone mineral density (BMD) was measured using dual x-ray absorptiometry, and Z-scores were calculated using healthy subjects from Oslo as reference.Results Of the patients identified, the median age was 40 years (range 25–49), and 63% were men. In 65% of the patients, the fracture occurred after a fall at the same level, in 16% it occurred after a fall from a higher level, and in 18% it occurred in a traffic accident. Twenty percent of the patients had a history of alcohol or drug abuse, 39% had neuromuscular diseases, and 12% had endocrine diseases. The patients examined had significantly more risk factors for osteoporosis than the reference population. The BMD expressed as Z-score for L2-4 was −1.0±0.9 (mean ± SD; p<0.001), for femoral neck was −1.5±1.0 (p<0.001), and for total body was −1.3±1.1 (p<0.001). BMD was significantly lower than in controls for patients sustaining low-energy and high-energy trauma. There was a negative correlation between the total number of risk factors and BMD for lumbar spine (r=−0.35, p<0.05), femoral neck (r=−0.37, p=0.04), and total body (r=−0.55, p=0.001), respectively.Conclusions The majority of the young patients with hip fracture have a history of low-energy trauma, comorbidity predisposing for falls or decreased bone strength, as well as several risk factors for osteoporosis. The BMD was significantly lower than in the reference population regardless of the trauma mechanism.     

The role of socioeconomic status on hip fracture

Introduction The impact of socioeconomic status—income and acculturation—on hip fracture is not well understood. We studied 116,919 fractures among 8,144,469 people in California. Greater income and English fluency predict lower fracture incidence. Lower income and immigrant populations are at increased risk for hip fracture and require intervention. Race/ethnicity is a major determinant of hip fracture risk. Although socioeconomic status (e.g., income and acculturation) is often associated with race/ethnicity, its impact on hip fracture incidence is less well understood.Methods We carried out a retrospective, population-based, study of persons with hip fractures in California, 1996 to 2000, compared to census estimates by zip code. We performed Poisson regression analyses to calculate hip fracture incident rate ratios for gender, age, race/ethnicity, income, language (percent non-English speakers)—a proxy for acculturation—and living in rural areas.Results During the 5-year period, 116,919 fractures occurred among 8,144,469 persons (2.87 fractures/1,000 persons per year). Higher income predicted lower hip fracture incidence. Persons in the highest decile of estimated income had an incident rate ratio (IRR) of 0.79 (95% confidence interval (CI) 0.77 to 0.82) compared with those in the lowest decile. Greater IRR of hip fracture was predicted for persons living in areas with a greater percent of non-English speakers (IRR 1.004, 95% CI 1.003 to 1.005).Conclusions Low income and language fluency are predictors of greater hip fracture incidence. Although much attention is given to the aging of the “baby boomers”, low income and immigrant populations are at increased risk for hip fracture and require intervention.     

骨质疏松髋部骨折区骨微结构变化研究

目的 分析骨质疏松髋部骨折区张力侧骨小梁微结构的变化。方法 实验组选择16例低能量创伤致股骨颈骨折需要行髋关节置换的老年患者,术前行健侧髋部骨密度检测。因活体取材困难,故选取5根青年同种异体股骨为对照组。在实验组与对照组股骨颈张力侧骨小梁中,切取5mm×5mm×10mm的松质骨,行Micro-CT扫描分析微结构参数。分析两组之间微结构参数的差异及实验组患者微结构参数与骨密度之间关系。结果 实验组微结构：骨体积分数(BV/TV) 0.0645±0.0259,骨小梁数量(Tb.N) (0.8078±0.2212) mm-1,骨小梁厚度(Tb.Th ) (0.0836±0.0212) mm, 骨小梁距离(Tb.Sp) (1.2197±0.4492) mm,连接密度(Conn.D) 1.8577±1.0217, 结构模型指数(SMI) 1.7780±0.5168。对照组微结构：BV/TV 0.1470±0.0633,Tb.N (1.2692±0.1376)mm－1,Tb.Th (0.1201±0.0414) mm,Tb.Sp (0.6810±0.1129) mm,Conn.D 3.3585±1.7851,SMI 0.8781±0.6665。与对照组相比,实验组髋部张力侧松质骨小梁显著破坏,各微结构指标均有明显的改变,差异有统计学意义（P＜0.05）。实验组微结构参数与骨密度之间无相关性（P＞0.05）。结论 骨质疏松髋部骨折区张力侧骨小梁明显破坏,这可能是髋部骨折发生的重要原因之一。     

老年髋部骨折患者骨组织形态计量分析

目的通过骨组织形态计量对老年髋部骨折患者的骨量和骨结构异常进行研究。方法 25例患者均接受髂骨活检。 A组 14例,为老年髋部骨折组,其中男 6例 (A1组 ),年龄 (75.01± 7.15)岁;女 8例 (A2组 ),年龄 (69.85± 11.58)岁。 B组 11例,为对照组,其中男 5例,女 6例;年龄 (41.44± 3.87)岁。所取标本经甲基丙烯酸甲酯包埋、硬组织切片、甲苯胺蓝染色后行组织形态计量分析。结果 (1)A组的骨小梁体积、皮质骨宽度、骨小梁密度、骨小梁厚度、结点末端比显著低于对照组 (P< 0.01),而骨小梁间距则明显高于对照组 (P< 0.01)。 (2)A组中 2例女性患者的病理改变较为特殊,其骨量参数与对照组相近;结点末端比在对照组 95％可信度区间之外,而与本组其他患者相似。结论 (1)骨小梁连续性显著下降,而非骨量降低是部分骨转换增高的绝经后女性髋部骨折的重要内因。 (2)按骨量、骨结构 (骨小梁连续性 )和骨转换状况,老年髋部骨折患者的骨组织病理改变可以分为三型。     

阿仑膦酸钠治疗伴骨质疏松症的髋部骨折

目的　观察阿仑膦酸钠 (固邦 )治疗髋部骨折的骨质疏松症患者的临床疗效及安全性。方法　对 77例髋部骨折的骨质疏松症患者进行为期 1年随机双盲对照研究。用骨密度测量仪测定骨密度。结果　固邦治疗 1年时 ,腰椎、股骨颈、Wards三角、大转子骨密度分别平均增加 7 0 %±13 0 %、7 3%± 11 1%、4 6 %± 5 9%、4 5 %± 3 2 % ,安慰剂组增加 - 2 0 %± 4 5 %、0 9%± 6 9%、-3 6 %± 4 9% ,- 1 14 %± 6 0 %、两组差异有显著意义 (P <0 0 5 )。治疗前后用药组及对照组血Ca、血P、血ALP、血BGP及尿Pyd/Cr差异均无显著性意义。副作用轻微 ,为一过性 ,主要为消化道反应。结论　阿仑膦酸钠治疗骨质疏松症骨折显著有效并且安全     

髋关节一过性骨质疏松症的诊断与治疗

目的：探讨髋关节一过性骨质疏松症的诊断与治疗效果。方法：2005年1月至2010年2月采用保守方法治疗髋关节一过性骨质疏松症5例,均为男性;年龄27～46岁,平均38.6岁。对其临床表现、体格检查及影像学改变进行分析总结,采用Harris髋关节评分对治疗效果进行评价。结果：所有患者获随访,时间12～36个月,平均24个月。治疗前Harris髋关节评分分别为63.1、86.0、74.9、63.6、64.8分,治疗6个月后分别为90.5、94.5、89.7、93.9、87.8分。治疗6个月后,X线片及MRI影像均基本恢复正常。结论：髋关节一过性骨质疏松症有典型的临床及影像学表现,保守和对症处理对髋关节一过性骨质疏松症有效。     

Increased bone resorption and decreased bone formation in Chinese patients with hip fracture

Biochemical markers of bone formation (bone-specific alkaline phosphatase and osteocalcin) and bone resorption (hydroxyproline excretion and bone isoenzyme of acid phosphatase) were measured in 30 patients (15 M and 15 F) with hip fracture and 30 healthy subjects matched for age and sex. Bone isoenzyme of tartrate-resistant acid phosphatase (TRACP) was measured by a recently developed specific immunoassay. Serum osteocalcin concentration and bone-specific alkaline phosphatase activity were significantly lower and serum TRACP concentration and urinary hydroxyproline excretion were elevated in patients compared with healthy subjects. We suggest that there is reduced bone formation and increased bone resorption in patients with hip fracture.     

Bone mineral density and walking ability of elderly patients with hip fracture: a strategy for prevention of hip fracture

The main risk factors for proximal femoral fracture include the hazard of falling and osteoporosis. The change in walking ability of patients before injury was evaluated over the last 10 years in a rapidly advancing aging society in Tokyo, Japan. The bone quality of patients was clarified in order to develop a strategy for prevention of hip fractures. The subjects were 157 women with proximal femoral fractures treated between 1989 and 1993 (group A) and 216 women treated between 1999 and 2003 (group B). Bone mineral density (BMD) of the radius of the patients showed slightly lower values than those of the elderly general population, but no statistically significant difference was observed in each age group except for the 75-79-year-old age group (p<0.05). Many patients had problems in walking, and 27% of patients in group A and 44% in group B could not walk outdoors or go shopping alone before the injury, and their bone mineral density was reduced. For the prevention of hip fractures, it is important to improve the physical function to avoid falls, which directly cause hip fracture. Patients who have difficulty performing effective physical exercise because of reduced walking ability require medication for osteoporosis.     

Effect of soft shell hip protectors on pressure distribution to the hip during sideways falls

INTRODUCTION: While hip protectors represent a promising strategy for preventing hip fractures, clinical efficacy has been limited by poor user compliance. Soft shell protectors may be more acceptable to users than traditional hard shell designs. However, before embarking on clinical trials to assess efficacy, laboratory experiments are required to determine how soft shell protectors affect the force applied during impact to the hip. This was the goal of the current study. METHODS: Fifteen women participated in "pelvis release experiments," which safely simulate the impact stage of a sideways fall. During the trials, we measured total impact force and mean pressure over the greater trochanter with the participant unpadded, and while wearing two commercially available soft shell protectors. RESULTS: Mean pressure over the greater trochanter was reduced by 76% by a 14-mm thick horseshoe-shaped protector and by 73% by a 16-mm thick continuous protector. Total force was reduced by 9% by the horseshoe and by 19% by the continuous protector. CONCLUSIONS: Soft shell hip protectors substantially reduce the pressure over the greater trochanter, while only modestly reducing total impact force during simulated sideways falls. These data support the need for clinical trials to determine whether soft shell protectors reduce hip fracture risk in vulnerable populations.     

Osteoporosis intervention in ambulatory patients with previous hip fracture: a multicentric, nationwide Italian survey

Our study investigated the patterns of treatment and adherence to prescribed therapies in 2,191 ambulatory patients with previous hip osteoporotic fractures at 207 participating orthopedic centers throughout Italy. All patients who came to the attention of the involved orthopedic surgeons were administered a questionnaire investigating: age, sex, height, weight, date of admission and length of stay in the hospital, other previous clinical fractures, bone density or biochemical testing concerning mineral metabolism, treatment with bone-active drugs in the six months before the fracture, treatment after discharge from the hospital, continuous use of prescribed drugs, pain at the site of hip surgery, and comorbidity. A multivariate logistic regression model was applied, considering a subset of the variables in the questionnaire, in order to determine the factors that significantly influenced discontinuation of treatment after hip fracture. Among the patients, 88.1% were female and 86.2% of the subjects were older than 65. The mean length of hospital stay for hip fracture was 19.0±25.3 days. At the time of interview, the mean time elapsed since hospitalization was 542.9±1,197.3 days. A previous clinical fracture was referred by 20.2% of patients. Before hip fracture occurrence, 52.8% of patients had never received any kind of treatment, and this figure reached 80% if we also included those who had taken only calcium and/or vitamin D. Corresponding proportions after fracture were 22% and 31.3%, respectively. Finally, 52% of patients had stopped treatment given for osteoporosis after a mean period of 1.4 years. According to the results of the logistic regression, increasing age, pain [odds ratio (OR): 1.36; 95% confidence interval (CI): 1.21–1.65] and no use of diagnostic tests (OR: 2.46; CI: 1.79–3.37) showed a positive effect on the probability of quitting the medication. On the other hand, being female reduces by half (OR: 0.49; CI: 0.37–0.45) the probability of quitting medication. Our data showed a low rate of primary prevention, a still insufficient post-fracture therapy, along with a high rate of early discontinuation of osteoporosis medication in patients with previous hip fracture.     

老年髋部骨折患者骨密度阈值的初步探讨

作者收集３９例６０岁以上髋部骨折病人作为病例组，其中男１７例，女２２例。另选８０例６０岁以上正常老年人作为对照组。其中男女各４０例。采用双能量骨密度仪分别测定其脊柱及髋部各部位的骨密度值。测量结果表明无论是脊柱还是髋部，骨折组骨密度均显著低于对照组（Ｐ＜０．０１）。其中髋部Ｗａｒｄ’ｓ三角区骨密度下降最为明显。骨折组Ｗａｒｄ’ｓ三角区ＢＭＤ值平均为０．４８８８±０．１１０８。作者提出对高危人群进行普查，如发现髋部Ｗａｒｄ’ｓ三角区ＢＭＤ值低于０．５ｇ／ｃｍ２时，对其采取治疗及保护措施是十分必要的。     

Effect of dynamic hip screw on the treatment of femoral neck fracture in the elderly

[Abstract] Objective： To discuss the indications, surgical procedures, and curative effect of dynamic hip screw （DHS） in the treatment of femoral neck fracture in the elderly. Methods： A retrospective study was conducted to analyse the clinical data of 42 elderly patients who had been treated for femoral neck fracture with DHS in our department between June 2009 and November 2011. There were 21 males and 21 females with a mean age of 68.5 years （range 60-75 years）. According to the Garden Classification, there were 19 cases of type II, 21 cases of type III and 2 cases of type IV fractures. By the Singh In- dex Classification, there were 3 cases of level 2, 19 cases of level 3 and 20 cases of level 4 fractures. The Harris cri- terion, complications and function recovery after operation were analysed. Results： The average hospitalization time in 42 patients was 11.2 days （range 7-21 days）. All patients were followed up for 12-26 months （mean 18 months）. No lung infection, deep venous thrombosis or other complications occurred. Partial backing-out of the screws was found in 2 cases. The internal fixation device was with- drawn after fracture healing. Internal fixation cutting was found in 1 case, and he had a good recovery after total hip arthroplasty. The time for fracture healing ranged from 3-6 months （average 4.5 months）. According to Harris criteri- on, 15 cases were rated as excellent, 24 good, 2 fair and 1 poor. The Harris scale was significantly improved from 30.52＋2.71 preoperatively to 86.61＋2.53 at 6 months post- operatively （P〈0.05）. Conclusion： DHS, being minimal invasive, al- lowing early activity and weight-bearing, is advisable for treatment of elderly patients with femoral neck fracture. In addition, it can avoid complications seen in artificial joint replacement. It is especially suitable for patients with mild osteoporosis.